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Prehospital Thrombolysis: A Manual from Berlin
Published on: November 27, 2013
Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis
M Dalby1, A Bouzamondo, P Lechat
1Institut de Cardiologie, Pitie-Salpetriere University Hospital, 47 Boulevard de l'Hopital, 75013 Paris, France.
Insights
Transferring patients with acute myocardial infarction (AMI) for primary percutaneous coronary intervention (PCI) significantly reduces adverse events compared to on-site thrombolysis. This strategy proves superior even when transfer is required, highlighting the importance of organized systems for AMI care.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Management
Background:
- Primary percutaneous coronary intervention (PCI) is proven effective for acute myocardial infarction (AMI).
- Optimal reperfusion strategy for AMI patients without immediate catheterization access remains debated.
- This study compares transfer for angioplasty versus immediate thrombolysis in AMI.
Purpose of the Study:
- To compare the efficacy of transferring acute myocardial infarction (AMI) patients for primary percutaneous coronary intervention (PCI) versus immediate on-site thrombolysis.
- To synthesize evidence from randomized clinical trials on these two reperfusion strategies.
- To evaluate the combined endpoint of death, reinfarction, and stroke.
Main Methods:
- Meta-analysis of published randomized trials and scientific congress presentations.
- Inclusion of 6 trials with a total of 3750 patients.
- Primary endpoint: Combined criteria (CC) of death/reinfarction/stroke; Relative Risk (RR) used for treatment effect evaluation.
Main Results:
- Transfer for primary PCI significantly reduced the combined endpoint (CC) by 42% (P<0.001) compared to thrombolysis.
- Reinfarction reduced by 68% (P<0.001) and stroke by 56% (P=0.015) with primary PCI.
- A trend towards reduced all-cause mortality (19%, P=0.08) was observed with transfer for PCI.
Conclusions:
- Primary PCI is superior to immediate thrombolysis for acute myocardial infarction (AMI), even necessitating patient transfer.
- Effective ambulance systems, prehospital care, and PCI capacity are crucial for optimal AMI reperfusion therapy.
- This meta-analysis supports the established benefit of primary PCI in AMI management.
Background:
The benefit of primary percutaneous coronary intervention (PCI) over thrombolysis has been clearly demonstrated in acute myocardial infarction (AMI). However, the best therapeutic strategy for a patient with AMI presenting to acute care services without catheterization facilities remains under debate. Our objective was to gather all available information from clinical trials comparing transfer of patients experiencing AMI for angioplasty versus immediate thrombolysis.
Methods And Results:
We performed a meta-analysis of all data available from published randomized trials and from presentations in scientific sessions of major cardiology congresses comparing the 2 strategies. The primary end point was the combined criteria (CC) of death/reinfarction/stroke as defined in each trial. Relative risk (RR) evaluated the treatment effect. We identified 6 clinical trials including 3750 patients. Transfer time was always <3 hours. The CC was significantly reduced by 42% (95% confidence interval [CI] 29% to 53%, P<0.001) in the group transferred for primary PCI compared with the group receiving on-site thrombolysis. When CC parameters were considered separately, reinfarction was significantly reduced by 68% (95% CI, 34% to 84%; P<0.001) and stroke by 56% (95% CI, -15% to 77%; P=0.015). There was a trend toward reduction in all-cause mortality of 19% (95% CI, -3% to 36%; P=0.08) with transfer for PCI.
Conclusions:
Even when transfer to an angioplasty center is necessary, primary PCI remains superior to immediate thrombolysis. Organization of ambulance systems, prehospital management, and adequate PCI capacity appear now to be the key issues in providing reperfusion therapy for AMI.
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