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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

View larger version (43K): [in a new window]   Figure 1 Meta-analysis profile. PCI = percutaneous coronary intervention.

View larger version (27K): [in a new window]   Figure 2 (A) Odds ratios for death with rescue angioplasty versus conservative approach within the first 30 days after randomization. The incidence of death rate was lower in the rescue group than in the conservative group. Overall odds ratio 0.63; 95% confidence interval (CI), 0.39 to 1.01; p = 0.055. The analysis for heterogeneity was nonsignificant (p = 0.53). (B) Odds ratios for death or reinfarction with rescue angioplasty versus conservative approach within the first 30 days of randomization. The incidence of death or reinfarction was lower in the rescue group than in the conservative group. Overall odds ratio 0.60; 95% CI, 0.41 to 0.89; p = 0.012. The analysis for heterogeneity was nonsignificant (p = 0.44). LIMI = LImburg Myocardial Infarction trial; MA = meta-analysis; MERLIN = Middlesbrough Early Revascularisation to Limit INfarction; PCI = percutaneous coronary intervention; PTCA = percutaneous transluminal coronary angioplasty; REACT = Rescue Angioplasty Versus Conservative Therapy or Repeat Thrombolysis Trial; RESCUE = Randomized Evaluation of Salvage Angioplasty with Combined Utilization of Endpoints.

View larger version (26K): [in a new window]   Figure 3 (A) Systematic and early percutaneous coronary intervention (PCI) was associated with a nonsignificant reduction of death in the "stent era" studies as compared with ischemia-guided PCI (odds ratio, 0.56; 95% confidence interval [CI], 0.29 to 1.05; p = 0.07; analysis for heterogeneity was nonsignificant, p = 0.71) whereas an increase in the rate of death was observed in the "balloon era studies" (odds ratio, 1.44; 95% CI, 0.69 to 3.06; p = 0.33; the analysis for heterogeneity was nonsignificant, p = 0.74). The overall analysis showed a nonsignificant trend toward a reduction of death in favor of systematic and early PCI (odds ratio, 0.83; 95% CI, 0.52 to 1.35; p = 0.47; the analysis for heterogeneity was nonsignificant, p = 0.41). (B) Systematic and early PCI was associated with a nonsignificant reduction of death or myocardial infarction in the "stent era" studies as compared with ischemia-guided PCI (odds ratio, 0.53; 95% CI, 0.33 to 0.83; p = 0.0067; the analysis for heterogeneity was nonsignificant (p = 0.95) whereas it was found to be detrimental in the "balloon era" studies (odds ratio, 1.76; 95% CI, 0.97 to 3.21; p = 0.064; the analysis for heterogeneity was nonsignificant, p = 0.74). The overall analysis showed a nonsignificant trend toward a reduction of death or myocardial infarction in favor of systematic and early PCI (odds ratio, 0.85; 95% CI, 0.47 to 1.55; p = 0.42). The analysis for heterogeneity was significant (p = 0.062). CAPITAL-MI = Combined Angioplasty and Pharmacological Intervention Versus Thrombolytics Alone in Acute Myocardial Infarction; GRACIA-1 = Randomized trial comparing stenting within 24 h of thrombolysis versus ischemia-guided approach to thrombolyzed acute myocardial infarction with ST-segment elevation; MA = meta-analysis; PTCA = percutaneous transluminal coronary angioplasty; SIAM = Comparison of Invasive and Conservative Strategies After Treatment with Streptokinase in Acute Myocardial Infarction; TAMI = Thrombolysis and Angioplasty in Myocardial Infarction.

View larger version (20K): [in a new window]   Figure 4 (A) Odds ratios for death within 90 days with fibrinolysis-facilitated percutaneous coronary intervention (PCI) versus primary PCI alone. Facilitated PCI had no significant impact on mortality. Overall odds ratios 1.30; 95% confidence interval (CI), 0.92 to 1.83; p = 0.13. The analysis for heterogeneity was nonsignificant (p = 0.46). (B) Odds ratios for reinfarction within 90 days with fibrinolysis-facilitated PCI versus primary PCI alone. Facilitated PCI led to a significant increase in reinfarction. Overall odd ratios, 1.68; 95% CI, 1.12 to 2.51; p = 0.013. The analysis for heterogeneity was nonsignificant (p = 0.46). ASSENT = Assessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction; PACT = Plasminogen Activator-Angioplasty Compatibility Trial; GRACIA-2 = Primary Optimal Percutaneous Coronary Intervention versus Facilitated Intervention in STEMI patients; MA = meta-analysis; PRAGUE = PRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis.