Abstract 12582: Routine Early Invasive Strategy After Thrombolysis Does Not Reduce Mortality in Patients With ST-segment Elevation Myocardial Infarction: a Meta-analysis of Randomized Clinical Trials
Background: Timely primary percutaneous coronary intervention reduces mortality compared to thrombolysis and is the preferred treatment for ST-segment elevation myocardial infarction (STEMI), but in the real world many patients are still treated with thrombolysis. Routine early invasive strategy (pharmacoinvasive) after thrombolysis is advocated based on improvement of the composite endpoint of death, reinfarction and recurrent ischemia. It is unclear if this strategy reduces mortality. We performed a meta-analysis of randomized clinical trials to evaluate the effect of pharmacoinvasive strategy on the individual endpoints of mortality, reinfarction and recurrent ischemia.
Methods: We searched MEDLINE database for studies comparing pharmacoinvasive vs. conventional (ischemia-guided) strategy after thrombolysis for STEMI. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for the respective outcomes using a random effects model.
Results: Six trials involving 2,755 patients (1,383 pharmacoinvasive and 1,372 conventional) were included. Median time from thrombolysis to PCI was 199 minutes. Based on the pooled estimate across the studies, pharmacoinvasive strategy did not reduce total mortality at either 30 days or 6 months compared to conventional strategy (OR=0.92, 95% CI 0.61–1.38, p=0.68 and OR=0.84, 95% CI 0.54–1.33, p=0.46, respectively), despite a significant decrease in 30-day and 6-month rates of reinfarction (OR=0.55, 95% CI 0.35–0.85, p=0.007 and OR=0.53, 95% CI 0.36–0.79, p=0.002, respectively) and recurrent ischemia (OR=0.23, 95% CI 0.11–0.47, p<0.0001 and OR=0.45, 95% CI 0.23–0.88, p=0.02, respectively). No significant heterogeneity was found, except for 6-month recurrent ischemia.
Conclusions: Pharmacoinvasive strategy did not reduce short- and mid-term mortality, despite a significant reduction of reinfarction and recurrent ischemia. Larger mortality-driven trials are needed to address this issue.
- © 2010 by American Heart Association, Inc.