CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY
Rescue Angioplasty or Repeat Fibrinolysis After Failed Fibrinolytic Therapy for ST-Segment Myocardial Infarction
A Meta-Analysis of Randomized Trials
Harindra C. Wijeysundera, MD*,
Ram Vijayaraghavan, MD*,
Brahmajee K. Nallamothu, MD, MPH ,
JoAnne M. Foody, MD , ,
Harlan M. Krumholz, MD, SM,||,
Christopher O. Phillips, MD, MPH¶,
Amir Kashani, MD, MS,
John J. You, MD#,,
Jack V. Tu, MD, PhD**, and
Dennis T. Ko, MD, MSc*,,*
* Division of Cardiology, Schulich Heart Centre and Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
Health Services and Research Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, Michigan
Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
West Haven Veterans Administration Medical Center, West Haven, Connecticut
|| Section of Health Policy and Administration, Department of Epidemiology and Public Health; Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine; and the Center for Outcomes Research and Evaluation, Yale-New Haven Health, New Haven, Connecticut
¶ The Cleveland Clinic Foundation, Cleveland, Ohio
# Department of General Internal Medicine, University Health Network, Ontario, Canada
** Department of Medicine, Sunnybrook Health Sciences Centre, Ontario, Canada
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
Manuscript received July 20, 2006;
revised manuscript received September 12, 2006,
accepted September 19, 2006.
* Reprint requests and correspondence: Dr. Dennis T. Ko, Room G1-06, 2075 Bayview Avenue, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada, M4N 3M5. (Email: dennis.ko{at}ices.on.ca).
OBJECTIVES: We sought to best estimate the benefits and risks associated with rescue percutaneous coronary intervention (PCI) and repeat fibrinolytic therapy as compared with conservative management in patients with failed fibrinolytic therapy for ST-segment myocardial infarction (STEMI).
BACKGROUND: Fibrinolytic therapy is the most common treatment for STEMI; however, the best therapy in patients who fail to achieve reperfusion after fibrinolytic therapy remains uncertain.
METHODS: We performed a meta-analysis of randomized trials using a fixed-effects model. We included 8 trials enrolling 1,177 patients with follow-up duration ranging from hospital discharge to 6 months.
RESULTS: Rescue PCI was associated with no significant reduction in all-cause mortality (relative risk [RR] 0.69; 95% confidence interval [CI] 0.46 to 1.05), but was associated with significant risk reductions in heart failure (RR 0.73; 95% CI 0.54 to 1.00) and reinfarction (RR 0.58; 95% CI 0.35 to 0.97) when compared with conservative treatment. Rescue PCI was associated with an increased risk of stroke (RR 4.98; 95% CI 1.10 to 22.5) and minor bleeding (RR 4.58; 95% CI 2.46 to 8.55). Repeat fibrinolytic therapy was not associated with significant improvements in all-cause mortality (RR 0.68; 95% CI 0.41 to 1.14) or reinfarction (RR 1.79; 95% CI 0.92 to 3.48), but was associated with an increased risk for minor bleeding (RR 1.84; 95% CI 1.06 to 3.18).
CONCLUSIONS: Rescue PCI is associated with improved clinical outcomes for STEMI patients after failed fibrinolytic therapy, but these benefits must be interpreted in the context of potential risks. On the other hand, repeat fibrinolytic therapy is not associated with significant clinical improvement and may be associated with increased harm.
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Abbreviations and Acronyms
| | CI = confidence interval | | NNT = number needed to treat | | PCI = percutaneous coronary intervention | | RR = relative risk | | STEMI = ST-segment elevation myocardial infarction | | TIMI = Thrombolysis In Myocardial Infarction |
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