Early Invasive Strategy Associated with Improved Clinical Outcomes for Patients with STEMI after Fibrinolytic Therapy
Fibrinolytic therapy is the most common form of reperfusion among patients with ST-segment elevation myocardial infarction (STEMI) worldwide. However, even after successful reperfusion, patients with STEMI carry a substantial risk of death and recurrent myocardial infarction, and it is unclear if an invasive strategy with routine coronary angiography after fibrinolytic therapy is efficacious in comparison to a strategy of catheterization restricted to patients with clinical evidence of ischemia. Investigators in this study conducted a meta-analysis to estimate the benefits and harms of an early invasive strategy in STEMI patients treated initially with full-dose intravenous fibrinolytic therapy, as compared to a traditional strategy of ischemia-guided management. Five randomized controlled trials that included patients with STEMI (n=1235) initially treated with fibrinolytic therapy and that compared a routine early invasive strategy versus ischemia-guided management were identified.
Findings show that an early invasive strategy was associated with significant reductions in mortality and re-infarction compared with ischemia-guided management. There were no significant differences in the risk of stroke or major bleeding. The authors suggest that these findings be confirmed by large randomized trials prior to routine implementation.
Wijeysundera H, You J, Nallamothu B, Krumholz H, Cantor W, and Ko D. An Early Invasive Strategy versus Ischemia-Guided Management after Fibrinolytic Therapy for ST-segment Elevation Myocardial Infarction: A Meta-Analysis of Contemporary Randomized Controlled Trials. American Heart Journal September 2008;156(3):564-72.
Dr. Nallamothu is part of HSR&D’s Center for Clinical Management Research.