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.
OBJECTIVE: 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).
CONCLUSIONS: 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.
OBJECTIVE: 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).
CONCLUSIONS: 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.
摘要：
背景：尽管急性ST段抬高型心肌梗死（STEMI）的心外膜血流恢复，微循环灌注不足很常见，预示预后不良。冠状动脉内（IC）溶栓治疗可以减少微血管血栓负担；然而，当代研究产生了相互矛盾的结果。
目的：本荟萃分析旨在评估STEMI患者在直接经皮冠状动脉介入治疗（PCI）时辅助IC溶栓治疗的有效性和安全性。
方法：对六个电子数据库进行综合文献检索，确定了相关的随机对照试验。主要结果是主要不良心脏事件（MACE）。计算95%CI的合并风险比(RR)和加权平均差(WMD)。
结果：纳入了12项研究，共1915例患者。IC溶栓与MACE发生率显著降低相关(RR=0.65,95%CI0.51~0.82,I2=0%,p<0.0004）并改善了左心室射血分数（WMD=1.87；95％CI1.07至2.67；I2=25％；p<0.0001）。亚组分析表明，使用非纤维蛋白的试验的MACE显着降低（RR=0.39，95％CI0.20至0.78，I2=0％，p=0.007）和中度纤维蛋白特异性溶栓剂（RR=0.62，95％CI0.47至0.83，I2=0％，p=0.001)。在使用高纤维蛋白特异性溶栓剂的研究中没有观察到显著降低(RR=1.10,95%CI0.62至1.96,I2=0%,p=0.75)。此外，死亡率(RR=0.91;95%CI0.48~1.71;I2=0%;p=0.77)或出血事件(大出血,RR=1.24；95%CI0.47至3.28；I2=0%；p=0.67；少量出血，RR=1.47；95%CI0.90至2.40；I2=0%；p=0.12)。
结论：STEMI患者行直接PCI时的辅助IC溶栓可改善临床和心肌灌注参数，而不增加出血率。需要进一步的研究来优化溶栓剂和治疗方案的选择。
目的：本荟萃分析旨在评估STEMI患者在直接经皮冠状动脉介入治疗（PCI）时辅助IC溶栓治疗的有效性和安全性。
方法：对六个电子数据库进行综合文献检索，确定了相关的随机对照试验。主要结果是主要不良心脏事件（MACE）。计算95%CI的合并风险比(RR)和加权平均差(WMD)。
结果：纳入了12项研究，共1915例患者。IC溶栓与MACE发生率显著降低相关(RR=0.65,95%CI0.51~0.82,I2=0%,p<0.0004）并改善了左心室射血分数（WMD=1.87；95％CI1.07至2.67；I2=25％；p<0.0001）。亚组分析表明，使用非纤维蛋白的试验的MACE显着降低（RR=0.39，95％CI0.20至0.78，I2=0％，p=0.007）和中度纤维蛋白特异性溶栓剂（RR=0.62，95％CI0.47至0.83，I2=0％，p=0.001)。在使用高纤维蛋白特异性溶栓剂的研究中没有观察到显著降低(RR=1.10,95%CI0.62至1.96,I2=0%,p=0.75)。此外，死亡率(RR=0.91;95%CI0.48~1.71;I2=0%;p=0.77)或出血事件(大出血,RR=1.24；95%CI0.47至3.28；I2=0%；p=0.67；少量出血，RR=1.47；95%CI0.90至2.40；I2=0%；p=0.12)。
结论：STEMI患者行直接PCI时的辅助IC溶栓可改善临床和心肌灌注参数，而不增加出血率。需要进一步的研究来优化溶栓剂和治疗方案的选择。
