Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis
Rajan Rehan1,2, Sohaib Virk3, Christopher C Y Wong4,5
1Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
Insights
Adjunctive intracoronary thrombolysis during primary percutaneous coronary intervention for ST-elevation myocardial infarction significantly reduces major adverse cardiac events and improves heart function without increasing bleeding risk.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Inadequate microcirculatory perfusion is a common complication in acute ST-elevation myocardial infarction (STEMI) despite restored epicardial blood flow, leading to poor prognosis.
- Intracoronary (IC) thrombolytic therapy is explored to address microvascular thrombosis, but existing study outcomes are conflicting.
Purpose of the Study:
- To evaluate the efficacy and safety of adjunctive IC thrombolytic therapy administered during primary percutaneous coronary intervention (PCI) for STEMI.
- To analyze the impact of IC thrombolysis on major adverse cardiac events (MACE) and myocardial perfusion.
Main Methods:
- A comprehensive literature search of six electronic databases was conducted to identify relevant randomized controlled trials.
- The primary outcome assessed was major adverse cardiac events (MACE).
- Pooled risk ratios (RR) and weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated for meta-analysis.
Main Results:
- The meta-analysis included 12 studies with 1915 patients.
- Adjunctive IC thrombolysis was associated with a significant reduction in MACE (RR=0.65, 95% CI 0.51 to 0.82) and improved left ventricular ejection fraction (WMD=1.87, 95% CI 1.07 to 2.67).
- Subgroup analysis showed significant MACE reduction with non-fibrin and moderately fibrin-specific agents, but not with highly fibrin-specific agents. No significant differences in mortality or bleeding events were observed.
Conclusions:
- Adjunctive IC thrombolysis during primary PCI in STEMI patients improves clinical outcomes and myocardial perfusion.
- The therapy does not appear to increase the risk of bleeding events.
- Further research is warranted to optimize the selection of thrombolytic agents and treatment protocols.
Background:
Despite restoration of epicardial blood flow in acute ST-elevation myocardial infarction (STEMI), inadequate microcirculatory perfusion is common and portends a poor prognosis. Intracoronary (IC) thrombolytic therapy can reduce microvascular thrombotic burden; however, contemporary studies have produced conflicting outcomes.
Objectives:
This meta-analysis aims to evaluate the efficacy and safety of adjunctive IC thrombolytic therapy at the time of primary percutaneous coronary intervention (PCI) among patients with STEMI.
Methods:
Comprehensive literature search of six electronic databases identified relevant randomised controlled trials. The primary outcome was major adverse cardiac events (MACE). The pooled risk ratio (RR) and weighted mean difference (WMD) with a 95% CI were calculated.
Results:
12 studies with 1915 patients were included. IC thrombolysis was associated with a significantly lower incidence of MACE (RR=0.65, 95% CI 0.51 to 0.82, I2=0%, p<0.0004) and improved left ventricular ejection fraction (WMD=1.87; 95% CI 1.07 to 2.67; I2=25%; p<0.0001). Subgroup analysis demonstrated a significant reduction in MACE for trials using non-fibrin (RR=0.39, 95% CI 0.20 to 0.78, I2=0%, p=0.007) and moderately fibrin-specific thrombolytic agents (RR=0.62, 95% CI 0.47 to 0.83, I2=0%, p=0.001). No significant reduction was observed in studies using highly fibrin-specific thrombolytic agents (RR=1.10, 95% CI 0.62 to 1.96, I2=0%, p=0.75). Furthermore, there were no significant differences in mortality (RR=0.91; 95% CI 0.48 to 1.71; I2=0%; p=0.77) or bleeding events (major bleeding, RR=1.24; 95% CI 0.47 to 3.28; I2=0%; p=0.67; minor bleeding, RR=1.47; 95% CI 0.90 to 2.40; I2=0%; p=0.12).
Conclusion:
Adjunctive IC thrombolysis at the time of primary PCI in patients with STEMI improves clinical and myocardial perfusion parameters without an increased rate of bleeding. Further research is needed to optimise the selection of thrombolytic agents and treatment protocols.
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