Chicago 2014

TFQO: Nikolaos Nikolaou COI#253EVREV 1: Nikolaos Nikolaou COI#253EVREV 2: Farzin BeyguiCOI#202Taskforce: ACS

STEMI transfer PCI vs. FL and routine early angio

(PICO ID#779)

COI Disclosure (SPECIFIC to this systematic review)

Nikolaos Nikolaou COI#253Commercial/industry: NonePotential intellectual conflicts: None

Farzin Beygui#202Commercial/industry: NonePotential intellectual conflicts: None

2010 Treatment Recommendation

2010: NO TREATMENT RECOMMENDATION

C2015 PICO

Population: Adult patients with STEMI in the ED (of a non-PCI capable hospital) Intervention: immediate inhospital fibrinolysis and routine transfer for angiography at 3-6 hours (or up to 24 hours)Comparison: transfer for PPCIOutcomes: (short term mortality: 9, reinfarction: 5, stroke: 6, major bleeding: 6.)

Inclusion/Exclusion& Articles Found

List Inclusions/ExclusionsStudies in which all or the majority of STEMI patients had:

• Recruitment in the ED of a non PCI hospital• FL in the emergency department • Angiography within >3and up to 24 h from FL.

Exclusion: Studies in which all or the majority of STEMI patients had:

• FL in the pre-hospital setting• angiography within 3 h from FL• half dose FL, or half dose FL+GPIIb-IIIa antgonists

Number of Articles initially identified: 706and number Finally Included in Evidence Profile tables

RCTs:2non-RCTs: 1

NN BF

For the critical outcome of “30 day mortality” we have identified low quality evidence -downgraded for imprecision and indirectness -from 2 RCTs enrolling 337 patients with STEMI showing no difference (OR 0.84 95% CI 0.24 – 2.98) For the critical outcome of “30 day mortality” we have also identified 1 nonRCT of very low quality evidence-downgraded for risk of bias and imprecision, showing no difference (OR 0.86 95% CI 0.48 – 1.55)For the critical outcome of ICH we have identified low quality evidence, downgraded for imprecision and indirectness, from 2 RCTs enrolling 337 patients with STEMI showing no difference (OR 3.14 95%CI: 0.13-78.08). 

For the important outcome of  “Reinfarction”, we have identified low quality evidence -downgraded for imprecision and indirectness -from the same 2 RCTs enrolling 337 patients with STEMI showing no difference (OR 2.11, 95% CI: 0.51 – 8.64). For the important outcome of “Reinfarction” we also identified 1 nonRCT of very low quality evidence-downgraded for risk of bias and imprecision-showing no difference (OR 2.2 95% CI 0.73 – 6.61)  For the important outcome of “Stroke” we have identified low quality evidence -downgraded for imprecision and indirectness -from the same 2 RCTs enrolling 416 patients with STEMI showing no difference (OR 0.96 95% CI: 0.06 – 15.58). For the important outcome of “Stroke” we also identified 1 non RCT of very low quality evidence-downgraded for risk of bias and imprecision showing no difference 1.52 95% CI 0.41 – 5.67) For the important outcome of  “Major bleeding” we have identified low quality evidence -downgraded for imprecision and indirectness -from the same 2 RCTs enrolling 337 patients with STEMI showing no difference (OR 1.33, 95% CI: 0.32 – 5.47). For the important outcome of “major bleeding” we also identified 1 non RCT of very low quality evidence-downgraded for risk of bias and imprecision (OR 0.65 95% CI 0.26 – 1.63)

Draft Treatment Recommendations

For patients presenting in the ED of a non-PCI hospital we suggest for fibrinolytic therapy with routine transfer for angiography as an equivalent to PPCI.In making this recommendation we place a higher value on not allocating resource to an unproven intervention over any yet to be proven benefit for critical or important outcomesPatients with contraindications to fibrinolysis were excluded.This recommendation is particularly valuable in case patients cannot be transferred to a PPCI capable center in a timely manner.

Knowledge Gaps *DO NOT USE FOR PLENARY* - BREAKOUT ONLY

Other specific worksheets that would be helpful

Patient subgroups (cardiogenic shock)Interventions (pharmakoinvasive approach-pre-hospital fibrinolysis)Outcomes:

Specific research required: same topic

30 day mortality-Inconsistency

Inconsistency-reinfarction

Inconsistency-Stroke

Inconsistency-Major bleeding

Inconsistency-ICH