Abstract 232: Comparison of Different Management Strategies for Acute Myocardial Infarction: A Multivariable Network Meta-analysis

Introduction: Many contemporary trials have compared different management strategies, involving combinations of reperfusion therapies and early invasive approaches, for treatment of ST-elevation myocardial infarction (STEMI). We used multivariable network meta - analysis to compare these approaches. Methods: We identified 29 trials in which patients with STEMI were randomized to at least two of the following strategies: thrombolytic therapy (n=4255), primary PCI (n=5850), or routine PCI after administration of thrombolytic therapy (n=4738). We categorized the latter approach as facilitated PCI (FPCI) when the median time interval between thrombolytic therapy and PCI was less than 2 hours and as a pharmacoinvasive approach when this interval was 2 hours or more. We excluded trials that did not routinely use stents during PCI. We identified short-term outcomes (up to 42 days) of death, nonfatal reinfarction, stroke, and major bleeding. We performed multivariable random-effects meta-analysis to compare these strategies. In addition, we estimated the probability that each strategy was associated with maximum risk for each outcome under a Bayesian model with flat priors. Results: Among the strategies evaluated, primary PCI was associated with the lowest mortality and nonfatal reinfarction rates, as well as the lowest risk of stroke ( Table- top panel ). Of the remaining strategies, the pharmacoinvasive approach was associated with the lowest risks of mortality, reinfarction, and stroke. The Bayesian model indicated that the probabilities of death, nonfatal reinfarction, stroke, and major bleeding were lowest for primary PCI and highest for thrombolytic therapy ( Table- bottom panel ). Furthermore, the probability of these outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions: Primary PCI is the preferred approach for treatment of STEMI. Our analysis suggests that a pharmacoinvasive approach may be more effective and safer as compared to facilitated PCI and thrombolytic therapy.