Abstract 5488: Comparison of Primary With Fibrinolytic-based Facilitated PCI and Comparison of Fibrinolytic-based PCI With Fibrinolysis Followed by Standard Care for STEMI: Updated Quantitative Review of Randomized Trials
Background: Facilitated PCI for STEMI is defined as the use of pharmacological substances before a planned immediate intervention (< 3h), to improve coronary patency. We undertook an updated meta-analysis of randomized controlled trials to compare
fibrinolytic-based facilitated and primary PCI and
fibrinolytic-based facilitated PCI and fibrinolysis followed by standard care.
Methods: We identified 12 trials of patients with STEMI assigned to
facilitated (n=2498) or primary (n=2488) PCI and
8 trials with comparison facilitated PCI (n=969) vs fibrinolysis with standard care (n=955).
Outcomes of death, stroke, non-fatal reinfarction, urgent TVR, and major bleeding were assessed.
Results: The facilitated approach resulted in a greater than two-fold increase in the number of patients with initial TIMI-3-flow compared with primary PCI approach (p<0.001); however, final rates did not differ (p=n.s.). Significantly more patients assigned to facilitated PCI than those assigned to primary PCI died (5.3% vs 3.9%; RR 1.36; 95% CI 1.04; 1.77; p=0.02), had higher non-fatal reinfarction rates (3.3% vs 1.7%; RR 1.99; 95% CI 1.36; 2.92; p<0.001), higher urgent TVR rates (3.3% vs 1.3%; RR 2.48; 95% CI 1.57; 3.97; p<0.001), and higher stroke rates (1.3% vs 0.5%; RR 2.76; 95% CI 1.38; 5.64; p=0.002). Facilitated PCI was also associated with higher rates of major bleeding (6.4% vs 3.9%; RR 1.62 95% CI 1.26; 2.09; p<0.001). In the 2nd comparison, facilitated PCI did not result in a mortality difference (5.1% vs 5.7%; RR 0.89; 95% CI 0.60; 1.33; p=0.63) and no difference in non-fatal reinfarction (4.2% vs 5.2%; RR 0.81; 95% CI 0.52; 1.25; p=0.37). However, there was a difference in non-fatal reinfarction in the stenting era (4.0% vs 7.0%; RR 0.57; 95% CI 0.34; 0.95; p=0.03). There was no difference in major bleeding and stroke in the comparison of facilitated PCI vs fibrinolysis with standard care.
Conclusions: Fibrinolytic-based facilitated PCI has substantial harm in comparison to primary PCI. In comparison to fibrinolysis with standard care facilitated PCI leads to a small reduction in reinfarction but has no beneficial effect on mortality. A strategy of primary PCI should therefore be implemented for all STEMI patients.