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Abstract
Background Prompt reperfusion following ST segment elevation acute myocardial infarction (STEMI) is pivotal to survival. Primary angioplasty is the gold standard in restoring reperfusion; however, thrombolytic therapy may need to be considered in places where achieving optimal call to balloon is not possible. Following thrombolysis and with evolving pharmacoinvasive therapies, the advantage of immediate percutaneous coronary intervention (PCI) over standard ischaemia-guided PCI remains debatable. We have therefore performed a meta-analysis of recent randomised trials comparing patients receiving thrombolysis transferred for immediate PCI within the first 24 h versus ischaemia-guided PCI.
Methods A Medline search was performed for studies from 1966 to the present, using the search terms “thrombolysis”, “immediate PCI” or “immediate stenting” and from the scientific sessions at the American College of Cardiology and European Society of Cardiology to identify relevant studies. Only randomised control studies were used and meta-analysis was performed using a random effects model. A primary endpoint of 30-day composite of mortality, ischaemia and re-infarction as well as the individual relative risk of mortality, ischaemia, re-infarction and major bleeding was analysed from the hazard ratio (HR).
Results A total of five trials was identified that fulfilled the search criterion (GRACIA, CAPITAL, CARESS, SIAM III and TRANSFER), of which a total of 2667 patients was studied. The combined endpoint of 30-day mortality, ischaemia and re-infarction was reached in 84/1313 (6.4%) patients in the immediate PCI group and 172/1316 (13.1%) patients in the ischaemia-guided PCI group. Meta-analysis of these data demonstrated HR 0.41 (95% CI 0.29 to 0.57; p<0.0001; see fig). This appears to be secondary to significant reductions in both ischaemia with HR 0.17 (95% CI 0.07 to 0.36; p<0.0001) and re-infarction with HR 0.58 (95% CI 0.39 to 0.86; p<0.007) in the immediate PCI group. There were no significant major bleeds with either strategy with HR 1.09 (95% CI 0.70 to 1.61; p = 0.63). There was no difference in the 30-day mortality between the two groups with HR 0.79 (95% CI 0.52 to 1.19; p = 0.29).
Conclusions When primary PCI is not feasible, our study supports the case for immediate PCI within 24 h of thrombolysis for acute STEMI—a strategy that is safe and a time-target easily achievable. In particular, immediate PCI is not associated with an increased risk of major haemorrhagic complications, and given the reduction in recurrence of ischaemic and re-infarction events, is likely to be cost-effective.
PCI, percutaneous coronary intervention.