Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST-segment myocardial infarction - A meta-analysis of randomized trials

Objectives We sought to best estimate the benefits and risks associated with rescue percutaneous coronary intervention (PCI) and repeat fibrinolytic therapy as compared with conservative management in patients with failed fibrinolytic therapy for ST-segment myocardial infarction (STEMI). Background Fibrinolytic therapy is the most common treatment for STEMI; however, the best therapy in patients who fail to achieve reperfusion after fibrinolytic therapy remains uncertain. Methods We performed a meta-analysis of randomized trials using a fixed-effects model. We included 8 trials enrolling 1,177 patients with follow-up duration ranging from hospital discharge to 6 months. Results Rescue PCI was associated with no significant reduction in all-cause mortality (relative risk [RR] 0.69; 95% confidence interval [Cl] 0.46 to 1.05), but was associated with significant risk reductions in heart failure (RR 0.73; 95% Cl 0.54 to 1.00) and reinfarction (RR 0.58; 95% Cl 0.35 to 0.97) when compared with conservative treatment. Rescue PCI was associated with an increased risk of stroke (RR 4.98; 95% Cl 1.10 to 22.5) and minor bleeding (RR 4.58; 95% Cl 2.46 to 8.55). Repeat fibrinolytic therapy was not associated with significant improvements in all-cause mortality (RR 0.68; 95% Cl 0.4:L to 1.14) or reinfarction (RR 1.79; 95% Cl 0.92 to 3.48), but was associated with an increased risk for minor bleeding (RR 1.84; 95% Cl 1.06 to 3.18). Conclusions Rescue PCI is associated with improved clinical outcomes for STEMI patients after failed fibrinolytic therapy, but these benefits must be interpreted in the context of potential risks. On the other hand, repeat fibrinolytic therapy is not associated with significant clinical improvement and may be associated with increased harm.