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Regionalized STEMI System

Question Type:
Intervention
Full Question:
Among patients with suspected ST-Elevated myocardial infarction (STEMI) outside the hospital
 (P), does transport to regional percutaneous coronary intervention (PCI) centre

 (I), compared with transport to local hospital for fibrinolytic therapy

 (C), change short term mortality, major bleeding, non-fatal stroke, non-fatal re-infarction (O)?
Consensus on Science:
For the critical outcome of short-term mortality (30-day), we have identified moderate quality of evidence (downgraded for imprecision) from three RCTs (Armstrong 2006, Thiele 2005, Bonnefoy 2002) enrolling 1099 patients showing no benefit to either therapy (OR 1.16 95% CI 0.63-2.13)For the important outcome of major bleeding, we have identified low quality of evidence (downgraded for inconsistency and imprecision) from three RCTs (Armstrong 2006, Thiele 2005, Bonnefoy 2002) enrolling 1099 patients showing no benefit to either therapy (OR 1.82 95% CI 0.56-5.92)For the important outcome of non-fatal stroke, we have identified moderate quality of evidence (downgraded for imprecision) from two RCTs (Thiele 2005, Bonnefoy 2002) enrolling 1004 patients showing no benefit to either therapy (OR 0.18 95% CI 0.02-1.57)For the important outcome of non-fatal re-infarction, we have identified moderate quality of evidence (downgraded for imprecision) from three RCTs (Armstrong 2006, Thiele 2005, Bonnefoy 2002) enrolling 1099 patients in favour of intervention over control (OR 0.40 95% CI 0.19-0.81)
Treatment Recommendation:
We suggest where PCI facilities are available, that direct transport for PCI is preferred (weak recommendation, moderate quality of evidence)We suggest that where PCI facilities are not available, that transport to local ED for fibrinolysis is a reasonable alternative (weak recommendation, low quality of evidence)In making this recommendation, we place a higher value on avoiding iatrogenic harm and a lower value on uncertain benefits for mortality
CoSTR Attachments:
ILCOR C2015 DALLAS_WOOLFREY_STEMI DIVERSION.ppt    
SoF_STEMI DIVERSION_Jan 30_15_n.docx    

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