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ED Fibrinolysis and Transport Only for Rescue PCI Versus Transport for PCI

Question Type:
Intervention
Full Question:
Among adult patients with STEMI in the ED (of a non–PCI-capable hospital)  (P), does does transfer to a PCI center  (I), compared with compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI (rescue PCI) in first 24 hours  (C), change short term survival, ICH, stroke, major bleeding, reinfarction (O)?
Consensus on Science:
For the critical outcome of 30-day mortality, we have identified moderate-quality evidence (downgraded for serious risk of bias) from 8 RCTs(Vermeer 1999, 426-431; Widimsky 2000, 823-831; Grines 2002, 1713-1719; Andersen 2003, 733-742; Widimsky 2003, 94-104; Dieker 2006, 39-45; Svensson 2006, 798; Dobrzycki 2007, 2438-2448) enrolling 3119 patients showing benefit of transfer without fibrinolysis to a PCI center compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI in the first 24 hours (OR, 0.66; 95% CI, 0.50–0.86) (Figure 10).For the important outcome of reinfarction, we have identified moderate-quality evidence (downgraded for serious risk of bias) from the same 8 RCTs(Vermeer 1999, 426-431; Widimsky 2000, 823-831; Grines 2002, 1713-1719; Andersen 2003, 733-742; Widimsky 2003, 94-104; Dieker 2006, 39-45; Svensson 2006, 798; Dobrzycki 2007, 2438-2448) enrolling 3119 patients showing benefit of transfer without fibrinolysis to a PCI center compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI in the first 24 hours (OR, 0.33; 95% CI, 0.21–0.51).For the important outcome of stroke, we have identified moderate-quality evidence (downgraded for serious risk of bias) from the same 8 RCTs(Vermeer 1999, 426-431; Widimsky 2000, 823-831; Grines 2002, 1713-1719; Andersen 2003, 733-742; Widimsky 2003, 94-104; Dieker 2006, 39-45; Svensson 2006, 798; Dobrzycki 2007, 2438-2448) enrolling 3119 patients showing benefit of transfer without fibrinolysis to a PCI center compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI in the first 24 hours (OR, 0.41; 95% CI, 0.22–0.76).For the important outcome of major hemorrhage, we have identified very-low-quality evidence (downgraded for serious risk of bias, imprecision, and publication bias) from 2 RCTs (Vermeer 1999, 426-431; Dobrzycki 2007, 2438-2448) enrolling 550 patients showing no benefit of transfer without fibrinolysis to a PCI center compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI in the first 24 hours (OR, 0.68; 95% CI, 0.20–2.29).
Treatment Recommendation:
For adult patients presenting with STEMI in the ED of a non–PCI-capable hospital, we recommend emergency transfer without fibrinolysis to a PCI center as opposed to immediate in-hospital fibrinolysis and transfer only for rescue PCI (strong recommendation, moderate-quality evidence).Values, Preferences, and Task Force InsightsIn making this recommendation, we put great weight on the patient benefits of mortality, reinfarction, and stroke with no additional harm in terms of major hemorrhage.
CoSTR Attachments:
ACS 332 Recemmendations table_n.docx    
ACS 332 SOF table_n.docx    
ACS332GRADEEPTable220315_n.docx    
AMSTAr acs332.pdf    

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