Prehospital fibrinolysis versus primary percutaneous coronary intervention in ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI), but its benefit over prehospital fibrinolysis (FL) is not clear.


METHODS
We performed a systematic review and meta-analysis of randomized controlled trials in which outcomes of patients with STEMI managed with FL early in the prehospital setting versus PPCI were compared.


RESULTS
Compared with PPCI, FL was consistently associated with similar rates of short-term (30-90 days) death (relative risk [RR] 0.94, 95 % CI 0.67-1.31) and cardiovascular death (RR 0.95, 95 % CI 0.64-1.4), a decreased risk of cardiogenic shock (RR 0.67, 95 % CI 0.48-0.95), and an increased risk of any stroke (RR 3.57, 95 % CI 1.39-9.17) and hemorrhagic stroke (RR 4.37, 95 % CI 1.25-15.26). FL was also associated with similar rates of 1-year mortality (RR 1.01, 95 % CI 0.75-1.34) and major bleeding (RR 1.31, 95 % CI 0.96-1.78) in comparison with PPCI, but with a notable level (I2index 30.5 % and 59.8 %) of heterogeneity among studies.


CONCLUSIONS
Our study suggests that, compared with PPCI, FL performed in the early prehospital setting is associated with similar mortality rates, lower rates of cardiogenic shock, and higher rates of stroke in patients with STEMI. Although the number of studies comparing the two strategies is relatively low, our results support prehospital FL and transfer to hub percutaneous coronary intervention (PCI) centers as a valid alternative to PPCI, allowing potential limitation of resources allocated to developing proximity 24/7 PCI facilities.
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France. roule-v@chu-caen.fr.
Vincent
V
Roule
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Pierre
P
Ardouin
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Katrien
K
Blanchart
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Adrien
A
Lemaitre
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Julien
J
Wain-Hobson
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Damien
D
Legallois
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Joachim
J
Alexandre
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Rémi
R
Sabatier
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Paul
P
Milliez
Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
Farzin
F
Beygui
D004632:Emergency Medical Services / Q000379:methods* / Q000639:trends; D005342:Fibrinolysis / Q000187:drug effects / Q000502:physiology; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D009026:Mortality / Q000639:trends; D062645:Percutaneous Coronary Intervention / Q000379:methods* / Q000401:mortality / Q000639:trends; D016032:Randomized Controlled Trials as Topic / Q000379:methods*; D000072657:ST Elevation Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome
D005343:Fibrinolytic Agents
Fibrinolysis; Mortality; Prehospital; Primary percutaneous coronary intervention; Stroke