Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials

Lancet. 2006 Feb 18;367(9510):579-88. doi: 10.1016/S0140-6736(06)68148-8.


Background: Facilitated percutaneous coronary intervention for ST-segment-elevation myocardial infarction (STEMI) is defined as the use of pharmacological substances before a planned immediate intervention, to improve coronary patency. We undertook a meta-analysis of randomised controlled trials (published and unpublished) to compare facilitated and primary percutaneous coronary intervention.

Methods: We identified 17 trials of patients with STEMI assigned to facilitated (n=2237) or primary (n=2267) percutaneous coronary intervention. We identified short-term outcomes (up to 42 days) of death, stroke, non-fatal reinfarction, urgent target vessel revascularisation, and major bleeding. Grade 3 flow rates for prethrombolysis and post-thrombolysis in myocardial infarction (TIMI) were also analysed.

Findings: The facilitated approach resulted in a greater than two-fold increase in the number of patients with initial TIMI grade 3 flow, compared with the primary approach (832 patients [37%] vs 342 [15%], odds ratio 3.18, 95% CI 2.22-4.55); however, final rates did not differ (1706 [89%] vs 1803 [88%]; 1.19, 0.86-1.64). Significantly more patients assigned to the facilitated approach than those assigned to the primary approach died (106 [5%] vs 78 [3%]; 1.38, 1.01-1.87), had higher non-fatal reinfarction rates (74 [3%] vs 41 [2%]; 1.71, 1.16-2.51), and had higher urgent target vessel revascularisation rates (66 [4%] vs 21 [1%]; 2.39, 1.23-4.66); the increased rates of adverse events seen with the facilitated approach were mainly seen in thrombolytic-therapy-based regimens. Facilitated intervention was associated with higher rates of major bleeding than primary intervention (159 [7%] vs 108 [5%]; 1.51, 1.10-2.08). Haemorrhagic stroke and total stroke rates were higher in thrombolytic-therapy-containing facilitated regimens than in primary intervention (haemorrhagic stroke 15 [0.7%] vs two [0.1%], p=0.0014; total stroke 24 [1.1%] vs six [0.3%], p=0.0008).

Interpretation: Facilitated percutaneous coronary intervention offers no benefit over primary percutaneous coronary intervention in STEMI treatment and should not be used outside the context of randomised controlled trials. Furthermore, facilitated interventions with thrombolytic-based regimens should be avoided.

Publication types

  • Comparative Study
  • Meta-Analysis
  • Review

MeSH terms

  • Aged
  • Aged, 80 and over
  • Angioplasty, Balloon, Coronary*
  • Female
  • Fibrinolytic Agents / therapeutic use*
  • Humans
  • Male
  • Myocardial Infarction / drug therapy
  • Myocardial Infarction / mortality
  • Myocardial Infarction / therapy*
  • Platelet Glycoprotein GPIIb-IIIa Complex / therapeutic use*
  • Randomized Controlled Trials as Topic


  • Fibrinolytic Agents
  • Platelet Glycoprotein GPIIb-IIIa Complex