Repeat thrombolysis or conservative therapy vs. rescue percutaneous coronary intervention for failed thrombolysis: systematic review and meta-analysis

Background: Despite proven advantages of primary percutaneous coronary intervention (PCI), thrombolysis remains the first line treatment for ST-elevation myocardial infarction (STEMI) worldwide. Management of patients with failed thrombolysis is still debated, and data from existing randomized controlled trials are conflicting. Aim: To compare the risk/benefit profile of repeat thrombolysis (RT) vs. rescue PCI in patients with failed thrombolysis. Methods: Search of BioMedCentral, CENTRAL, mRCT and PubMed for randomized controlled trials comparing rescue PCI vs. conservative therapy and/or RT vs. conservative therapy. Outcomes of interest assessed by adjusted indirect meta-analysis: major adverse events (MAE, defined as the composite of overall mortality and re-infarction), stroke, congestive heart failure (CHF), major bleeds (MB), and minor bleeds. Overall mortality and re-infarction have been also analysed individually. Results: Eight trials were included ( 1318 patients). Follow-up ranged from ' in-hospital' to 6 months. No significant difference was found for the risk of MAE [ OR 0.93( 0.26-3.35), P=0.4], overall mortality [ OR 1.01( 0.52-1.95), P=0.15], stroke [ OR 5.03( 0.64-39.1), P=0.58] and CHF [ OR 0.74( 0.28-1.96), P=0.6]. Compared with conservative therapy, rescue PCI was associated with a 70% reduction in the risk of re- infarction [ OR 0.32( 0.14 - 0.74), P= 0.008], number needed to treat 17. No difference in terms of MB was found [ OR 0.5( 0.1 - 2.5), P= 0.09], while a greater risk of minor bleeds was observed with rescue PCI [ OR 2.48( 1.08 - 5.7), P= 0.04], number needed to harm 50. Conclusion: Although the observed benefit is modest, these data support the use of PCI after failed thrombolysis.