Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic: A systematic review and meta-analysis
Bibliographic record
Abstract
e are in the midst of a generation-defining global pandemic, the scope, scale, and pace of which is unprecedented.Coronavirus 2019 (CO-VID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus), occurs in addition to existing challenges to emergency services, like ST-elevation myocardial infarction (STEMI).Both conditions may coexist, initial presentations can overlap, and true and reliable point-of-care testing does not exist.Furthermore, symptoms alone are unhelpful, as most screened for COVID-19 test negative (30% can be false negative) and ≈80% of COVID-19 infections are asymptomatic.Experts dealing with the COVID-19 epidemic in China recommend fibrinolytic therapy (FT) over primary percutaneous coronary intervention (PPCI) for STEMI.In this perspective, we analyze the arguments for a FT-based strategy in patients presenting with STEMI in the COVID-19 era.Collectively, we feel that this is a reasonable consideration, because fibrinolysis may be the best compromise of prompt reperfusion for the patient with the least resource implications for the institution, buying time for a complete clinical picture to be made.In caring for our patients, we must recognize that optimal care strategies, established outside the challenges of a pandemic, may be potentially suboptimal during one. SAFETY AND EFFICACY OF FIBRINOLYTIC THERAPYFT was the first effective reperfusion treatment to be systematically implemented for STEMI.Subsequently, PPCI was proven superior to FT, becoming the standard of STEMI care across the Western world.Yet, geographically isolated areas with low population density retain fibrinolytic-focused reperfusion strategies (≈2% to 13% of STEMIs in contemporary US practice), 1 as do most developing countries.STREAM (Strategic Reperfusion Early After Myocardial Infarction) was a contemporary fibrinolytic trial, recruiting STEMI patients ≤3 hours of symptom onset, who were unable to access PPCI ≤1 hour of first medical contact.Patients were randomized to FT, with PCI after 6 to 24 hours, or PPCI (median difference between fibrinolytic administration and PCI ≥78 minutes).Outcomes of FT versus PPCI were similar for the composite of death, shock, heart failure, or reinfarction.Need for emergent angiography in the fibrinolytic arm was 36%; mortality was <5% in both groups.Intracranial hemorrhage was higher with FT (1.0% vs 0.5%, P=0.02). 2 Bottom line: When delays in PPCI are unavoidable, a pharmacoinvasive approach is not worse than PPCI in the P2Y12 inhibitor era. SYSTEM DELAYS IN PPCITimely PPCI relies heavily on systems of care, not just individual operators.PPCI treatment delays in the COVID-19 era arise, even among COVID-19 negative
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.008 | 0.026 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.017 | 0.027 |
| Bibliometrics | 0.005 | 0.006 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.001 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.004 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".