Search by:

Source

Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. Lancet 1994; 343:311-22.

Efficacy Endpoints

Death at 1 month following acute heart attack (STEMI)

Harm Endpoints

Major bleeding (brain bleeding or bleeding requiring transfusion).

Narrative

This systematic review includes 9 trials and 58600 patients randomized to receive a fibrinolytic drug or placebo for suspected heart attack. Patients were enrolled based on strong suspicion of heart attack by the treating doctor. Most (76%) were men, and most had ST-elevations on their EKG (68%). There was an overall mortality benefit of 1.9% (9.6 vs. 11.5) in favor of fibrinolytics. There was also a 0.4% increase in hemorrhagic stroke (1.2 vs. 0.8). Benefit was demonstrably greater with earlier treatment, with the most benefit apparent for treatment given within a few hours of symptom onset. Benefits were smaller and less statistically robust in the 12 to 24 hour period. Patients with ST-depressions were harmed rather than helped.

Caveats

There was no gold standard to prove STEMI (e.g. catheterization or biomarkers) and some patients had normal EKG’s (5%). There is heterogeneity between trials, including inconsistency in the use of aspirin. However, groups appear to have been randomized well and treated equally with respect to other interventions.

Author

Joshua Quaas, MD

Published/Updated

January 19, 2010