QJM Advance Access published online on February 19, 2008
QJM, doi:10.1093/qjmed/hcn018
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Repeat thrombolysis or conservative therapy vs. rescue percutaneous coronary intervention for failed thrombolysis: systematic review and meta-analysis
From the 1Institute of Cardiology, John Radcliffe Hospital, Oxford, UK, 2Division of Cardiology, University of Turin, Turin, Italy, 3Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA and 4Antwerp Cardiovascular Institute Middelheim, AZ Middelheim, Antwerp, Belgium
Address correspondence to Dr Luca Testa, MD, Interventional Cardiology Fellow at John Radcliffe Hospital, Oxford, UK, Fellow of the European Association of Percutaneous Coronary Intervention Research Fellow in Molecular Biology at Policlinico Gemelli, Institute of Cardiology, Rome, Italy. Work Address: Cardiology Ward, level 2, John Radcliffe Hospital, Headley Way, Hoxford, OX3 9DU, UK. email: luctes{at}gmail.com
Received 9 December 2007 and in revised form 18 January 2008
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Abstract |
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Background: Despite proven advantages of primary percutaneous coronary intervention (PCI), thrombolysis remains the first line treatment for ST-elevation myocardial infarction (STEMI) worldwide. Management of patients with failed thrombolysis is still debated, and data from existing randomized controlled trials are conflicting.
Aim: To compare the risk/benefit profile of repeat thrombolysis (RT) vs. rescue PCI in patients with failed thrombolysis.
Methods: Search of BioMedCentral, CENTRAL, mRCT and PubMed for randomized controlled trials comparing rescue PCI vs. conservative therapy and/or RT vs. conservative therapy. Outcomes of interest assessed by adjusted indirect meta-analysis: major adverse events (MAE, defined as the composite of overall mortality and re-infarction), stroke, congestive heart failure (CHF), major bleeds (MB), and minor bleeds. Overall mortality and re-infarction have been also analysed individually.
Results: Eight trials were included (1318 patients). Follow-up ranged from ‘in-hospital’ to 6 months. No significant difference was found for the risk of MAE [OR 0.93(0.26–3.35), P = 0.4], overall mortality [OR 1.01(0.52–1.95), P = 0.15], stroke [OR 5.03(0.64–39.1), P = 0.58] and CHF [OR 0.74(0.28–1.96), P = 0.6]. Compared with conservative therapy, rescue PCI was associated with a 70% reduction in the risk of re-infarction [OR 0.32(0.14–0.74), P = 0.008], number needed to treat 17. No difference in terms of MB was found [OR 0.5(0.1–2.5), P = 0.09], while a greater risk of minor bleeds was observed with rescue PCI [OR 2.48(1.08–5.7), P = 0.04], number needed to harm 50.
Conclusion: Although the observed benefit is modest, these data support the use of PCI after failed thrombolysis.