ST-segment resolution and prognosis after facilitated versus primary percutaneous coronary intervention in acute myocardial infarction: a meta-analysis

Abstract

Complete ST-segment resolution (STR) is associated with favorable prognosis in ST-elevation myocardial infarction (STEMI). The optimal reperfusion strategy in patients with STEMI presenting early after symptom-onset is still a matter of debate. So far, there are only a few studies comparing the effect of facilitated and primary percutaneous coronary intervention (PCI) on early myocardial reperfusion assessed by STR. The objective of this meta-analysis was, therefore, to evaluate the extent of early STR and subsequent prognosis in facilitated versus primary PCI. From 1990 to 2008, we identified 14 trials of patients with STEMI reporting STR data assigned to facilitated or primary PCI. The primary endpoint of this pooled analysis was STR before and after PCI. Clinical efficacy outcomes included short-term all-cause mortality at 30-90 days and mortality after 6 months. Together, these 14 trials randomly assigned 6,439 patients (3,605 to facilitated PCI, 2,834 to primary PCI). The facilitation agents were platelet glycoprotein IIb/IIIa inhibitors in nine (1,589 patients), fibrinolysis in three (1,037 patients), and the combination of platelet glycoprotein IIb/IIIa inhibitors plus reduced-dose fibrinolysis in three trials (979 patients). STR data were available in 4,105 patients (2,215 facilitated PCI, 1,890 primary PCI). Patients undergoing facilitated PCI were significantly more likely to achieve STR before catheterization and after PCI [OR pre-PCI 1.59 (CI 1.3, 1.90); OR post-PCI 1.69 (CI 1.28, 2.24)]. Despite this significantly improved surrogate parameter of effective myocardial reperfusion, mortality was similar between groups [OR 1.11 (CI 0.84, 1.45)]. Prehospital initiated facilitated PCI results in a higher percentage of complete STR before and after PCI when compared with primary PCI. However, this enhanced early reperfusion did not significantly improve the outcome after facilitated PCI. Therefore, the current data suggest that facilitated PCI does not offer an advantage over primary PCI. The results from ongoing clinical trials in STEMI patients presenting early (<3 h) after symptom-onset with more effective antithrombotic co-therapy will provide guidance regarding the utility of a facilitated PCI strategy.