title: Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis.
abstract: BACKGROUND
  Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered.
  
  
  OBJECTIVE
  To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships.
  
  
  METHODS
  A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (CrI)) as a function of the additional time delay associated with angioplasty.
  
  
  RESULTS
  22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean (SE) angioplasty-related time delay (over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis (OR = 0.68 (95% CrI 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 (95% CrI 0.20 to 0.51); for non-fatal stroke OR = 0.24 (95% CrI 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation.
  
  
  CONCLUSIONS
  The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1-month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.
authors.affiliation: Centre for Health Economics, University of York, Heslington, York, UK.
authors.forename: Christian
authors.initials: C
authors.lastname: Asseburg
authors.forename: Yolanda Bravo
authors.initials: YB
authors.lastname: Vergel
authors.forename: Stephen
authors.initials: S
authors.lastname: Palmer
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Fenwick
authors.forename: Mark
authors.initials: M
authors.lastname: de Belder
authors.forename: Keith R
authors.initials: KR
authors.lastname: Abrams
authors.forename: Mark
authors.initials: M
authors.lastname: Sculpher
mesh_terms: D017130:Angioplasty / Q000401:mortality / Q000592:standards*; D001499:Bayes Theorem; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D016017:Odds Ratio; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents