A systematic review 1 including 15 studies with a total of 5253 subjects was abstracted in DARE. A meta-analysis of randomized trials that enrolled ST-segment elevation myocardial infarction patients treated with fibrinolysis was performed to assess the potential benefits of: 1) rescue PCI (less than 12 hours after failed fibrinolysis) versus no PCI after failed fibrinolysis (5 studies, n=920); 2) systematic and early (within 24 hours) PCI, regardless of success of fibrinolysis, versus delayed or ischemia-guided PCI (6 studies, n=1507); 3) fibrinolysis-facilitated PCI (with less than 6 hours delay between fibrinolysis and PCI) versus primary PCI alone (4 studies, n=2679). The included studies were conducted during the 'stent era' (stenting rate greater than 25%) and the 'balloon era'. In studies evaluating systematic and early angioplasty conducted in the 'stent era', aspirin and thienopyridines were given to more than 80% of patients receiving early PCI and glycoprotein IIb/IIIa receptor antagonists were given to between 10 and 30% of patients. The duration of follow-up in the included studies ranged from hospital stay to 1 year.
Rescue PCI for failed fibrinolysis reduced mortality (6.9% vs. 10.7%; OR 0.63, 95% CI 0.39 to 0.99) and the rate of death or reinfarction (10.8% vs. 16.8%; OR 0.60 95% CI 0.41 to 0.89) but increased major bleeding (11.9% vs. 1.3%; OR 9.05, 95% CI 3.71 to 22.06). Bleeding most commonly (82%) originated in the femoral sheath and no cases were fatal. Systematic and early PCI performed during the "stent era" led to a nonsignificant reduction in mortality compared with delayed or ischemia-guided PCI (3.8% vs. 6.7%; OR 0.56, 95% CI 0.29 to 1.05), to a 2-fold reduction in the rate of death or reinfarction (7.5% vs. 13.2%; OR 0.53 95% CI 0.33 to 0.83), and no significant increase in major bleeding (OR 1.18, 95% CI 0.60 to 2.30). This benefit contrasted with a nonsignificant increase in the rate of both mortality (5.5% vs. 3.9%, p = 0.33) or death or reinfarction (9.6% vs. 5.7%, p = 0.06) observed in the "balloon era." Fibrinolysis-facilitated PCI was associated with more reinfarction as compared with primary PCI alone (5.0% vs. 3.0%; OR 1.68, 95% CI 1.12 to 2.51) without significant impact on mortality (OR 1.30, 95% CI 0.92 to 1.83). There was no significant difference between strategies in the risk of major bleeding (OR 1.23, 95% CI 0.74 to 2.05).
Comment: The quality of evidence is downgraded by limitations in the review quality (study quality was not assessed).
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