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ED Fibrinolysis and Then Routine Early Angiography Versus Only Rescue PCI

Question Type:
Intervention
Full Question:
Among adult patients with STEMI in the ED (of a non–PCI-capable hospital) who have received immediate in-hospital fibrinolysis
 (P), does does routine transport for angiography at 3 to 6 hours (or up to 24 hours)  (I), compared with compared with only transfer for ischemia-driven PCI (rescue PCI) in first 24 hours  (C), change medium term mortality (30 day), long term mortality (6-60 months), major bleeding, stroke, reinfarction (O)?
Consensus on Science:
For the critical outcome of 30-day mortality, we have identified moderate-quality evidence (downgraded for imprecision) from 7 RCTs(Widimsky 2000, 823-831; Scheller 2003, 634-641; Fernandez-Aviles 2004, 1045-1053; Le May 2005, 417-424; Armstrong 2006, 1530-1538; Cantor 2009, 2705-2718; Bohmer 2010, 102-110) enrolling 2355 patients showing no differential benefit to either therapy (immediate in-hospital fibrinolysis and routine transfer for angiography at 3 to 6 hours [or up to 24 hours], compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI [rescue PCI] in first 24 hours) (OR, 0.96; 95% CI, 0.64–1.44) (Figure 12). For the critical outcome of 1-year mortality, we have identified moderate-quality evidence (downgraded for imprecision) from 6 RCTs(Bednar 2003, 1133-1137; Scheller 2003, 634-641; Fernandez-Aviles 2004, 1045-1053; Armstrong 2006, 1530-1538; Bohmer 2010, 102-110; Bagai 2013, 630-637) enrolling 2275 STEMI patients showing no benefit to either therapy (immediate in-hospital fibrinolysis and routine transfer for angiography at 3 to 6 hours [or up to 24 hours], compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI [rescue PCI] in first 24 hours) (OR, 0.54; 95% CI, 0.16–1.89). For the critical outcome of intracranial hemorrhage, we have identified moderate-quality evidence (downgraded for imprecision) from 6 RCTs(Scheller 2003, 634-641; Fernandez-Aviles 2004, 1045-1053; Le May 2005, 417-424; Armstrong 2006, 1530-1538; Cantor 2009, 2705-2718; Bohmer 2010, 102-110) enrolling 2156 STEMI patients, showing no differential harm from either therapy (immediate in-hospital fibrinolysis and routine transfer for angiography at 3 to 6 hours [or up to 24 hours], compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI [rescue PCI] in first 24 hours) (OR, 0.71; 95% CI, 0.34–1.44). For the important outcome of major bleeding, we have identified moderate-quality evidence (downgraded for imprecision) from 6 RCTs(Scheller 2003, 634-641; Fernandez-Aviles 2004, 1045-1053; Le May 2005, 417-424; Armstrong 2006, 1530-1538; Cantor 2009, 2705-2718; Bohmer 2010, 102-110) enrolling 2156 STEMI patients showing no differential harm from either therapy (immediate in-hospital fibrinolysis and routine transfer for angiography at 3 to 6 hours [or up to 24 hours], compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI [rescue PCI] in first 24 hours) (OR, 0.88; 95% CI, 0.61–1.27). For the important outcome of stroke we have identified moderate-quality evidence (downgraded for imprecision) from 4 RCTs(Widimsky 2000, 823-831; Scheller 2003, 634-641; Le May 2005, 417-424; Bohmer 2010, 102-110) enrolling 798 STEMI patients showing no differential harm from either therapy (immediate in-hospital fibrinolysis and routine transfer for angiography at 3 to 6 hours [or up to 24 hours], compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI [rescue PCI] in first 24 hours) (OR, 0.99; 95% CI, 0.39–2.51). For the important outcome of reinfarction, we have identified moderate-quality evidence (downgraded for risk of bias) from 7 RCTs(Widimsky 2000, 823-831; Scheller 2003, 634-641; Fernandez-Aviles 2004, 1045-1053; Le May 2005, 417-424; Armstrong 2006, 1530-1538; Cantor 2009, 2705-2718; Bohmer 2010, 102-110) in 2355 patients of benefit of immediate in-hospital fibrinolysis and routine transfer for angiography at 3 to 6 hours (or up to 24 hours), compared with immediate in-hospital fibrinolysis and only transfer for ischemia-driven PCI (rescue PCI) in first 24 hours (OR, 0.57; 95% CI, 0.38–0.85).
Treatment Recommendation:
After fibrinolysis of STEMI patients in the ED (when primary PCI is not available on-site), we suggest transport for early routine angiography in the first 3 to 6 hours (or up to 24 hours) rather than only transport for ischemia-guided angiography (weak recommendation, moderate-quality evidence). Values, Preferences, and Task Force Insights In making this suggestion, we place a higher value on a measurable benefit in the important outcome of reinfarction despite no apparent benefit in 30-day or 1-year mortality and with no harm from bleeding or stroke. However, there may be circumstances or geography where transfer for angiography within 24 hours is particularly difficult or not available. In these cases, the small measurable benefit in reinfarction only may not outweigh any prolonged or difficult transfer.
CoSTR Attachments:
2014 334 ED lysis and transfer PCI 30Dec2014.xls.rm5    
334 ED STEMI lysis and angio versus ischemia guided SOF Table.pdf    

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