Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jun 26, 2023; 15(6): 309-323
Published online Jun 26, 2023. doi: 10.4330/wjc.v15.i6.309
Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic: A systematic review and meta-analysis
Anwar Khedr, Hussam Al Hennawi, Muhammed Khuzzaim Khan, Mostafa Elbanna, Abbas B Jama, Ekaterina Proskuriakova, Hisham Mushtaq, Mikael Mir, Sydney Boike, Ibtisam Rauf, Aalaa Eissa, Meritxell Urtecho, Thoyaja Koritala, Nitesh Jain, Lokesh Goyal, Salim Surani, Syed A Khan
Anwar Khedr, Department of Internal Medicine, BronxCare Health System, Bronx, NY 10457, United States
Hussam Al Hennawi, Department of Internal Medicine, Jefferson Abington Hospital, Abington, PA 19001, United States
Muhammed Khuzzaim Khan, Department of Internal Medicine, Dow University of Health Science, Karachi 74200, Pakistan
Mostafa Elbanna, Department of Internal Medicine, Rochester Regional Health, Rochester, NY 14621, United States
Abbas B Jama, Department of Critical Care, Mayo Clinic Health System, Mankato, MN 56001, United States
Ekaterina Proskuriakova, Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, United States
Hisham Mushtaq, Department of Internal Medicine, St. Vincent's Medical Center, Bridgeport, CT 06606, United States
Mikael Mir, Sydney Boike, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
Ibtisam Rauf, Department of Medicine, St. George's University, School of Medicine, St George SW17 0RE, Grenada
Aalaa Eissa, Department of Medicine, KFS University, KFS 33511, Egypt
Meritxell Urtecho, Department of Medicine, Robert D and Patricia E. Kern Center of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, United States
Thoyaja Koritala, Department of Hospital Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
Nitesh Jain, Department of Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
Lokesh Goyal, Department of Hospital Medicine, Christus Sphon Hospital-shoreline, Corpus Christo, TX 78404, United States
Salim Surani, Department of Pulmonary, Critical Care & Sleep Medicine, Texas A&M University, College Station, TX 77843, United States
Syed A Khan, Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
Author contributions: Khedr A substantial contributions to conception and design of the study, drafting the article, final approval; Hennawi HA acquisition of data, or analysis and interpretation of data, drafting the article, final approval; Khan MK analysis of data, revising and drafting the article, final approval; Elbanna M performed the data analysis, drafting the article, final approval; Jama AB and Proskuriakova E interpretation of data, drafting the article, final approval; Mushtaq H and Jain N contributed to the acquisition of data, revising the article, final approval; Mir M, Boike S, Rauf I, Eissa A, Koritala T, and Khan SA contributed to the interpretation of data, revising the article, final approval; Urtecho M contributed to the interpretation of data, making critical revisions, final approval; Surani S contributed to the acquisition of data, making critical revisions, final approval.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Salim Surani, FCCP, MD, MHSc, Professor, Department of Pulmonary, Critical Care & Sleep Medicine, Texas A&M University, Administration Building, 400 Bizzell St, College Station, TX 77843, United States. srsurani@hotmail.com
Received: December 9, 2022
Peer-review started: December 9, 2022
First decision: March 15, 2023
Revised: March 30, 2023
Accepted: May 19, 2023
Article in press: May 19, 2023
Published online: June 26, 2023
Abstract
BACKGROUND

ST-elevation myocardial infarction (STEMI) is the result of transmural ischemia of the myocardium and is associated with a high mortality rate. Primary percutaneous coronary intervention (PPCI) is the recommended first-line treatment strategy for patients with STEMI. The timely delivery of PPCI became extremely challenging for STEMI patients during the coronavirus disease 2019 (COVID-19) pandemic, leading to a projected steep rise in mortality. These delays were overcome by the shift from first-line therapy and the development of modern fibrinolytic-based reperfusion. It is unclear whether fibrinolytic-based reperfusion therapy is effective in improving STEMI endpoints.

AIM

To determine the incidence of fibrinolytic therapy during the COVID-19 pandemic and its effects on STEMI clinical outcomes.

METHODS

PubMed, Google Scholar, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were queried from January 2020 up to February 2022 to identify studies investigating the effect of fibrinolytic therapy on the prognostic outcome of STEMI patients during the pandemic. Primary outcomes were the incidence of fibrinolysis and the risk of all-cause mortality. Data were meta-analyzed using the random effects model to derive odds ratios (OR) and 95% confidence intervals. Quality assessment was carried out using the Newcastle-Ottawa scale.

RESULTS

Fourteen studies including 50136 STEMI patients (n = 15142 in the pandemic arm; n = 34994 in the pre-pandemic arm) were included. The mean age was 61 years; 79% were male, 27% had type 2 diabetes, and 47% were smokers. Compared with the pre-pandemic period, there was a significantly increased overall incidence of fibrinolysis during the pandemic period [OR: 1.80 (1.18 to 2.75); I2= 78%; P = 0.00; GRADE: Very low]. The incidence of fibrinolysis was not associated with the risk of all-cause mortality in any setting. The countries with a low-and middle-income status reported a higher incidence of fibrinolysis [OR: 5.16 (2.18 to 12.22); I2 = 81%; P = 0.00; GRADE: Very low] and an increased risk of all-cause mortality in STEMI patients [OR: 1.16 (1.03 to 1.30); I2 = 0%; P = 0.01; GRADE: Very low]. Meta-regression analysis showed a positive correlation of hyperlipidemia (P = 0.001) and hypertension (P < 0.001) with all-cause mortality.

CONCLUSION

There is an increased incidence of fibrinolysis during the pandemic period, but it has no effect on the risk of all-cause mortality. The low- and middle-income status has a significant impact on the all-cause mortality rate and the incidence of fibrinolysis.

Keywords: ST-elevation myocardial infarction, Myocardial infarction, Thrombolytic therapy, Fibrinolysis, COVID-19, Pandemics

Core Tip: The guideline-recommended time goals for primary percutaneous coronary intervention (PPCI) could not be met during the coronavirus disease 2019 (COVID-19) pandemic for the treatment of ST-elevation myocardial infarction (STEMI) patients. Leading cardiology societies recommended considering a new fibrinolytic-based reperfusion strategy during the time of the COVID-19 pandemic; however, previous large-scale studies have indicated that fibrinolytic therapy may offer a reduced prognostic value and poor survival outcomes in patients with STEMI compared to PPCI. We investigated the differential prevalence of the use of fibrinolytic therapy by healthcare systems belonging to countries with distinct income status, and its effect on the risk of all-cause mortality in STEMI patients.