LATE PERCUTANEOUS CORONARY INTERVENTION AFTER MYOCARDIAL INFARCTION: A META-ANALYSIS Presenter: Darryn L. Appleton, MBChB Coauthors: Antonio Abbate, MD,

LATE PERCUTANEOUS LATE PERCUTANEOUS CORONARY INTERVENTION CORONARY INTERVENTION

AFTER MYOCARDIAL AFTER MYOCARDIAL INFARCTION: INFARCTION:

A META-ANALYSISA META-ANALYSISPresenter: Darryn L. Appleton, MBChBPresenter: Darryn L. Appleton, MBChB

Coauthors: Antonio Abbate, MD, Giuseppe GL Coauthors: Antonio Abbate, MD, Giuseppe GL Biondi-Zoccai, MD, Venkat Ramachandran, MD, Biondi-Zoccai, MD, Venkat Ramachandran, MD, Michael J. Lipinski, MD, Pierfrancesco Agostoni, Michael J. Lipinski, MD, Pierfrancesco Agostoni,

MD, George W Vetrovec, MDMD, George W Vetrovec, MD

BackgroundBackground

Late presentation with acute STEMI Late presentation with acute STEMI a relatively common and challenging a relatively common and challenging problemproblem

Clear evidence supporting efficacy of Clear evidence supporting efficacy of primary PCI early in acute STEMI primary PCI early in acute STEMI (within 12hrs)(within 12hrs)

Utility of PCI late in the course of Utility of PCI late in the course of STEMI in otherwise stable patients STEMI in otherwise stable patients (>12hrs) has not been proven(>12hrs) has not been proven

Late Open-Artery Late Open-Artery HypothesisHypothesis

Late patency of the IRA correlates Late patency of the IRA correlates closely with improved survival after closely with improved survival after acute MIacute MI Observational studies (retrospective) have Observational studies (retrospective) have

shown improved outcomes in patients shown improved outcomes in patients with patent IRA vs permanent occlusionwith patent IRA vs permanent occlusion

Experimental data in lab animals shows Experimental data in lab animals shows increased apoptosis and adverse increased apoptosis and adverse remodeling with permanent coronary remodeling with permanent coronary occlusionocclusion

Clinical Question & Clinical Question & ObjectivesObjectives

Clinical Question: Clinical Question: Does mechanical intervention (PCI) to achieve Does mechanical intervention (PCI) to achieve

reperfusion of the IRA late in the course of acute reperfusion of the IRA late in the course of acute MI (>12hrs from symptom onset) translate to MI (>12hrs from symptom onset) translate to clinical benefit?clinical benefit?

Hypothesis: That PCI late in acute MI Hypothesis: That PCI late in acute MI improves survival by means of reduced improves survival by means of reduced adverse remodeling and improved cardiac adverse remodeling and improved cardiac function function

Objectives: to perform a meta-analysis of all Objectives: to perform a meta-analysis of all relevant trials testing the above hypothesisrelevant trials testing the above hypothesis

MethodsMethods Databases: Pubmed, PubMed Central and mRCTDatabases: Pubmed, PubMed Central and mRCT Search updated Sept 06 (and later March 07)Search updated Sept 06 (and later March 07) Search terms: Search terms:

‘‘randomized’, ‘percutaneous coronary intervention’, randomized’, ‘percutaneous coronary intervention’, ‘PCI’, ‘stent’, ‘angioplasty’, ‘revasc*’, ‘recanaliz*’, ‘acute ‘PCI’, ‘stent’, ‘angioplasty’, ‘revasc*’, ‘recanaliz*’, ‘acute myocardial infarction’, ‘AMI’, ‘infarct*’, ‘occlusion’, myocardial infarction’, ‘AMI’, ‘infarct*’, ‘occlusion’, ‘occlu*’(where * denotes a wildcard) ‘occlu*’(where * denotes a wildcard)

Inclusion criteria for trials: Inclusion criteria for trials: Random treatment allocationRandom treatment allocation Comparison of PCI to optimal medical managementComparison of PCI to optimal medical management Randomized >12 hrs following onset of proven acute Randomized >12 hrs following onset of proven acute

myocardial infarctionmyocardial infarction Hemodynamically Hemodynamically stable patientsstable patients that would not need that would not need

and urgent cardiac cathetization for other indications and urgent cardiac cathetization for other indications such as post-infarction angina or inducible ischemiasuch as post-infarction angina or inducible ischemia

MethodsMethods Data collectionData collection

Pre-specified forms used to collect data on Pre-specified forms used to collect data on baseline characteristics and outcomesbaseline characteristics and outcomes

Statistical methodsStatistical methods performed using Review Manager 4.2.4performed using Review Manager 4.2.4 binary outcomes combined with Peto fixed effect binary outcomes combined with Peto fixed effect

model model continuous variables compared using fixed effect continuous variables compared using fixed effect

inverse variance weighting methodinverse variance weighting method formal Cochran Q chi-square tests performed to formal Cochran Q chi-square tests performed to

investigate heterogeneity between trialsinvestigate heterogeneity between trials reported values were two-tailed and results reported values were two-tailed and results

were considered statistically significant at the were considered statistically significant at the 0.05 level. 0.05 level.

MethodsMethods

Primary outcome: Death from all Primary outcome: Death from all causescauses

Secondary outcomes:Secondary outcomes: Composite endpoint of death, recurrent Composite endpoint of death, recurrent

MI or hospitalization for CHFMI or hospitalization for CHF Change in Left-ventricular EFChange in Left-ventricular EF Cardiac remodeling: changes in ESV Cardiac remodeling: changes in ESV

and EDVand EDV

ResultsResults

4361 citations from initial search

17 articles retrieved4345 excluded as non-

relevant at citation level

9 studies excluded 8 studies selected

Total of 1193 patients

601 patients with late PCI

592 patients with medical management

only

Results: Study Results: Study characteristicscharacteristics

Year Patients Clinical scenario Time to PCI (days)

Longest F/U (months)

Primary outcome

TOPS 1992 87 STEMI 7 12 LVEF

TOMIIS 1994 44 STEMI 11 4 LVEF

Horie et al. 1998 83 STEMI 8.3 60 LVEF

TOAT 2002 66 Anterior STEMI 26 12 LVEF (baseline not available, LV size, exercise tolerance

Zeymer et al. 2003 300 STEMI 23 56 Death, AMI, revascularization, hospitalization

DECOPI 2004 212 Q-wave AMI (>48 hours after pain)

5 35 Cardiac death, AMI, VT/VF

BRAVE-2 2005 365 STEMI 1.1 3 Infarct size (3 months)

Silva et al. 2005 36 Anterior STEMI 8.3 6 LVEDV

Results: Primary Results: Primary outcomeoutcome

Study PCI Medical Rx Peto OR Weight Peto OR

or sub-category n/N n/N 95% CI % 95% CI Year

TOPS 0/42 0/45 Not estimable 1992

TOMIIS 1/25 1/19 3.14 0.75 [0.04, 12.76] 1994

Horie 1/44 5/39 9.20 0.21 [0.04, 1.11] 1998

TOAT 2/32 1/34 4.76 2.12 [0.21, 21.13] 2002

Zeymer et al 6/149 17/151 34.92 0.36 [0.15, 0.84] 2003

DECOPI 8/109 9/103 25.73 0.83 [0.31, 2.23] 2004

BRAVE-2 4/182 8/183 19.07 0.51 [0.16, 1.60] 2005

Silva et al 0/18 2/18 3.18 0.13 [0.01, 2.12] 2005

Total (95% CI) 601 592 100.00 0.49 [0.30, 0.81]

Total events: 22 (PCI), 43 (Medical Rx)

Test for heterogeneity: Chi² = 5.09, df = 6 (P = 0.53), I² = 0%

Test for overall effect: Z = 2.80 (P = 0.005)

0.1 0.2 0.5 1 2 5 10

Favours PCI Favours medical Rx

Outcome: Death from all causesOutcome: Death from all causes

Results: Secondary Results: Secondary outcomesoutcomes

Study PCI Medical Rx Peto OR Weight Peto OR

or sub-category n/N n/N 95% CI % 95% CI Year

TOPS 2/42 3/45 4.18 0.71 [0.12, 4.26] 1992 TOMIIS 1/25 1/19 1.68 0.75 [0.04, 12.76] 1994 Horie 4/44 12/39 11.42 0.25 [0.09, 0.75] 1998 TOAT 9/32 8/34 11.23 1.27 [0.42, 3.79] 2002 Zeymer et al 9/149 24/151 25.85 0.37 [0.18, 0.76] 2003

DECOPI 14/109 16/103 22.68 0.80 [0.37, 1.73] 2004 BRAVE-2 13/182 12/183 20.48 1.10 [0.49, 2.47] 2005 Silva et al 0/18 3/18 2.48 0.12 [0.01, 1.23] 2005

Total (95% CI) 100.00 0.61 [0.42, 0.88]


Test for heterogeneity: Chi² = 10.56, df = 7 (P = 0.16), I² = 33.7%


0.1 0.2 0.5 1 2 5 10


Outcome: Composite of death, non-fatal MI, Outcome: Composite of death, non-fatal MI,

hospitalization for CHFhospitalization for CHF


Study EF change % (random) Weight EF change % (random)

or sub-category EF change % (SE) 95% CI % 95% CI Year

Total (95% CI) 100.00 3.17 [1.65, 4.68]


Test for overall effect: Z = 4.1 (P < 0.0001)

Horie 2.8000 (1.2100) 17.50 2.80 [0.43, 5.17] 1998

TOPS 2.0000 (1.1800) 18.00 2.00 [-0.31, 4.31] 1992

TOMIIS 1.2000 (1.5100) 13.28 1.20 [-1.76, 4.16] 1994

DECOPI 5.0000 (0.8500) 24.61 5.00 [3.33, 6.67] 2004

Silva et al 4.2400 (1.9100) 9.45 4.24 [0.50, 7.98] 2005

10 5 0 -5 -10

Favours PCI

Favours Medical Rx

Outcome: Change in LVEFOutcome: Change in LVEF

Results: Impact of OAT & Results: Impact of OAT & TOSCA-2 studiesTOSCA-2 studies

NIH funded OAT study published Dec NIH funded OAT study published Dec 2006 in NEJM2006 in NEJM

2166 patients 3-28 days following acute 2166 patients 3-28 days following acute STEMI, randomized to PCI or optimal STEMI, randomized to PCI or optimal medical management, followed for mean medical management, followed for mean of 3 yearsof 3 years

TOSCA-2 is a subgroup of the patients TOSCA-2 is a subgroup of the patients randomized in the OAT who had randomized in the OAT who had additional baseline and follow-up EF additional baseline and follow-up EF measurementsmeasurements

Results: Impact of OAT Results: Impact of OAT studystudy

Study PCI Medical Rx Peto OR Peto OR

or sub-category n/N n/N 95% CI 95% CI Year

Dzavik et al (1994) 1/25 1/19 0.75 [0.04, 12.76] 1994

OAT (2006) 87/1082 84/1084 1.04 [0.76, 1.42] 2006

Ellis et al 0/42 0/45 Not estimable 1992

Hochman et al 2/32 1/34 2.12 [0.21, 21.13] 2002

Horie et al 1/44 5/39 0.21 [0.04, 1.11] 1998

Schoemig et al 4/182 8/183 0.51 [0.16, 1.60] 2005

Silva et al 0/18 2/18 0.13 [0.01, 2.12] 2005

Steg et al 8/109 9/103 0.83 [0.31, 2.23] 2004

Zeymer et al 6/149 17/151 0.36 [0.15, 0.84] 2003

Total (95% CI) 1683 1676 0.84 [0.65, 1.10]




0.1 0.2 0.5 1 2 5 10


Outcome: Death from all causes

Results: Impact of OAT Results: Impact of OAT studystudy

Study PCI Medical Rx Peto OR Peto ORor sub-category n/N n/N 95% CI 95% CI Year

Dzavik et al (1994) 1/25 1/19 0.75 [0.04, 12.76] 1994 OAT (2006) 173/1082 153/1084 1.16 [0.91, 1.47] 2006 Ellis et al 2/42 3/45 0.71 [0.12, 4.26] 1992 Hochman et al 9/32 8/34 1.27 [0.42, 3.79] 2002 Horie et al 4/44 12/39 0.25 [0.09, 0.75] 1998 Schoemig et al 13/182 12/183 1.10 [0.49, 2.47] 2005 Silva et al 0/18 3/18 0.12 [0.01, 1.23] 2005 Steg et al 14/109 16/103 0.80 [0.37, 1.73] 2004 Zeymer et al 9/149 24/151 0.37 [0.18, 0.76] 2003

Total (95% CI) 1683 1676 0.96 [0.79, 1.17]Total events: 225 (PCI), 232 (Medical Rx)Test for heterogeneity: Chi² = 18.82, df = 8 (P = 0.02), I² = 57.5%Test for overall effect: Z = 0.39 (P = 0.69)

0.1 0.2 0.5 1 2 5 10


Outcome: Composite of death, non-fatal MI, Outcome: Composite of death, non-fatal MI,

hospitalization for CHFhospitalization for CHF

Results: Impact of OATResults: Impact of OAT

Study EF change % (random) EF change % (random)

or sub-category EF change % (SE) 95% CI 95% CI Year

Dzavik et al (1994) 1.2000 (1.5100) 1.20 [-1.76, 4.16] 1994

TOSCA-2 (2006) 0.8000 (0.4500) 0.80 [-0.08, 1.68] 2006

Ellis et al -1.0000 (0.8600) -1.00 [-2.69, 0.69] 1992

Horie et al 3.8000 (0.7600) 3.80 [2.31, 5.29] 1998

Silva et al 4.2400 (1.9100) 4.24 [0.50, 7.98] 2005

Steg et al 5.0000 (0.8500) 5.00 [3.33, 6.67] 2004

Total (95% CI) 2.25 [0.30, 4.19]

Test for heterogeneity: Chi² = 38.41, df = 5 (P < 0.00001), I² = 87.0%


10 5 0 -5 -10

Favours PCI Favours Medical Rx

Outcome: Change in LVEF

Results: Impact of OATResults: Impact of OATOutcomes: Changes in EDV and ESV

Study ESVI change (random) ESVI change (random)or sub-category ESVI change (SE) 95% CI 95% CI Year

Horie et al -7.3000 (1.7900) -7.30 [-10.81, -3.79] 1998Silva et al -6.4000 (2.2900) -6.40 [-10.89, -1.91] 2005TOSCA-2 (OAT) 2006 -2.7000 (1.6900) -2.70 [-6.01, 0.61] 2006

Total (95% CI) -5.33 [-8.32, -2.35]Test for heterogeneity: Chi² = 3.84, df = 2 (P = 0.15), I² = 47.9%Test for overall effect: Z = 3.50 (P = 0.0005)

-10 -5 0 5 10


Study EDVI change (random) EDVI change (random)or sub-category EDVI change (SE) 95% CI 95% CI Year

Horie et al -8.7000 (2.0000) -8.70 [-12.62, -4.78] 1998Silva et al -5.2000 (2.5700) -5.20 [-10.24, -0.16] 2005TOSCA-2 (OAT) 2006 -2.1000 (1.1100) -2.10 [-4.28, 0.08] 2006

Total (95% CI) -5.10 [-9.44, -0.77]Test for heterogeneity: Chi² = 8.64, df = 2 (P = 0.01), I² = 76.9%Test for overall effect: Z = 2.31 (P = 0.02)

-10 -5 0 5 10


LimitationsLimitations Conflicting results for clinical end-points before and Conflicting results for clinical end-points before and

after addition OAT trial dataafter addition OAT trial data Inherent limitations of individual studies within Inherent limitations of individual studies within

meta-analysis impact on overall resultmeta-analysis impact on overall result Possible small study selection biasPossible small study selection bias Wide range of publication datesWide range of publication dates

Significant improvements in the medical management of acute Significant improvements in the medical management of acute MI over timeMI over time

Change in PCI technology itself over timeChange in PCI technology itself over time Some important differences in study designSome important differences in study design

Lack of apparent statistical heterogeneityLack of apparent statistical heterogeneity Important to note some key methodologic differencesImportant to note some key methodologic differences

Pre-treatment with thrombolyticsPre-treatment with thrombolytics Inclusion of patients with total IRA occlusion vs “significant Inclusion of patients with total IRA occlusion vs “significant

stenosis”stenosis” Variable length of follow-upVariable length of follow-up

ConclusionsConclusions

Regarding PCI in Regarding PCI in stable stable survivors of survivors of acute STEMI, current data including acute STEMI, current data including the recent OAT shows that the recent OAT shows that late (> late (> 12hrs) PCI12hrs) PCI is is neitherneither superiorsuperior nor nor inferiorinferior to optimal medical therapy to optimal medical therapy alone in terms of altering survival, or alone in terms of altering survival, or any other combined clinical endpointany other combined clinical endpoint

ConclusionsConclusions

Change in EF and measurements of EDV and Change in EF and measurements of EDV and ESV show statistically significant improvement ESV show statistically significant improvement with PCI beyond medical therapy alonewith PCI beyond medical therapy alone

Discrepancy between lack of clinical benefit Discrepancy between lack of clinical benefit and apparent improvement in EF raises and apparent improvement in EF raises interesting questions:interesting questions: Is the difference in the change in EF a real Is the difference in the change in EF a real

phenomenon, and if so, is it large enough to be phenomenon, and if so, is it large enough to be clinically relevant?clinically relevant?

Are benefits of reduction in adverse cardiac Are benefits of reduction in adverse cardiac remodeling and improved EF offset by late adverse remodeling and improved EF offset by late adverse events?events?

AcknowledgementsAcknowledgements

A special thanks to Dr George A special thanks to Dr George Vetrovec and the VCU Pauley Heart Vetrovec and the VCU Pauley Heart Center Department of CardiologyCenter Department of Cardiology

DiscussionDiscussion

Areas of ongoing uncertaintyAreas of ongoing uncertainty Patients with contraindications to important Patients with contraindications to important

medications considered standard of care post-medications considered standard of care post-MI, e.g. beta-blockers, statins, ACE inhibitorsMI, e.g. beta-blockers, statins, ACE inhibitors

Subgroups of patients may preferentially Subgroups of patients may preferentially benefit from revascularization in the setting benefit from revascularization in the setting of late MIof late MI

Patients with more severe LV dysfunction e.g. < Patients with more severe LV dysfunction e.g. < 30%30%

Patients presenting between 12-72 hoursPatients presenting between 12-72 hours Patients with demonstrable myocardial viabilityPatients with demonstrable myocardial viability

Excluded StudiesExcluded StudiesStudyStudy Reason for Reason for

exclusionexclusionGershlick AHGershlick AH, et al. , et al. NEJM 2005 Dec 29;353(26):2758-68. NEJM 2005 Dec 29;353(26):2758-68. Randomized within 12 hrsRandomized within 12 hrs

Sutton AG,Sutton AG, et al et al. . MERLINMERLIN trial. JACC 2004 Jul trial. JACC 2004 Jul 21;44(2):287-96. 21;44(2):287-96.

Randomized within 12 hrsRandomized within 12 hrs

Miyamoto S,Miyamoto S, et al. et al. Jpn Circ J. 2001 May;65(5):389-94. Jpn Circ J. 2001 May;65(5):389-94. Randomized within 12 hrsRandomized within 12 hrs

Vermeer FVermeer F, , et al. Heart 1999 Oct;82(4):426-31. et al. Heart 1999 Oct;82(4):426-31. Randomized within 12 hrsRandomized within 12 hrs

Ellis SGEllis SG, et al., et al. Circulation 1994 Nov;90(5):2280-4. Circulation 1994 Nov;90(5):2280-4. Randomized within 8 hrsRandomized within 8 hrs

Topol EJTopol EJ, et al., et al. Circulation. 1992 Jun;85(6):2090-9. Circulation. 1992 Jun;85(6):2090-9. Randomized within 12 hrsRandomized within 12 hrs

Gibson CM,Gibson CM, et al. et al. Am J Cardiol. 1997 Jul 1;80(1):21-6. Am J Cardiol. 1997 Jul 1;80(1):21-6. Comparison of PCTA vs non-PCTA outcomes was Comparison of PCTA vs non-PCTA outcomes was retrospective and non-randomized.retrospective and non-randomized.

Barbash GI,Barbash GI, et al et al. 1990 Sep 1;66(5):538-45.. 1990 Sep 1;66(5):538-45. Randomized to angiography rather than intervention, only Randomized to angiography rather than intervention, only small percentage of invasive arm had intervention, small percentage of invasive arm had intervention, significant cross-over observed for recurrent ischemia in the significant cross-over observed for recurrent ischemia in the control arm – rate of angioplasty in invasive arm 49/97 control arm – rate of angioplasty in invasive arm 49/97 (50.5%), rate of angioplasty in conservative arm 20/104 (50.5%), rate of angioplasty in conservative arm 20/104 (19.2%)(19.2%)

van Loon RBvan Loon RB, et al. , et al. The VIAMI-trialThe VIAMI-trial Curr Control Trials Curr Control Trials Cardiovasc Med. 2004 Nov 11;5(1):11.Cardiovasc Med. 2004 Nov 11;5(1):11.

Randomization limited to angiography and not specifically to Randomization limited to angiography and not specifically to the PCI as the intervention of interest. Only 77 out of 106 the PCI as the intervention of interest. Only 77 out of 106 patients randomized to angiography were then non-randomly patients randomized to angiography were then non-randomly selected to undergo PCI.selected to undergo PCI.

Study Design of Included Study Design of Included StudiesStudiesStudyStudy Key Study FeaturesKey Study Features

TOPS LyticsLytics within 6hrs of symptom onset within 6hrs of symptom onset

Negative / Equivocal stress testNegative / Equivocal stress test

IRA stenosis ≥ 50% IRA stenosis ≥ 50% (total occlusion (total occlusion notnot a requirement) a requirement)

TOMIIS First Q-wave MI 5 days to 6 weeks from onsetFirst Q-wave MI 5 days to 6 weeks from onset

Randomized if found to have Randomized if found to have total IRA occlusiontotal IRA occlusion

Horie et al. STEMI 24hrs to 3 weeks from onsetSTEMI 24hrs to 3 weeks from onset

TOAT Acute anterior MI, stable patientsAcute anterior MI, stable patients

EF < 50% or ≥ 3 pathologic Q-wavesEF < 50% or ≥ 3 pathologic Q-waves

Total IRA occlusion Total IRA occlusion on angiogramon angiogram

Zeymer et al. STEMI within 8-42 daysSTEMI within 8-42 days

IRA occlusion OR significant stenosis IRA occlusion OR significant stenosis (total occlusion (total occlusion notnot a requirement) a requirement)

DECOPI First Q-wave MIFirst Q-wave MI

Total occlusion of IRATotal occlusion of IRA on angiogram performed at least 48hrs from onset on angiogram performed at least 48hrs from onset

BRAVE-2 STEMI 12-48 hrs from onsetSTEMI 12-48 hrs from onset

Excluded if unstable or Excluded if unstable or if lytics givenif lytics given

Silva et al. Anterior MI 12hrs to 14 days from onsetAnterior MI 12hrs to 14 days from onset

Total occlusionTotal occlusion of IRAof IRA and persistent ST elevation of ≥ 1mm in ≥2 leads and persistent ST elevation of ≥ 1mm in ≥2 leads

OAT Evidence of acute MI within past 3-28 daysEvidence of acute MI within past 3-28 days

Total occlusion of IRATotal occlusion of IRA

Stable (no ischemia / angina, hemodynamically stable), ≥ 1 high risk featureStable (no ischemia / angina, hemodynamically stable), ≥ 1 high risk feature

Studies excluded from EF Studies excluded from EF datadata

StudyStudy Reason for excluding from Reason for excluding from EF calculationsEF calculations

ZeymerZeymer Baseline and follow-up EF data Baseline and follow-up EF data not available for comparisonnot available for comparison

BRAVE-2BRAVE-2 Follow-up EF data not available Follow-up EF data not available for comparisonfor comparison

TOATTOAT Earliest EF data at 6 weeks Earliest EF data at 6 weeks post-randomization, thus no post-randomization, thus no true baseline EF data available true baseline EF data available for comparisonfor comparison


(sensitivity analysis including TOAT)(sensitivity analysis including TOAT)

Study EF change % (random) Weight EF change % (random)

or sub-category EF change % (SE) 95% CI % 95% CI Year

TOPS 2.0000 (1.1800) 18.00 2.00 [-0.31, 4.31] 1992

TOMIIS 1.2000 (1.5100) 13.28 1.20 [-1.76, 4.16] 1994

Horie 2.8000 (1.2100) 17.50 2.80 [0.43, 5.17] 1998

TOAT 2.0000 (1.2300) 17.17 2.00 [-0.41, 4.41] 2002

DECOPI 5.0000 (0.8500) 24.61 5.00 [3.33, 6.67] 2004

Silva et al 4.2400 (1.9100) 9.45 4.24 [0.50, 7.98] 2005

Total (95% CI) 100.00 2.98 [1.67, 4.30]


Test for overall effect: Z = 4.45 (P < 0.00001)

10 5 0 -5 -10

Favours PCI

Favours Medical Rx

Outcome: Change in LVEFOutcome: Change in LVEF

Test for small study biasTest for small study bias

Review: Late percutaneous coronary intervention for infarct-related artery occlusionComparison: 01 Late percutaneous coronary intervention vs best medical therapy for infarct-related artery occlusion Outcome: 01 Death

0.1 0.2 0.5 1 2 5 10

0.0

0.4

0.8

1.2

1.6

SE(log Peto OR)

Peto OR

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LATE PERCUTANEOUS CORONARY INTERVENTION AFTER MYOCARDIAL INFARCTION: A META-ANALYSIS Presenter: Darryn L. Appleton, MBChB Coauthors: Antonio Abbate, MD,