Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis

TY - JOUR

T1 - Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis

AU - Asseburg, Christian

AU - Vergel, Yolanda Bravo

AU - Palmer, Stephen

AU - Fenwick, Elisabeth

AU - de Belder, Mark

AU - Abrams, Keith R.

AU - Sculpher, Mark

N1 - Copyright © 2007 the authors. This is an author produced version of a paper published in Heart. Uploaded in accordance with the publisher's self-archiving policy.

PY - 2007/10

Y1 - 2007/10

N2 - Background: Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered.Objective: To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships.Methods: A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (Crl)) as a function of the additional time delay associated with angioplasty. \ Results: 22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean ( SE) angioplasty-related time delay ( over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis ( OR = 0.68 ( 95% Crl 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 ( 95% Crl 0.20 to 0.51); for non-fatal stroke OR = 0.24 ( 95% Crl 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation.Conclusions: The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1- month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.

AB - Background: Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered.Objective: To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships.Methods: A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (Crl)) as a function of the additional time delay associated with angioplasty. \ Results: 22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean ( SE) angioplasty-related time delay ( over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis ( OR = 0.68 ( 95% Crl 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 ( 95% Crl 0.20 to 0.51); for non-fatal stroke OR = 0.24 ( 95% Crl 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation.Conclusions: The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1- month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.

KW - ACUTE MYOCARDIAL-INFARCTION

KW - PERCUTANEOUS CORONARY INTERVENTION

KW - TISSUE-PLASMINOGEN ACTIVATOR

KW - INDIVIDUAL PATIENT DATA

KW - IMMEDIATE THROMBOLYSIS

KW - FIBRINOLYTIC THERAPY

KW - RANDOMIZED-TRIAL

KW - INTRAVENOUS STREPTOKINASE

KW - METAANALYSIS

KW - REPERFUSION

U2 - 10.1136/hrt.2006.093336

DO - 10.1136/hrt.2006.093336

M3 - Article

SN - 1355-6037

VL - 93

SP - 1244

EP - 1250

JO - Heart

JF - Heart

IS - 10

ER -