Repeat thrombolysis or conservative therapy vs. rescue percutaneous coronary intervention for failed thrombolysis: systematic review and meta-analysis.
BACKGROUND
Despite proven advantages of primary percutaneous coronary intervention (PCI), thrombolysis remains the first line treatment for ST-elevation myocardial infarction (STEMI) worldwide. Management of patients with failed thrombolysis is still debated, and data from existing randomized controlled trials are conflicting.


OBJECTIVE
To compare the risk/benefit profile of repeat thrombolysis (RT) vs. rescue PCI in patients with failed thrombolysis.


METHODS
Search of BioMedCentral, CENTRAL, mRCT and PubMed for randomized controlled trials comparing rescue PCI vs. conservative therapy and/or RT vs. conservative therapy. Outcomes of interest assessed by adjusted indirect meta-analysis: major adverse events (MAE, defined as the composite of overall mortality and re-infarction), stroke, congestive heart failure (CHF), major bleeds (MB), and minor bleeds. Overall mortality and re-infarction have been also analysed individually.


RESULTS
Eight trials were included (1318 patients). Follow-up ranged from 'in-hospital' to 6 months. No significant difference was found for the risk of MAE [OR 0.93(0.26-3.35), P = 0.4], overall mortality [OR 1.01(0.52-1.95), P = 0.15], stroke [OR 5.03(0.64-39.1), P = 0.58] and CHF [OR 0.74(0.28-1.96), P = 0.6]. Compared with conservative therapy, rescue PCI was associated with a 70% reduction in the risk of re-infarction [OR 0.32(0.14-0.74), P = 0.008], number needed to treat 17. No difference in terms of MB was found [OR 0.5(0.1-2.5), P = 0.09], while a greater risk of minor bleeds was observed with rescue PCI [OR 2.48(1.08-5.7), P = 0.04], number needed to harm 50.


CONCLUSIONS
Although the observed benefit is modest, these data support the use of PCI after failed thrombolysis.
Testa
L
L
Institute of Cardiology, John Radcliffe Hospital, Oxford, UK. luctes@gmail.com
van Gaal
W J
WJ
Biondi-Zoccai
G G L
GG
Abbate
A
A
Agostoni
P
P
Bhindi
R
R
Banning
A P
AP
D015906:Angioplasty, Balloon, Coronary / Q000379:methods* / Q000592:standards; D006801:Humans; D009203:Myocardial Infarction / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D019233:Retreatment; D013223:Statistics as Topic; D015912:Thrombolytic Therapy / Q000379:methods* / Q000592:standards