Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis.

Autor:	Rehan R; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.; Concord Hospital, Concord, New South Wales, Australia., Virk S; Systematic Reviews, CORE Group, Sydney, New South Wales, Australia., Wong CCY; Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia.; Stanford Hospital, Stanford, California, USA., Passam F; Department of Hematology, University of Sydney, Sydney, New South Wales, Australia., Layland J; Monash University, Melbourne, Victoria, Australia., Keech A; NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia., Yong A; Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia., White HD; Cardiology Department, Green Lane Cardiovascular Service and Green Lane Cardiovascular Research Unit, Auckland City Hospital, Auckland, New Zealand., Fearon W; Stanford University, Stanford, California, USA., Ng M; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia Martin.ng@sydney.edu.au.; Department of Cardiology, The University of Sydney, Sydney, New South Wales, Australia.
Jazyk:	angličtina
Zdroj:	Heart (British Cardiac Society) [Heart] 2024 Jul 10; Vol. 110 (15), pp. 988-996. Date of Electronic Publication: 2024 Jul 10.
DOI:	10.1136/heartjnl-2024-324078
Abstrakt:	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, I 2 =0%, p<0.0004) and improved left ventricular ejection fraction (WMD=1.87; 95% CI 1.07 to 2.67; I 2 =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, I 2 =0%, p=0.007) and moderately fibrin-specific thrombolytic agents (RR=0.62, 95% CI 0.47 to 0.83, I 2 =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, I 2 =0%, p=0.75). Furthermore, there were no significant differences in mortality (RR=0.91; 95% CI 0.48 to 1.71; I 2 =0%; p=0.77) or bleeding events (major bleeding, RR=1.24; 95% CI 0.47 to 3.28; I 2 =0%; p=0.67; minor bleeding, RR=1.47; 95% CI 0.90 to 2.40; I 2 =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. Competing Interests: Competing interests: JL has received minor honoraria from Abbott Vascular, Boehringer Ingelheim and Bayer. AY has received minor honoraria and research support from Abbot Vascular and Philips Healthcare. WF has received research support from Abbott Vascular and Medtronic; and has minor stock options with HeartFlow. MN has received research support from Abbot Vascular. HDW has received grant support paid to the institution and fees for serving on Steering Committees of the ODYSSEY trial from Sanofi and Regeneron Pharmaceuticals, the ISCHEMIA and MINT Study from the National Institutes of Health, the STRENGTH trial from Omthera Pharmaceuticals, the HEART-FID Study from American Regent, the DAL-GENE Study from DalCor Pharma UK, the AEGIS-II Study from CSL Behring, the CLEAR OUTCOMES Study from Esperion Therapeutics, and the SOLIST-WHF and SCOREDS trials from Sanofi Aventis Australia. The remaining authors have nothing to disclose. (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
Databáze:	MEDLINE
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