Percutaneous coronary intervention after fibrinolysis: a multiple meta-analyses approach according to the type of strategy.
OBJECTIVE
We performed a meta-analysis of randomized trials that enrolled ST-segment elevation myocardial infarction patients treated with fibrinolysis to assess the potential benefits of: 1) rescue percutaneous coronary intervention (PCI) versus no PCI; 2) systematic and early (< or =24 h) PCI versus delayed or ischemia-guided PCI; 3) fibrinolysis-facilitated PCI versus primary PCI alone.


BACKGROUND
The impact of PCI strategies after fibrinolysis on mortality or reinfarction remains to be established.


METHODS
The meta-analysis was performed using the odds ratio (OR) as the parameter of efficacy with a random effect model. Fifteen randomized trials (5,253 patients) were selected. The primary end point was mortality or the combined end point of death or reinfarction.


RESULTS
Rescue PCI for failed fibrinolysis reduced mortality (6.9% vs. 10.7%) (OR, 0.63; 95% confidence interval [CI], 0.39 to 0.99; p = 0.055) and the rate of death or reinfarction (10.8% vs. 16.8%) (OR, 0.60; 95% CI, 0.41 to 0.89; p = 0.012) compared with a conservative approach. Systematic and early PCI performed during the "stent era" led to a nonsignificant reduction in mortality compared with delayed or ischemia-guided PCI (3.8% vs. 6.7%) (OR, 0.56; 95% CI, 0.29 to 1.05; p = 0.07) and to a 2-fold reduction in the rate of death or reinfarction (7.5% vs. 13.2%) (OR, 0.53; 95% CI, 0.33 to 0.83; p = 0.0067). This benefit contrasted with a nonsignificant increase in the rate of both mortality (5.5% vs. 3.9%, p = 0.33) or death or reinfarction (9.6% vs. 5.7%, p = 0.06) observed in the "balloon era." Fibrinolysis-facilitated PCI was associated with more reinfarction as compared with primary PCI alone (5.0% vs. 3.0%) (OR, 1.68; 95% CI, 1.12 to 2.51; p = 0.013) without significant impact on mortality (OR, 1.30; 95% CI, 0.92 to 1.83; p = 0.13).


CONCLUSIONS
Our findings support rescue PCI and systematic and early PCI after fibrinolysis. However, the current data do not support fibrinolysis-facilitated PCI in lieu of primary PCI alone.
Collet
Jean-Philippe
JP
Pitié-Salpêtrière University Hospital, Paris, France.
Montalescot
Gilles
G
Le May
Michel
M
Borentain
Maria
M
Gershlick
Anthony
A
D015906:Angioplasty, Balloon, Coronary; D003327:Coronary Disease / Q000150:complications / Q000628:therapy*; D005342:Fibrinolysis; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality*; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D013997:Time Factors; D017211:Treatment Failure