Revascularization strategies in acute myocardial infarction: a meta-analysis.
OBJECTIVE
Many treatments and procedures have been tested to reduce complications after myocardial infarction. Our objective was to assess in this clinical situation the best evidence-based medicine revascularization strategy including the most recently developed interventions such as thrombolysis, angioplasty, stent implantation and glycoprotein IIb/IIIa (GpIIb/IIIa) antagonists.


METHODS
We performed the meta-analyses of randomized controlled trials by testing the addition of a stent to primary angioplasty, the addition of GpIIb/IIIa antagonists to primary angioplasty, the addition of GpIIb/IIa antagonists to primary angioplasty + stent and finally addition of GpIIb/IIIa antagonists to thrombolytics. The primary outcome was the combined endpoint of death or myocardial infarction or urgent revascularization at 1 month.


RESULTS
The combined endpoint was significantly reduced by 31% (95% CI: 11% - 47%) at 30 days when stent was added to primary angioplasty. GpIIb/IIIa blockers provided an additional benefit by reducing the combined criteria by 50% (95% CI: 27% - 66%) in patients who underwent primary angioplasty, and by 42% (95% CI: 16% - 60%) when associated with angioplasty and stent implantation. Administration of GpIIb/IIIa in addition to thrombolytics, aspirin and heparin was associated with a significant reduction in the combined criteria by 17% (95% CI: 10% - 23%) and a significant excess of major bleeding by 69% (95% CI: 38% - 109%). However, the risk/benefit ratio indicates that patients with this association should be treated with the corresponding doses used in these trials.


CONCLUSIONS
In acute myocardial infarction, stent implantation provides therapeutic benefit when added to primary angioplasty. The addition of GpIIb/IIIa blockers appears to provide further benefit if bleeding complications are minimized.
Bouzamondo
A
A
Pharmacology Department, Pitié-Salpêtrière Hospital, Paris, France. anissa.bouzamondo@psl.ap-hop-paris.fr
Damy
T
T
Montalescot
G
G
Lechat
P
P
D000800:Angioplasty, Balloon / Q000379:methods; D000925:Anticoagulants / Q000627:therapeutic use; D003131:Combined Modality Therapy; D006801:Humans; D009203:Myocardial Infarction / Q000601:surgery / Q000628:therapy*; D009204:Myocardial Revascularization / Q000379:methods*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D016032:Randomized Controlled Trials as Topic; D015607:Stents; D015912:Thrombolytic Therapy
D000925:Anticoagulants; D019039:Platelet Glycoprotein GPIIb-IIIa Complex