TY - JOUR
T1 - Comparison of reperfusion strategies for st-segment–elevation myocardial infarction
T2 - A multivariate network meta-analysis
AU - Fazel, Reza
AU - Joseph, Timothy I.
AU - Sankardas, Mullasari A.
AU - Pinto, Duane S.
AU - Yeh, Robert W.
AU - Kumbhani, Dharam J.
AU - Nallamothu, Brahmajee K.
N1 - Funding Information:
Dr Yeh receives grant support from Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic and has served as a consultant to Abbott Vascular, AstraZeneca, Boston Scientific and Medtronic.
Publisher Copyright:
© 2020, American Heart Association Inc.. All rights reserved.
PY - 2020/6/16
Y1 - 2020/6/16
N2 - BACKGROUND: We systematically reviewed trials comparing different reperfusion strategies for ST-segment–elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. METHODS AND RESULTS: We identified 31 contemporary trials in which patients with ST-segment–elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as “facilitated PCI” when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a “pharmacoinvasive approach” when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61–0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59–1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. CONCLUSIONS: A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment–elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment–elevation myocardial infarction, is not available.
AB - BACKGROUND: We systematically reviewed trials comparing different reperfusion strategies for ST-segment–elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. METHODS AND RESULTS: We identified 31 contemporary trials in which patients with ST-segment–elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as “facilitated PCI” when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a “pharmacoinvasive approach” when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61–0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59–1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. CONCLUSIONS: A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment–elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment–elevation myocardial infarction, is not available.
KW - Facilitated percutaneous coronary intervention
KW - Fibrinolytic therapy
KW - Pharmacoinvasive approach
KW - Primary percutaneous coronary intervention
KW - ST-segment–elevation myocardial infarction
UR - http://www.scopus.com/inward/record.url?scp=85086525545&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85086525545&partnerID=8YFLogxK
U2 - 10.1161/JAHA.119.015186
DO - 10.1161/JAHA.119.015186
M3 - Review article
C2 - 32500800
AN - SCOPUS:85086525545
SN - 2047-9980
VL - 9
JO - Journal of the American Heart Association
JF - Journal of the American Heart Association
IS - 12
M1 - e015186
ER -