Chicago 2014 TFQO: Nikolaos Nikolaou COI#253 EVREV 1: Nikolaos Nikolaou COI#253 EVREV 2: Farzin BeyguiCOI#202 Taskforce: ACS STEMI transfer PCI vs. FL and routine early angio (PICO ID#779)

COI Disclosure (SPECIFIC to this systematic review) Nikolaos Nikolaou COI#253 Commercial/industry: None Potential intellectual conflicts: None Farzin Beygui#202 Commercial/industry: None Potential intellectual conflicts: None

2010 Treatment Recommendation 2010: NO TREATMENT RECOMMENDATION

C2015 PICO Population: Adult patients with STEMI in the ED (of a non-PCI capable hospital) Intervention: immediate inhospital fibrinolysis and routine transfer for angiography at 3-6 hours (or up to 24 hours) Comparison: transfer for PPCI Outcomes: (short term mortality: 9, reinfarction: 5, stroke: 6, major bleeding: 6.)

Inclusion/Exclusion & Articles Found List Inclusions/Exclusions Studies in which all or the majority of STEMI patients had: Recruitment in the ED of a non PCI hospital FL in the emergency department Angiography within >3and up to 24 h from FL. Exclusion: Studies in which all or the majority of STEMI patients had: FL in the pre-hospital setting angiography within 3 h from FL half dose FL, or half dose FL+GPIIb-IIIa antgonists

Number of Articles initially identified: 706 and number Finally Included in Evidence Profile tables RCTs:2 non-RCTs: 1

NN BF

Non-RCT bias asssesment StudyYearDesign Total Patients PopulationIndustry Funding Eligibility Criteria Exposure/Outcome Confounding Follow up Danchin 2008 Non-RCT 828STEMI Pfizer, Servier, French Caisse Nationale d’Assurance Maladie (National Health) Low HighLow

For the critical outcome of “30 day mortality” we have identified low quality evidence -downgraded for imprecision and indirectness -from 2 RCTs enrolling 337 patients with STEMI showing no difference (OR % CI 0.24 – 2.98) For the critical outcome of “30 day mortality” we have also identified 1 nonRCT of very low quality evidence-downgraded for risk of bias and imprecision, showing no difference (OR % CI 0.48 – 1.55) For the critical outcome of ICH we have identified low quality evidence, downgraded for imprecision and indirectness, from 2 RCTs enrolling 337 patients with STEMI showing no difference (OR %CI: ).

For the important outcome of “Reinfarction”, we have identified low quality evidence -downgraded for imprecision and indirectness -from the same 2 RCTs enrolling 337 patients with STEMI showing no difference (OR 2.11, 95% CI: 0.51 – 8.64). For the important outcome of “Reinfarction” we also identified 1 nonRCT of very low quality evidence-downgraded for risk of bias and imprecision- showing no difference (OR % CI 0.73 – 6.61) For the important outcome of “Stroke” we have identified low quality evidence -downgraded for imprecision and indirectness -from the same 2 RCTs enrolling 416 patients with STEMI showing no difference (OR % CI: 0.06 – 15.58). For the important outcome of “Stroke” we also identified 1 non RCT of very low quality evidence-downgraded for risk of bias and imprecision showing no difference % CI 0.41 – 5.67) For the important outcome of “Major bleeding” we have identified low quality evidence -downgraded for imprecision and indirectness -from the same 2 RCTs enrolling 337 patients with STEMI showing no difference (OR 1.33, 95% CI: 0.32 – 5.47). For the important outcome of “major bleeding” we also identified 1 non RCT of very low quality evidence-downgraded for risk of bias and imprecision (OR % CI 0.26 – 1.63)

Draft Treatment Recommendations For patients presenting in the ED of a non-PCI hospital we suggest for fibrinolytic therapy with routine transfer for angiography as an equivalent to PPCI. In making this recommendation we place a higher value on not allocating resource to an unproven intervention over any yet to be proven benefit for critical or important outcomes Patients with contraindications to fibrinolysis were excluded. This recommendation is particularly valuable in case patients cannot be transferred to a PPCI capable center in a timely manner.

Knowledge Gaps *DO NOT USE FOR PLENARY* - BREAKOUT ONLY Other specific worksheets that would be helpful Patient subgroups (cardiogenic shock) Interventions (pharmakoinvasive approach- pre-hospital fibrinolysis) Outcomes: Specific research required: same topic

30 day mortality-Inconsistency

Inconsistency-reinfarction

Inconsistency-Stroke

Inconsistency-Major bleeding

Inconsistency-ICH