Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis

Rajan Rehan; Sohaib Virk; Christopher C Y Wong; Freda Passam; Jamie Layland; Anthony Keech; Andy Yong; Harvey D White; William Fearon; Martin Ng

doi:10.1136/heartjnl-2024-324078

Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis

Heart. 2024 Jul 10;110(15):988-996. doi: 10.1136/heartjnl-2024-324078.

Authors

Rajan Rehan^{1

2}, Sohaib Virk³, Christopher C Y Wong^{4

5}, Freda Passam⁶, Jamie Layland⁷, Anthony Keech⁸, Andy Yong⁴, Harvey D White⁹, William Fearon¹⁰, Martin Ng^{11

12}

Affiliations

¹ Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
² Concord Hospital, Concord, New South Wales, Australia.
³ Systematic Reviews, CORE Group, Sydney, New South Wales, Australia.
⁴ Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia.
⁵ Stanford Hospital, Stanford, California, USA.
⁶ Department of Hematology, University of Sydney, Sydney, New South Wales, Australia.
⁷ Monash University, Melbourne, Victoria, Australia.
⁸ NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia.
⁹ Cardiology Department, Green Lane Cardiovascular Service and Green Lane Cardiovascular Research Unit, Auckland City Hospital, Auckland, New Zealand.
¹⁰ Stanford University, Stanford, California, USA.
¹¹ Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia Martin.ng@sydney.edu.au.
¹² Department of Cardiology, The University of Sydney, Sydney, New South Wales, Australia.

Abstract

Background: Despite restoration of epicardial blood flow in acute ST-elevation myocardial infarction (STEMI), inadequate microcirculatory perfusion is common and portends a poor prognosis. Intracoronary (IC) thrombolytic therapy can reduce microvascular thrombotic burden; however, contemporary studies have produced conflicting outcomes.

Objectives: This meta-analysis aims to evaluate the efficacy and safety of adjunctive IC thrombolytic therapy at the time of primary percutaneous coronary intervention (PCI) among patients with STEMI.

Methods: Comprehensive literature search of six electronic databases identified relevant randomised controlled trials. The primary outcome was major adverse cardiac events (MACE). The pooled risk ratio (RR) and weighted mean difference (WMD) with a 95% CI were calculated.

Results: 12 studies with 1915 patients were included. IC thrombolysis was associated with a significantly lower incidence of MACE (RR=0.65, 95% CI 0.51 to 0.82, I²=0%, p<0.0004) and improved left ventricular ejection fraction (WMD=1.87; 95% CI 1.07 to 2.67; I²=25%; p<0.0001). Subgroup analysis demonstrated a significant reduction in MACE for trials using non-fibrin (RR=0.39, 95% CI 0.20 to 0.78, I²=0%, p=0.007) and moderately fibrin-specific thrombolytic agents (RR=0.62, 95% CI 0.47 to 0.83, I²=0%, p=0.001). No significant reduction was observed in studies using highly fibrin-specific thrombolytic agents (RR=1.10, 95% CI 0.62 to 1.96, I²=0%, p=0.75). Furthermore, there were no significant differences in mortality (RR=0.91; 95% CI 0.48 to 1.71; I²=0%; p=0.77) or bleeding events (major bleeding, RR=1.24; 95% CI 0.47 to 3.28; I²=0%; p=0.67; minor bleeding, RR=1.47; 95% CI 0.90 to 2.40; I²=0%; p=0.12).

Conclusion: Adjunctive IC thrombolysis at the time of primary PCI in patients with STEMI improves clinical and myocardial perfusion parameters without an increased rate of bleeding. Further research is needed to optimise the selection of thrombolytic agents and treatment protocols.

Keywords: Acute Coronary Syndrome; Atherosclerosis; Meta-Analysis; Myocardial Infarction.

Publication types

Systematic Review
Meta-Analysis

MeSH terms

Coronary Circulation / drug effects
Coronary Circulation / physiology
Fibrinolytic Agents* / administration & dosage
Fibrinolytic Agents* / therapeutic use
Humans
Microcirculation / drug effects
Percutaneous Coronary Intervention* / methods
ST Elevation Myocardial Infarction* / mortality
ST Elevation Myocardial Infarction* / physiopathology
ST Elevation Myocardial Infarction* / therapy
Thrombolytic Therapy* / methods
Treatment Outcome

Substances

Fibrinolytic Agents