title: Consistency of benefit from an early invasive strategy after fibrinolysis: a patient-level meta-analysis.
abstract: BACKGROUND
  Randomised controlled trials have demonstrated improved outcomes with an early invasive strategy compared with routine care after fibrinolysis among patients with ST-elevation myocardial infarction. However, it remains uncertain whether specific patient subsets derive differential benefit from an early invasive strategy.
  
  
  METHODS
  Using patient-level data from seven randomised trials, we studied the relationship between treatment assignment (early invasive vs standard care) and adverse cardiovascular events. The outcomes assessed were death/reinfarction at 30 days and at 1 year, as well as death/reinfarction/recurrent ischaemia, major bleeding and stroke at 30 days. The analyses were conducted in strata (age, sex, diabetes, prior infarction, Killip class, anterior infarction and time from symptom onset to fibrinolysis) to assess for an interaction between the stratifying variable and treatment assigned.
  
  
  RESULTS
  There were 101 deaths and 115 recurrent infarctions at 30 days in 3010 patients. There were no strata where an invasive strategy conferred a differential treatment effect. With the exception of a marginally significant interaction between Killip class and treatment for death/reinfarction at 30 days and 1 year (p values for interaction 0.044 and 0.038, respectively), no interactions between the stratifying variables and treatment assignment were observed.
  
  
  CONCLUSIONS
  Benefit from an early invasive strategy after fibrinolysis for ST-elevation myocardial infarction is similar across patient subgroups stratified by these clinical characteristics. Therefore, prediction of risk and benefit from an early invasive strategy after fibrinolysis for ST-elevation myocardial infarction is best achieved by global risk evaluation rather than specific patient characteristics.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada Division of Cardiology, Women's College Hospital, Toronto, Ontario, Canada.
authors.forename: Husam
authors.initials: H
authors.lastname: Abdel-Qadir
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada Division of Cardiology, Terrence Donnelly Heart Centre, St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
authors.affiliation: Canadian Heart Research Centre, Toronto, Ontario, Canada.
authors.forename: Mary
authors.initials: M
authors.lastname: Tan
authors.affiliation: Federico II University, Naples, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Borgia
authors.affiliation: University of Salerno, University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: Piscione
authors.affiliation: NIHR Cardiovascular BRU, Royal Brompton Hospital & NHLI Imperial College, London, UK.
authors.forename: Carlo
authors.initials: C
authors.lastname: Di Mario
authors.affiliation: Oslo University Hospital Ulleval, Oslo, Norway.
authors.forename: Sigrun
authors.initials: S
authors.lastname: Halvorsen
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada Southlake Regional Health Centre, Newmarket, Ontario, Canada.
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Cantor
authors.affiliation: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Westerhout
authors.affiliation: Innere Medizin III, Universitat des Saarlandes, Homburg, Germany.
authors.forename: Bruno
authors.initials: B
authors.lastname: Scheller
authors.affiliation: University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
authors.forename: Michel R
authors.initials: MR
authors.lastname: Le May
authors.affiliation: Hospital General Universitario Gregorio Marañón, Madrid, Spain.
authors.forename: Francisco
authors.initials: F
authors.lastname: Fernandez-Aviles
authors.affiliation: Hospital Universitario Salamanca-IBSAL, Salamanca, Spain.
authors.forename: Pedro L
authors.initials: PL
authors.lastname: Sánchez
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Lee
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada Division of Cardiology, Terrence Donnelly Heart Centre, St. Michael's Hospital, Toronto, Ontario, Canada Canadian Heart Research Centre, Toronto, Ontario, Canada Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
mesh_terms: D000368:Aged; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D016017:Odds Ratio; D018579:Patient Selection; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000139:chemically induced; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents