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Background <p>Timely reperfusion is essential in ST-elevation myocardial infarction (STEMI), with primary percutaneous coronary intervention (PPCI) recognized as the gold-standard strategy. Logistical challenges, however, often delay PPCI, and pharmaco-invasive (PI) strategies—initial fibrinolysis followed by planned or rescue PCI—offer a practical alternative. Evidence comparing PI and PPCI remains heterogeneous and inconclusive.</p> ​Objective <p>To systematically evaluate the efficacy and safety of PI versus PPCI in STEMI patients through a meta-analysis of randomized controlled trials (RCTs).​.</p> Methods <p>We systematically searched MEDLINE, Embase, and trial registries for RCTs comparing PI and PPCI in adult STEMI patients. Data on demographics, reperfusion times, pharmacologic regimens, and clinical outcomes were extracted. The primary composite endpoint included all-cause mortality, shock, heart failure, and reinfarction at 30 days. Secondary outcomes included TIMI 3 flow, major bleeding, and stroke. Random-effects meta-analysis was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI).</p> Results <p>Thirteen RCTs (<i>n</i> = 7002) were included. The primary composite endpoint occurred in 13.0% of PI versus 11.5% of PPCI patients (RR 1.16, 95% CI 0.93–1.43; <i>p</i> = 0.19). All-cause mortality was similar (5.0% vs. 4.4%; RR 1.03, 95% CI 0.79–1.34). TIMI 3 flow was achieved in 88.1% versus 90.1% (RR 0.98, 95% CI 0.96–1.01). PI therapy was associated with a significantly higher risk of intracranial hemorrhage (1.0% vs. 0.1%; RR 5.27, 95% CI 1.93–14.42) and increased minor-to-moderate bleeding (RR 1.60, 95% CI 1.21–2.12).</p> Conclusions <p>PI and PPCI achieve comparable 30-day survival and major adverse cardiac event rates, though the certainty of evidence is low. However, the efficacy of PI comes at the cost of increased bleeding risk. Clinical use of PI strategies should carefully weigh the benefits of early reperfusion against the bleeding risk on an individual patient basis.</p>

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Percutaneous Coronary Intervention (PPCI) vs. Phrmaco-Invasive Approach for ST-Segment Elevated Myocardial Infarction (STEMI): A Systematic Review and Meta-Analysis

  • 期刊论文

  • 发表日期：

    2026年3月6日

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  • Alok Singh,
  • Roshan Mathew,
  • Naman Agrawal,
  • Madhusudan Prasad Singh,
  • Pankaj Kumar Kannauje

摘要

Background

Timely reperfusion is essential in ST-elevation myocardial infarction (STEMI), with primary percutaneous coronary intervention (PPCI) recognized as the gold-standard strategy. Logistical challenges, however, often delay PPCI, and pharmaco-invasive (PI) strategies—initial fibrinolysis followed by planned or rescue PCI—offer a practical alternative. Evidence comparing PI and PPCI remains heterogeneous and inconclusive.

​Objective

To systematically evaluate the efficacy and safety of PI versus PPCI in STEMI patients through a meta-analysis of randomized controlled trials (RCTs).​.

Methods

We systematically searched MEDLINE, Embase, and trial registries for RCTs comparing PI and PPCI in adult STEMI patients. Data on demographics, reperfusion times, pharmacologic regimens, and clinical outcomes were extracted. The primary composite endpoint included all-cause mortality, shock, heart failure, and reinfarction at 30 days. Secondary outcomes included TIMI 3 flow, major bleeding, and stroke. Random-effects meta-analysis was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI).

Results

Thirteen RCTs (n = 7002) were included. The primary composite endpoint occurred in 13.0% of PI versus 11.5% of PPCI patients (RR 1.16, 95% CI 0.93–1.43; p = 0.19). All-cause mortality was similar (5.0% vs. 4.4%; RR 1.03, 95% CI 0.79–1.34). TIMI 3 flow was achieved in 88.1% versus 90.1% (RR 0.98, 95% CI 0.96–1.01). PI therapy was associated with a significantly higher risk of intracranial hemorrhage (1.0% vs. 0.1%; RR 5.27, 95% CI 1.93–14.42) and increased minor-to-moderate bleeding (RR 1.60, 95% CI 1.21–2.12).

Conclusions

PI and PPCI achieve comparable 30-day survival and major adverse cardiac event rates, though the certainty of evidence is low. However, the efficacy of PI comes at the cost of increased bleeding risk. Clinical use of PI strategies should carefully weigh the benefits of early reperfusion against the bleeding risk on an individual patient basis.