Effect of fibrinolytic therapy on ST-elevation myocardial infarction clinical outcomes during the COVID-19 pandemic: A systematic review and meta-analysis


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, Rochester Regional HealthFollow
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, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States.
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.


Internal Medicine

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World Journal of Cardiology


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.

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