Early angiography and angioplasty following thrombolytic therapy of acute myocardial infarction. Metaanalysis of the randomized control trials.
OBJECTIVE
There have been at least 10 randomized control trials (RCTs) of early intervention in patients with acute myocardial infarction published, and all are inconclusive with regard to impact on mortality. Metaanalysis offers an opportunity to assess the efficacy of an early intervention following thrombolytic therapy in the treatment of acute myocardial infarction.


METHODS
Data on the number of patients who died in the hospital, and the total number of patients randomized to aggressive versus conservative therapies, were drawn from 9 publications and combined using both a fixed and a random-effects metaanalysis model. Quality of the trials was assessed under blinded conditions.


METHODS
The 10 RCTs to be combined were each carried out in individual institutions.


METHODS
A total of 5882 patients have been randomized, with 305 deaths (5.2%), indicating that this group of patients had a relatively low mortality rate compared to patients in general with acute myocardial infarction. COMPARISON OF TREATMENTS: No matter how the 10 trials were combined for analysis, there was no evidence that aggressive intervention was trending towards saving lives. Data on other endpoints such as need for repeat percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass grafting (CABG), or recurrent myocardial infarction were sparse, but the same adverse trend was apparent.


CONCLUSIONS
In spite of the fact that early angiography and PTCA when indicated have been advocated for more than a decade, there is still no evidence that they reduce overall mortality after fibrinolysis in a specific subgroup. Further studies of early intervention should be done in an effort to answer subgroup questions which include the search for appropriate timing and patient selection for PTCA after fibrinolysis. As more RCTs with mortality data are published they will be added to these metaanalyses in The Online Journal of Current Clinical Trials.
Jovell
A J
AJ
Technology Assessment Group, Harvard School of Public Health, Boston, MA 02115.
Lau
J
J
Berkey
C
C
Kupelnick
B
B
Chalmers
T C
TC
D015906:Angioplasty, Balloon, Coronary; D003131:Combined Modality Therapy; D017023:Coronary Angiography; D017052:Hospital Mortality; D006801:Humans; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D015912:Thrombolytic Therapy; D013997:Time Factors