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Pharmaco-Invasive Strategy Vs Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial
Carlos Diaz-Arocutipa1, Cynthia Vargas-Rivas2, Daniel Mendoza-Quispe3
1Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru.
Insights
In Latin America, a pharmaco-invasive strategy for ST-segment elevation myocardial infarction (STEMI) showed similar outcomes to primary percutaneous coronary intervention (PCI). However, this evidence is low-quality, necessitating randomized trials for definitive conclusions.
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- Primary percutaneous coronary intervention (PCI) is the standard treatment for ST-segment elevation myocardial infarction (STEMI).
- Access to primary PCI is limited in low-resource settings, particularly in Latin America.
- The pharmaco-invasive strategy offers an alternative when primary PCI is unavailable.
Purpose of the Study:
- To compare the safety and efficacy of the pharmaco-invasive strategy versus primary PCI for STEMI in Latin America.
- To evaluate key cardiovascular outcomes and bleeding events associated with each strategy.
- To synthesize existing evidence from observational studies in the region.
Main Methods:
- A systematic literature search was conducted across MEDLINE, Embase, and LILACS up to September 2023.
- Included studies compared pharmaco-invasive strategy to primary PCI in Latin America.
- Random-effects meta-analyses were performed to calculate risk ratios (RRs) and 95% confidence intervals (CIs) for primary and secondary outcomes, with risk of bias assessed using ROBINS-I.
Main Results:
- Six cohort studies (n=6621) were included; no randomized trials were identified.
- No significant differences were observed between the pharmaco-invasive strategy and primary PCI in major adverse cardiovascular events (RR 0.82; 95% CI 0.59-1.16) or major bleeding (RR 1.18; 95% CI 0.69-2.02).
- Rates of all-cause mortality, cardiovascular mortality, recurrent myocardial infarction, and stroke were also similar, though confidence intervals were wide. Most studies exhibited serious or critical risk of bias.
Conclusions:
- Low-quality observational evidence suggests similar cardiovascular outcomes and bleeding rates between pharmaco-invasive strategy and primary PCI for STEMI in Latin America.
- The findings highlight the need for high-quality randomized controlled trials in Latin America.
- Development of STEMI networks is crucial for improving patient care and facilitating robust research in the region.
Background:
Primary percutaneous coronary intervention (PCI) is the established treatment for ST-segment elevation myocardial infarction (STEMI), but often it is not readily available in low-resource settings. We assessed the safety and efficacy of the pharmaco-invasive strategy compared to primary PCI for STEMI in Latin America.
Methods:
MEDLINE, Embase, and Latin American and Caribbean Health Sciences Literature (LILACS) were searched for the period from their inception to September 2023, for studies that compared a pharmaco-invasive strategy vs primary PCI in Latin America. Primary outcomes were major adverse cardiovascular events and bleeding. Secondary outcomes were all-cause mortality, cardiovascular mortality, recurrent myocardial infarction, and stroke. Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I) tool. Risk ratios (RRs) and 95% confidence intervals (CIs) from random-effects meta-analyses were reported.
Results:
Six cohort studies (n = 6621) were included; no clinical trials were found. The follow-up duration ranged from the in-hospital period to 1 year. Patients who underwent a pharmaco-invasive strategy (n = 841) vs a primary PCI (n = 5780) had similar rates of major adverse cardiovascular events (RR 0.82; 95% CI 0.59-1.16), major bleeding (RR 1.18; 95% CI 0.69-2.02), all-cause mortality (RR 0.70; 95% CI 0.47-1.05), cardiovascular mortality (RR 0.80; 95% CI 0.44-1.44), recurrent myocardial infarction (RR 0.54; 95% CI 0.18-1.61), and stroke (RR 1.27; 95% CI 0.17-9.73). Most studies had a serious (33%) or critical (50%) risk of bias.
Conclusions:
Among patients with STEMI in Latin America, only low-quality observational evidence indicated that cardiovascular outcomes and major bleeding rates were similar for those treated with a pharmaco-invasive strategy vs primary PCI. Randomized studies are needed in Latin America with the development of STEMI networks for better care.
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