Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction - A meta-analysis

Background - The benefit of primary percutaneous coronary intervention (PCI) over thrombolysis has been clearly demonstrated in acute myocardial infarction ( AMI). However, the best therapeutic strategy for a patient with AMI presenting to acute care services without catheterization facilities remains under debate. Our objective was to gather all available information from clinical trials comparing transfer of patients experiencing AMI for angioplasty versus immediate thrombolysis. Methods and Results - We performed a meta-analysis of all data available from published randomized trials and from presentations in scientific sessions of major cardiology congresses comparing the 2 strategies. The primary end point was the combined criteria (CC) of death/reinfarction/stroke as defined in each trial. Relative risk (RR) evaluated the treatment effect. We identified 6 clinical trials including 3750 patients. Transfer time was always < 3 hours. The CC was significantly reduced by 42% (95% confidence interval [CI] 29% to 53%, P < 0.001) in the group transferred for primary PCI compared with the group receiving on-site thrombolysis. When CC parameters were considered separately, reinfarction was significantly reduced by 68% ( 95% CI, 34% to 84%; P < 0.001) and stroke by 56% ( 95% CI, - 15% to 77%; P = 0.015). There was a trend toward reduction in all-cause mortality of 19% ( 95% CI, - 3% to 36%; P = 0.08) with transfer for PCI. Conclusion - Even when transfer to an angioplasty center is necessary, primary PCI remains superior to immediate thrombolysis. Organization of ambulance systems, prehospital management, and adequate PCI capacity appear now to be the key issues in providing reperfusion therapy for AMI.