Transferring patients with ST-segment elevation myocardial infarction for mechanical reperfusion: a meta-regression
Giuseppe De Luca1, Giuseppe Biondi-Zoccai, Paolo Marino
1Division of Cardiology, Maggiore della Carità Hospital, Eastern Piedmont University A. Avogadro, Novara, Italy. giuseppe.deluca@maggioreosp.novara.it
Insights
Transferring ST-segment elevation myocardial infarction (STEMI) patients for primary angioplasty significantly reduces mortality and reinfarction compared to on-site thrombolysis. This updated meta-analysis confirms survival benefits, even with delays.
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- Primary angioplasty improves survival in ST-segment elevation myocardial infarction (STEMI) patients.
- Few STEMI patients access 24-hour primary percutaneous coronary intervention due to hospital limitations.
- Previous meta-analyses showed inconclusive survival benefits for transfer, possibly due to limited statistical power.
Purpose of the Study:
- To conduct an updated meta-analysis of randomized trials.
- To evaluate if transfer for primary angioplasty significantly improves survival compared to on-site thrombolysis in STEMI patients.
Main Methods:
- Systematic literature search of MEDLINE, CENTRAL, and EMBASE databases (1990-2008).
- Inclusion criteria: randomized trials comparing on-site thrombolysis with transfer for primary angioplasty, with complete mortality data.
- Weighted least-square regression analyzed the relationship between mortality benefits, reinfarction, baseline mortality, and PCI time delay.
Main Results:
- Eleven randomized trials involving 5,741 STEMI patients were analyzed.
- Transfer for primary angioplasty significantly reduced mortality (5.6% vs. 6.8%, P=.02), reinfarction (2.1% vs. 4.7%, P<.0001), and stroke (0.7% vs. 1.7%, P=.0005) at 30 days.
- Benefits were independent of baseline mortality and percutaneous coronary intervention time delays.
Conclusions:
- Transfer for mechanical reperfusion (primary angioplasty) significantly reduces mortality in STEMI patients.
- This strategy also provides benefits in reducing reinfarction and stroke.
- The findings support transfer for primary angioplasty as a superior reperfusion strategy for STEMI.
Study Objective:
Primary angioplasty is associated with benefits in survival as compared with thrombolysis among patients with ST-segment elevation myocardial infarction (STEMI). However, in daily practice only a minority of STEMI patients are admitted to 24-hour primary percutaneous coronary intervention hospitals. A previous meta-analysis failed to show significant benefits in terms of survival, potentially because of a limited statistical power. Thus, the aim of the current study is to perform an updated meta-analysis of randomized trials to evaluate whether transfer for primary angioplasty provides significant benefits in terms of survival compared with on-site thrombolysis among STEMI patients.
Methods:
The literature was scanned by formal searches of electronic databases (MEDLINE, CENTRAL, EMBASE) and the Cochrane Central Register of Controlled trials (http://www.mrw.interscience.wiley.com/cochrane/Cochrane_clcentral_articles_ fs.html) from January 1990 to April 2008. The following key words were used: "randomized trial;" "myocardial infarction;" "reperfusion;" "thrombolysis;" "primary angioplasty;" "angioplasty;" "mechanical reperfusion;" "facilitation;" "transfer;" "transportation;" "mortality;" and "survival." Inclusion criteria were (1) randomized comparison between on-site thrombolysis and transferring for primary angioplasty; and (2) complete data on mortality. We did not exclude trials or trial arms that specifically addressed transfer for percutaneous coronary intervention after thrombolysis. Crude data were extracted by 2 investigators. No language restrictions were enforced. The relationship between benefits in mortality and reinfarction, baseline mortality of the thrombolytic group in each study (study level variable), and percutaneous coronary intervention-related time delay was evaluated by using a weighted least-square regression.
Results:
A total of 11 randomized trials were identified, including 5,741 patients (51.8% transferred for primary angioplasty and 48.2% treated with thrombolysis). Transfer for primary angioplasty was associated with a significant reduction in mortality (5.6% versus 6.8%; P=.02), reinfarction (2.1% versus 4.7%; P<.0001 and stroke (0.7% versus 1.7%, P=.0005) at 30-day follow-up. The benefits in mortality and reinfarction of transfer for primary percutaneous coronary intervention over thrombolysis were not significantly related to baseline mortality of the lytic group or to percutaneous coronary intervention-related time delay.
Conclusion:
This meta-analysis demonstrates that, among STEMI patients, transfer for mechanical reperfusion is associated, in addition to benefits in reinfarction and stroke, with a significant reduction in mortality at 30-day follow-up.
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