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

Background: Despite proven advantages of primary percutaneouscoronary intervention (PCI), thrombolysis remains the firstline treatment for ST-elevation myocardial infarction (STEMI)worldwide. Management of patients with failed thrombolysis isstill debated, and data from existing randomized controlledtrials 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 forrandomized controlled trials comparing rescue PCI vs. conservativetherapy and/or RT vs. conservative therapy. Outcomes of interestassessed 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), andminor bleeds. Overall mortality and re-infarction have beenalso analysed individually. Results: Eight trials were included (1318 patients). Follow-upranged from ‘in-hospital’ to 6 months. No significantdifference 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 wasassociated with a 70% reduction in the risk of re-infarction[OR 0.32(0.14–0.74), P = 0.008], number needed to treat17. 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 observedwith rescue PCI [OR 2.48(1.08–5.7), P = 0.04], numberneeded to harm 50. Conclusion: Although the observed benefit is modest, these datasupport the use of PCI after failed thrombolysis.