Invasive Therapy After Fibrinolytics

Study Questions:

Are there specific patient subsets that benefit from an early invasive approach after fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI)?


The authors performed a patient-level meta-analysis of seven trials to assess the impact of early invasive versus standard care on adverse cardiovascular events. The outcomes assessed were death/reinfarction at 30 days and at 1 year, as well as death/reinfarction/recurrent ischemia, major bleeding, and stroke at 30 days. Specific subgroups that were explored included age, sex, diabetes, prior infarction, Killip class, anterior infarction, and time from symptom onset to fibrinolysis.


The early invasive strategy was associated with a lower risk of death or recurrent infarction at 30 days (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.50-0.86; p = 0.0024). This benefit was sustained on follow-up with the early invasive strategy being associated with a lower risk of death or recurrent infarction at 1 year (HR, 0.72; 95% CI, 0.58-0.91; p = 0.0047). The benefit of the invasive approach was similar across different strata with the exception of a marginally significant interaction between Killip class and treatment for death/reinfarction at 30 days and 1 year (p values for interaction, 0.044 and 0.038, respectively).


The authors concluded that benefit from an early invasive strategy after fibrinolysis for STEMI is similar across patient subgroups.


Primary percutaneous coronary intervention remains the preeminent therapy for STEMI, but fibrinolytic therapy is still used in a small minority, especially for patients in sparsely populated areas. Recent trials have supported a role for routine early invasive therapy after fibrinolysis. This meta-analysis was not able to conclusively demonstrate any subgroup where the benefit of this approach was not present, and for now, routine early invasive therapy after fibrinolysis should continue to remain the default practice.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Anterior Wall Myocardial Infarction, Diabetes Mellitus, Fibrinolysis, Hemorrhage, Ischemia, Percutaneous Coronary Intervention, Stroke, Thrombolytic Therapy

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