FOCUS ISSUE: CARDIAC INTERVENTION: INTERVENTION IN ACUTE CORONARY SYNDROME
Percutaneous Coronary Intervention After Fibrinolysis
A Multiple Meta-Analyses Approach According to the Type of Strategy
Jean-Philippe Collet, MD, PhD*,
Gilles Montalescot, MD, PhD*,*,
Michel Le May, MD ,
Maria Borentain, MD* and
Anthony Gershlick, MD
* Pitié-Salpêtrière University Hospital, Paris, France
University of Ottawa Heart Institute, Ottawa, Ontario, Canada
University Hospital of Leicester, Leicester, United Kingdom.
Manuscript received December 13, 2005;
revised manuscript received February 27, 2006,
accepted March 16, 2006.
* Reprint requests and correspondence: Dr. Gilles Montalescot, Institut de Cardiologie, Bureau 2-236, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France. (Email: Gilles.montalescot{at}psl.aphp.fr).
OBJECTIVES: We performed a meta-analysis of randomized trials that enrolled ST-segment elevation myocardial infarction patients treated with fibrinolysis to assess the potential benefits of: 1) rescue percutaneous coronary intervention (PCI) versus no PCI; 2) systematic and early ( 24 h) PCI versus delayed or ischemia-guided PCI; 3) fibrinolysis-facilitated PCI versus primary PCI alone.
BACKGROUND: The impact of PCI strategies after fibrinolysis on mortality or reinfarction remains to be established.
METHODS: The meta-analysis was performed using the odds ratio (OR) as the parameter of efficacy with a random effect model. Fifteen randomized trials (5,253 patients) were selected. The primary end point was mortality or the combined end point of death or reinfarction.
RESULTS: Rescue PCI for failed fibrinolysis reduced mortality (6.9% vs. 10.7%) (OR, 0.63; 95% confidence interval [CI], 0.39 to 0.99; p = 0.055) and the rate of death or reinfarction (10.8% vs. 16.8%) (OR, 0.60; 95% CI, 0.41 to 0.89; p = 0.012) compared with a conservative approach. Systematic and early PCI performed during the "stent era" led to a nonsignificant reduction in mortality compared with delayed or ischemia-guided PCI (3.8% vs. 6.7%) (OR, 0.56; 95% CI, 0.29 to 1.05; p = 0.07) and to a 2-fold reduction in the rate of death or reinfarction (7.5% vs. 13.2%) (OR, 0.53; 95% CI, 0.33 to 0.83; p = 0.0067). This benefit contrasted with a nonsignificant increase in the rate of both mortality (5.5% vs. 3.9%, p = 0.33) or death or reinfarction (9.6% vs. 5.7%, p = 0.06) observed in the "balloon era." Fibrinolysis-facilitated PCI was associated with more reinfarction as compared with primary PCI alone (5.0% vs. 3.0%) (OR, 1.68; 95% CI, 1.12 to 2.51; p = 0.013) without significant impact on mortality (OR, 1.30; 95% CI, 0.92 to 1.83; p = 0.13).
CONCLUSIONS: Our findings support rescue PCI and systematic and early PCI after fibrinolysis. However, the current data do not support fibrinolysis-facilitated PCI in lieu of primary PCI alone.
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Abbreviations and Acronyms
| | CI = confidence interval | | GP = glycoprotein | | OR = odds ratio | | PCI = percutaneous coronary intervention | | REACT = Rescue Angioplasty Versus Conservative Therapy or Repeat Thrombolysis Trial | | STEMI = ST-segment elevation myocardial infarction |
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