title: Role of routine early angiography post-fibrinolysis for ST elevation myocardial infarction--a meta-regression analysis using angiography rate in the non-routine arm.
abstract: BACKGROUND
  The current European and American Guidelines differ with regard to the recommended level for the use of routine early angiography after fibrinolysis for STEMI. Previous meta-analyses on randomized controlled trials have supported the routine early approach, but its advantage may be because of an excessively low angiography rate among patients in the non-routine strategy arm of the trials.
  
  
  METHODS
  We update the meta-analysis and apply meta-regression to evaluate whether the difference in outcome between the 2 randomized arms could be explained by the angiography rates in the non-routine strategy arm. Because reinfarction and recurrent ischemia are often the reported indication for angiography, we only use mortality endpoint in our meta-regression analysis.
  
  
  RESULTS
  Among the eight trials included with 3195 patients, the angiography rate in the non-routine strategy arms ranges from 15% to 100%. The overall odds ratio for 30-day mortality comparing the routine early angiography arm vs the non-routine arm is 0.86 (95% confidence interval 0.60-1.24). On the plot listing the eight trials according to angiography rates, there is no visual trend in the odds ratio estimates for mortality when comparing the 2 treatment strategies as angiography rate decreases. In meta-regression analysis, angiography rate does not predict 30-day mortality (p=0.461).
  
  
  CONCLUSIONS
  For STEMI, mortality endpoint trumps the softer endpoints of recurrent infarction and ischemia. The current study shows that the equipoise between the routine early invasive versus the non-routine strategy on 30-day mortality cannot be explained by the variable performance of angiography in the non-routine strategy arm.
authors.affiliation: Department of Cardiology, Dunedin School of Medicine, University of Otago, Dunedin Public Hospital, Dunedin, New Zealand. cheuk-kit.wong@healthotago.co.nz
authors.forename: Cheuk-Kit
authors.initials: CK
authors.lastname: Wong
authors.forename: Sophia
authors.initials: S
authors.lastname: Leon de la Barra
authors.forename: Peter
authors.initials: P
authors.lastname: Herbison
mesh_terms: D002986:Clinical Trials as Topic / Q000379:methods; D017023:Coronary Angiography / Q000379:methods*; D005342:Fibrinolysis / Q000187:drug effects / Q000502:physiology; D006801:Humans; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000628:therapy; D012044:Regression Analysis; D013997:Time Factors; D016896:Treatment Outcome