Immediate angioplasty after thrombolysis: a systematic review

Abstract

Background: The role of immediate transfer for percutaneous coronary intervention (PCI) after thrombolysis for ST-segment elevation myocardial infarction remains controversial. We performed a systematic review of the related literature to determine whether thrombolysis followed by transfer for immediate or early PCI is safe, feasible and superior to conservative management.

Methods: A systematic literature search of MEDLINE, EMBASE, the Cochrane Database for Systematic Reviews and Cochrane Central Register of Controlled Trials, and the American Heart Association EndNote 7 Master Library databases, was performed to 2004 for relevant published studies. The level of evidence and the quality of the study design and methods were rated by 2 reviewers according to a standardized classification. A quantitative meta-analysis was performed to assess the effect at 6-12 months on mortality of immediate or early PCI after thrombolysis.

Results: We found 13 articles that were supportive of immediate or early PCI after thrombolysis and 16 that were neutral or provided evidence opposing it. The largest randomized trials and meta-analyses showed no benefit of routine PCI immediately or shortly after thrombolysis. The studies that were supportive were generally more recent and more frequently involved coronary stents. One large trial supported early PCI after thrombolysis for patients with myocardial infarction complicated by cardiogenic shock. Overall, the difference in mortality rates between the invasive strategy and conservative care was nonsignificant. The 3 stent-era trials showed a significantly lower mortality among patients randomly assigned to the invasive strategy (5.8% v. 10.0%, odds ratio 0.55, 95% confidence interval 0.32-0.92). Analysis of variance found a significant difference in treatment effect between stent-era and pre-stent-era trials.

Interpretation: At present, there is inadequate evidence to recommend routine transfer of patients for immediate or early PCI after successful thrombolysis. Results of recent trials using contemporary PCI techniques, including coronary stents, appear more favourable but need to be confirmed in large randomized trials, which are currently in progress. Transfer for immediate PCI is recommended for patients with cardiogenic shock, hemodynamic instability or persistent ischemic symptoms after thrombolysis.

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Fig. 1: Literature-search flow chart. DSR = Database for Systematic Reviews, CRCT = Cochrane Central Register of Controlled Trials, AHA = American Heart Association, PCI = percutaneous coronary intervention.

Fig. 3: Forest plot of odds ratios for combined death and myocardial reinfarction within 12 months (6 months, in the SIAM-3 trial). This plot shows a fixed-model analysis; similar numbers from a random-model analysis are included in an online version of Fig. 3 (available at www.cmaj.ca/cgi/content/full/173/12/1473/DC3).

Fig. 2: Forest plot of odds ratios for death within 12 months (6 months, in the SIAM-3 trial). This plot shows a fixed-model analysis; similar numbers from a random-model analysis are included in an online version of Fig. 2 (available at www.cmaj.ca/cgi/content/full/173/12/1473/DC3).