Role of routine early angiography post-fibrinolysis for ST elevation myocardial infarction — A meta-regression analysis using angiography rate in the non-routine arm Cheuk-Kit Wong a, ⁎, Sophia Leon de la Barra b , Peter Herbison b a Department of Cardiology, Dunedin School of Medicine, University of Otago, Dunedin Public Hospital, Dunedin, New Zealand b Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand abstract article info Article history: Received 2 February 2012 Received in revised form 24 April 2012 Accepted 28 April 2012 Available online xxxx Keywords: Routine angiography Fibrinolysis Meta-regression Background: The current European and American Guidelines differ with regard to the recommended level for the use of routine early angiography after fibrinolysis for STEMI. Previous meta-analyses on randomized con- trolled trials have supported the routine early approach, but its advantage may be because of an excessively low angiography rate among patients in the non-routine strategy arm of the trials. Methods: We update the meta-analysis and apply meta-regression to evaluate whether the difference in out- come between the 2 randomized arms could be explained by the angiography rates in the non-routine strat- egy arm. Because reinfarction and recurrent ischemia are often the reported indication for angiography, we only use mortality endpoint in our meta-regression analysis. Results: Among the eight trials included with 3195 patients, the angiography rate in the non-routine strategy arms ranges from 15% to 100%. The overall odds ratio for 30-day mortality comparing the routine early angi- ography arm vs the non-routine arm is 0.86 (95% confidence interval 0.60–1.24). On the plot listing the eight trials according to angiography rates, there is no visual trend in the odds ratio estimates for mortality when comparing the 2 treatment strategies as angiography rate decreases. In meta-regression analysis, angiogra- phy rate does not predict 30-day mortality (p = 0.461). Conclusion: For STEMI, mortality endpoint trumps the softer endpoints of recurrent infarction and ischemia. The current study shows that the equipoise between the routine early invasive versus the non-routine strat- egy on 30-day mortality cannot be explained by the variable performance of angiography in the non-routine strategy arm. © 2012 Elsevier Ireland Ltd. All rights reserved. 1. Introduction The European recommendations give a class I recommendation (level of evidence A) for routine early percutaneous coronary inter- vention (PCI) within 24 h following successful fibrinolysis [1], but the American recommendations take a softer stance. The ACC/AHA 2009 update to the STEMI guidelines [2] gives a class IIb recommen- dation (level of evidence C) stating that “Patients who are not at high risk who receive fibrinolytic therapy as primary reperfusion therapy at a non‐PCI-capable facility may be considered for transfer as soon as possible to a PCI-capable facility where PCI can be per- formed either when needed or as a pharmacoinvasive strategy”, and a class IIa (level of evidence B) recommendation for this strategy for high-risk patients. The 2011 ACCF/AHA/SCAI recommendations for Percutaneous Coronary Intervention [3] for STEMI patients initially treated by fibrinolysis are similar. In the latest meta-analysis [4] on clinical trials that randomly assigned patients following fibrinolysis to routine early coronary angi- ography and PCI vs the “non-routine” strategy, there were respectively 38% and 79% significant reductions in recurrent MI and recurrent ische- mia in the routine early strategy arm with no substantial reduction in mortality. While almost all patients in the routine early strategy arm had angi- ography, the proportion undergoing angiography in the non-routine strategy arm of the included studies varied widely. Angiography, by providing unique information for revascularization, might have been the crucial step altering outcome. However, the decision on angiogra- phy in the non-routine arm would have been affected by factors includ- ing recurrent MI and ischemia, which are also the softer endpoints of the randomized trials. Mortality is the hard endpoint in STEMI. The impact on mortality from a routine early invasive strategy over a non-routine strategy may International Journal of Cardiology xxx (2012) xxx–xxx ⁎ Corresponding author. Tel.: + 64 3 4747980; fax: + 64 3 4747655. E-mail address: cheuk-kit.wong@healthotago.co.nz (C-K. Wong). IJCA-14823; No of Pages 4 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2012.04.151 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Please cite this article as: Wong C-K, et al, Role of routine early angiography post-fibrinolysis for ST elevation myocardial infarction — A meta-regression..., Int J Cardiol (2012), doi:10.1016/j.ijcard.2012.04.151