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ED Fibrinolysis and Immediate PCI Versus Immediate PCI Alone

Question Type:
Intervention
Full Question:
Among adults who are having STEMI in the ED

 (P), does does fibrinolytic administration combined with immediate PCI


 (I), compared with compared with immediate PCI alone



 (C), change death, Intracranial Hemorrhage, reinfarction, urgent target vessel revascularization, major bleeding (O)?
Consensus on Science:
For the critical outcome of 30-day mortality, we have identified moderate-quality evidence (downgraded for imprecision) from 5 RCTs(Kurihara 2004, E14; Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators 2006, 569-578; Thiele 2006, 1132-1139; Ellis 2008, 2205-2217; Itoh 2010, 1625-1634) enrolling 3533 patients showing no benefit when fibrinolytic administration is combined with immediate PCI versus immediate PCI alone (OR, 1.29; 95% CI, 0.96–1.74) (Figure 8). For the critical outcome of intracranial hemorrhage, we have identified moderate-quality evidence (downgraded for imprecision) from 3 RCTs(Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators 2006, 569-578; Ellis 2008, 2205-2217; Itoh 2010, 1625-1634) enrolling 3342 patients showing harm when fibrinolytic administration is combined with immediate PCI versus immediate PCI alone (OR, 7.75; 95% CI, 1.39–43.15) (Figure 9). For the important outcome of nonfatal myocardial infarction, we have identified low-quality evidence (downgraded for bias, inconsistency, and imprecision) from 5 RCTs(Kurihara 2004, E14; Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators 2006, 569-578; Thiele 2006, 1132-1139; Ellis 2008, 2205-2217; Itoh 2010, 1625-1634) enrolling 3498 patients showing no benefit when fibrinolytic administration is combined with immediate PCI versus immediate PCI alone (OR, 1.15; 95% CI, 0.73–1.81). For the important outcome of target vessel revascularization, we have identified low-quality evidence (downgraded for inconsistency and imprecision) from 4 RCTs(Kurihara 2004, E14; Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators 2006, 569-578; Ellis 2008, 2205-2217; Itoh 2010, 1625-1634) enrolling 3360 patients showing no benefit when fibrinolytic administration is combined with immediate PCI versus immediate PCI alone (OR, 1.16; 95% CI, 0.91–1.47). For the important outcome of major bleeding, we have identified high-quality evidence from 5 RCTs(Kurihara 2004, E14; Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention (ASSENT-4 PCI) investigators 2006, 569-578; Thiele 2006, 1132-1139; Ellis 2008, 2205-2217; Itoh 2010, 1625-1634) enrolling 3543 patients showing harm when fibrinolytic administration is combined with immediate PCI versus immediate PCI alone (OR, 1.52; 95% CI, 1.05–2.20).
Treatment Recommendation:
We recommend against the routine use of fibrinolytic administration combined with immediate* PCI, compared with immediate PCI alone in patients with STEMI (strong recommendation, moderate-quality evidence). *In these studies, the time frame from fibrinolysis to PCI ranged from 1 to 4 hours. Values, Preferences, and Task Force Insights In making this recommendation, we place a higher value on avoiding harm (intracranial hemorrhage and major bleeding), given that the evidence suggests no mortality benefit for fibrinolytic administration combined with immediate PCI.
CoSTR Attachments:
ForestPlot1150112Nonogi.pdf    
ILCOR ACS 882 AMSTARguideline.pdf    
Should combined PCI vs. Primary PCI new 2015-2-3.pdf    

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