Elsevier

American Heart Journal

Volume 156, Issue 3, September 2008, Pages 564-572.e2
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
An early invasive strategy versus ischemia-guided management after fibrinolytic therapy for ST-segment elevation myocardial infarction: A meta-analysis of contemporary randomized controlled trials

https://doi.org/10.1016/j.ahj.2008.04.024Get rights and content

Background

Although the use of an early invasive strategy among patients with ST-segment elevation myocardial infarctions (STEMI) who are treated initially with fibrinolytic therapy is common, the safety and efficacy of this approach remains uncertain. We performed a meta-analysis to best estimate the benefits and harms of an early invasive strategy in STEMI patients treated initially with full-dose intravenous fibrinolytic therapy, as compared to a traditional strategy of ischemia-guided management.

Methods

We included contemporary randomized controlled trials, defined a priori as those with >50% stent use during percutaneous coronary intervention (PCI). Outcomes extracted from the published results of eligible trials included all-cause mortality, reinfarction, stroke, and in-hospital major bleeding.

Results

We identified 5 contemporary trials enrolling 1,235 patients who met our inclusion criteria. Of the patients randomized to an early invasive strategy, 86% underwent PCI with 87% receiving stents. Follow-up duration ranged from 30 days to 1 year. An early invasive strategy was associated with significant reductions in mortality (odds ratio [OR] 0.55, 95% CI 0.34-0.90) and reinfarction (OR 0.53, 95% CI 0.33-0.86) compared with ischemia-guided management. There were no significant differences in the risk of stroke (OR 1.31, 95% CI 0.42-4.10) or major bleeding (OR 1.41, 95% CI 0.74-2.69).

Conclusions

An early invasive strategy after fibrinolytic therapy is associated with significant reductions in mortality and reinfarction. Our results suggest a potentially important role for this strategy in the management of STEMI patients but should be confirmed by large randomized trials.

Section snippets

Data sources

Relevant published studies were identified through a computerized literature search of the Cochrane library, Embase, and Medline electronic databases from January 1950 to February 2007, using the key words angioplasty, stent, myocardial infarction, thrombolytic therapy, and fibrinolytic therapy (Figure 1). In addition, bibliographies of journal articles and relevant reviews were extensively hand-searched to locate additional studies.

Study selection

Two investigators (H.C.W., J.J.Y.) independently evaluated

Study selection

The process of study selection and exclusion is outlined in Figure 1. We found 20 relevant articles of which we excluded 1 study that assessed only intracoronary fibrinolytic therapy10 and 1 study of combination half-dose fibrinolytic therapy with a glycoprotein GpIIb/IIIa receptor (Gp2b/3a) inhibitor.11 Of the remaining articles, there were 13 randomized trials of balloon angioplasty12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 5 contemporary PCI trials.25, 26, 27, 28, 29 All of the

Discussion

In this systematic review of contemporary treatment strategies among STEMI patients treated with fibrinolytic therapy, we found that an early invasive strategy was associated with significant reductions in the risk of death and reinfarction, as compared to a strategy of ischemia-guided management. Furthermore, we did not find a significantly increased risk of stroke or major bleeding associated with an early invasive strategy; however, given that the CIs around these safety estimates were

References (34)

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Dr. Wijeysundera is supported by a University of Toronto, Department of Medicine Clinician Scientist Training Program, and a research fellowship award from the Canadian Institute of Health Research (CIHR) (Ottawa, Ontario, Canada). Dr. You is supported by a McMaster University Department of Medicine Internal Career Research Award. Dr. Ko is supported by a Heart and Stroke Foundation of Ontario Clinician Scientist Award. This project is funded in part by a CIHR operating grant.

Dr. Warren Cantor has received consulting fees, speaker's honoraria, and unrestricted research grants from Hoffman La Roche Canada (Montreal, Quebec, Canada).

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