Abstract 18226: Fibrinolysis Before Percutaneous Coronary Intervention Reduces the Rate of Cardiogenic Shock in Patients Presenting Within 3 Hours After Symptom Onset

Abstract

Introduction: Primary percutaneous coronary intervention (PCI) has become the standard of care for the treatment of ST-elevation myocardial infarction (STEMI) when it can be performed within 90 to 120 minutes after first medical contact. Whether fibrinolysis given before the intervention reduces the incidence of cardiogenic shock is not known. Methods: We identified randomized trials of fibrinolysis pre-PCI versus primary PCI in STEMI and assessed the incidence of cardiogenic shock in both groups. The Mantel-Haenszel method was used to calculate the weighted relative risk and the Chi-square test to determine the overall effect. Results: The results of the STREAM, FINESSE, WEST, ASSENT-4 PCI and CAPTIM trials were included. The first four trials investigated facilitated or pharmaco-invasive PCI with full or half dose fibrinolysis. In CAPTIM, fibrinolysis was compared to primary PCI and the majority of patients in the fibrinolysis group underwent PCI. In total 3097 patients were randomized to the fibrinolysis pre-PCI group and 3088 to the primary PCI group. The incidence of cardiogenic shock was not different between both groups (4.8% vs. 5.7% respectively, p =0.12). This result is largely driven by the ASSENT-4 PCI trial. In a subgroup analysis of patients presenting within 3 hours after symptom onset, the incidence of cardiogenic shock was significantly lower in patients receiving fibrinolysis pre-PCI (4.1% vs. 6.5%, p =0.002). However, administration of a fibrinolytic agent pre-PCI increased the risk of major bleeding (5.6% vs. 3.7%, p =0.004) and was not associated with an early mortality reduction (5.1% vs. 4.8%, p =0.29). Conclusion: Our analysis suggests that in STEMI patients presenting within 3 hours after symptom onset, early reperfusion with a fibrinolytic agent before PCI reduces the risk of cardiogenic shock when compared with primary PCI alone, at the cost of an increased risk of bleeding. Whether such a strategy improves long-term survival is not known.