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Siddiqi TJ, Usman MS, Khan MS, Sreenivasan J, Kassas I, Riaz H, Raza S, Deo SV, Sharif H, Kalra A, Yadav N. Meta-Analysis Comparing Primary Percutaneous Coronary Intervention Versus Pharmacoinvasive Therapy in Transfer Patients with ST-Elevation Myocardial Infarction. Am J Cardiol 2018; 122:542-547. [PMID: 30205885 DOI: 10.1016/j.amjcard.2018.04.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 12/24/2022]
Abstract
ST-elevation myocardial infarction patients presenting at non-percutaneous coronary intervention (PCI)-capable hospitals often need to be transferred for primary percutaneous coronary intervention (PPCI). This increases time to revascularization, leading to increased risk of in-hospital mortality. With recent focus on total ischemic time rather than door-to-balloon time as the principal determinant of outcomes in ST-elevation myocardial infarction patients, pharmacoinvasive therapy (PIT) has gained attention as a possible improvement over PPCI in patients requiring transfer. Our objective was to observe how PIT stands against PPCI in terms of safety and efficacy. Electronic databases were searched for randomized controlled trials and observational studies comparing PPCI to PIT. PIT was defined as administration of thrombolytic drugs followed by immediate PCI only in case of failed thrombolysis. Results from studies were pooled using a random-effects model. We identified 17 relevant studies (6 randomized controlled trials, 11 observational studies) including 13,037 patients. Overall, there was no significant difference in short-term mortality (odds ratio [OR] = 1.20 [0.97 to 1.49]; I2 = 14.2%; p = 0.099); however, PIT significantly decreased short-term mortality (OR = 1.46 [1.08 to 1.96]; I2 = 0%; p = 0.01) in those studies with a symptom-onset-to-device time ≥200 minutes. There was a significantly lower risk reinfarction (OR = 0.69 [0.49 to 0.97]; I2 = 0%; p = 0.033) in the PPCI group, while the risk of cardiogenic shock was significantly higher (OR = 1.48 [1.13 to 1.94]; I2 = 0%; p = 0.005). In conclusion, PIT versus PPCI decisions should preferably be customized in patients presenting to non-PCI capable hospitals. Factors that need to be considered include symptom-onset to first medical contact time, expected time of transfer to a PCI-capable hospital, and patients risk factors.
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Affiliation(s)
| | | | | | | | - Ibrahim Kassas
- Division of Cardiology, New York University School of Medicine, New York, New York
| | - Haris Riaz
- Division of Cardiology, Cleveland Clinic, Cleveland Ohio
| | - Sajjad Raza
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Salil V Deo
- Department of Cardiac Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Hasanat Sharif
- Department of Cardiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Ankur Kalra
- Department of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Neha Yadav
- Division of Cardiology, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
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Roncalli J. An update on primary findings and new designs in biotherapy studies for acute myocardial infarction. Future Cardiol 2014; 10:781-8. [DOI: 10.2217/fca.14.65] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
ABSTRACT Treatment of acute myocardial infarction in the future should focus not only on improving acute treatment, as it has been done over the past decades, but also on secondary prevention of left ventricular dysfunction and/or progression to heart failure by preserving left ventricular shape, avoiding left ventricular remodeling and stimulating cardiac regeneration. Biotherapies with adult stem cells and bone marrow-derived endothelial cell progenitors, combined or not with biomaterials, and new drugs are under investigation and will probably be part of routine clinical practice for patients suffering from myocardial infarction in the near future.
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Huynh T, Perron S, O'Loughlin J, Joseph L, Labrecque M, Tu JV, Théroux P. Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction. Circulation 2009; 119:3101-9. [PMID: 19506117 DOI: 10.1161/circulationaha.108.793745] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies.
Methods and Results—
We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (≤6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (≥1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies.
Conclusions—
Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies.
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Affiliation(s)
- Thao Huynh
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Stephane Perron
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Jennifer O'Loughlin
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Lawrence Joseph
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Michel Labrecque
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Jack V. Tu
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Pierre Théroux
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
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