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ED Fibrinolysis and Routine Early Angiography 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 immediate in-hospital fibrinolysis and routine transfer for angiography at 3 to 6 hours (or up to 24 hours)  (I), compared with compared with transfer to a PCI center  (C), change 30 day mortality, stroke, major bleeding, reinfarction (O)?
Consensus on Science:
For the critical outcome of 30-day mortality, we have identified very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from 2 RCTs(Armstrong 2006, 1530-1538; Fernandez-Aviles 2007, 949-960) enrolling 337 patients with STEMI showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 0.84; 95% CI, 0.24–2.98) (Figure 11). For the critical outcome of 30-day mortality, we have also identified 1 non-RCT enrolling 1714 patients (Danchin 2008, 268-276) of very-low-quality evidence (downgraded for risk of bias and imprecision), showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 0.86; 95% CI, 0.48–1.55).For the critical outcome of intracranial hemorrhage, we have identified very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from the same 2 RCTs(Armstrong 2006, 1530-1538; Fernandez-Aviles 2007, 949-960) enrolling 337 patients with STEMI showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 3.14; 95% CI, 0.13–78.08). For the important outcome of reinfarction, we have identified very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from the same 2 RCTs(Armstrong 2006, 1530-1538; Fernandez-Aviles 2007, 949-960) enrolling 337 patients with STEMI showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 2.11; 95% CI, 0.51–8.64). For the important outcome of reinfarction, we also identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 non-RCT enrolling 1714 patients (Danchin 2008, 268-276) showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 2.2; 95% CI, 0.73–6.61). For the important outcome of stroke, we have identified very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from the same 2 RCTs(Armstrong 2006, 1530-1538; Fernandez-Aviles 2007, 949-960) enrolling 416 patients with STEMI showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 0.96; 95% CI, 0.06–15.58). For the important outcome of stroke, we also identified 1 non RCT enrolling 1714 patients(Danchin 2008, 268-276) of very-low-quality evidence (downgraded for risk of bias and imprecision) showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 1.52; 95% CI, 0.41–5.67). For the important outcome of major bleeding, we have identified very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from the same 2 RCTs(Armstrong 2006, 1530-1538; Fernandez-Aviles 2007, 949-960) enrolling 337 patients with STEMI showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 1.33; 95% CI, 0.32–5.47). For the important outcome of major bleeding, we also identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 non-RCT(Danchin 2008, 268-276) enrolling 1714 patients with STEMI showing no differential benefit of immediate in-hospital fibrinolysis and routine transfer for angiography compared with transfer to a PCI center (OR, 0.65; 95% CI, 0.26–1.63).
Treatment Recommendation:
We suggest fibrinolytic therapy with routine transfer for angiography as an alternative to immediate transfer to PCI for patients presenting with STEMI in the ED of a non–PCI-capable hospital (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force InsightsThis recommendation indicates that either therapy would be appropriate according to the evidence. Fibrinolysis and routine transfer may be appropriate where patients cannot be transferred to a PCI-capable center in a timely manner. Alternatively, transfer to PCI may be appropriate when this can be accomplished quickly or the patient has greater risks with fibrinolysis. Given the lack of mortality benefit, if transport directly to PCI is delayed, fibrinolysis before transport for routine early angiography is a reasonable option. We are not suggesting the addition of new PCI facilities for this indication and recognize that fewer high-volume centers may provide better outcomes.
CoSTR Attachments:
AMSTAr acs779.pdf    
FL and routine angio vs ppci non-rcts_n.docx    
FL+routine angio vs PPCI_n.docx    
should-fl-and-routine-early-angiography-vs-transfer-to-pci-be-used-for-stemi_n.docx    

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