Comparative efficacy of fibrinolytics and glycoprotein IIb/IIIa inhibitors in preventing coronary no-reflow: a network meta-analysis

Abstract

Abstract Background Coronary no-reflow is a potentially lethal complication of percutaneous coronary intervention (PCI). The optimal approach to preserve coronary reflow during primary PCI is still controversial. Purpose Therefore, we aimed to compare and rank the adjunctive use of fibrinolytic agents and glycoprotein IIb/IIIa inhibitors by network meta-analysis of randomized controlled trials. Methods Pairwise and network meta-analysis were performed using the random-effects model within a frequentist framework. The primary outcome was coronary TIMI flow grade immediately following the intervention. Results 82 studies with a total of 20666 participants were identified, including 7 multi-arm studies. This enabled 94 pairwise comparisons of 35 different adjunctive anticoagulant regimens, all administered in the context of primary PCI. Overall, risk of bias in these studies was rated moderate, and heterogeneity was low with a global I2 value of 20.8%. The figure shows the ranking of the interventions in relation to no adjunctive treatment (NON) and placebo (PLA). In particular, Tirofiban (TIR) alone or in combination with Adenosin (ADE) Nicorandil (NIC) was effective in preventing coronary no-reflow. The route of its administration, intravenous (IV) vs intracoronary (IC), did not matter much. However, its timing as an early IV injection upstream of primary PCI was not beneficial. Eptifibatide (EPT) given as IC bolus followed by continuous IV infusion had an effect comparable to TIR, as well as, among the fibrinolytics, Pamiteplase (PAM) given IV and Urokinase (URO) given IC. Conclusions This comprehensive comparison of fibrinolytics and glycoprotein IIb/IIIa inhibitors demonstrates that TIR, EPT, PAM, and URO can effectively and equally prevent coronary no-reflow in primary PCI. Funding Acknowledgement Type of funding sources: None.