A COMPREHENSIVE SYSTEMATIC REVIEW: EFFICACY AND SAFETY OF PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Abstract

Introduction: ST-segment elevation myocardial infarction (STEMI) remains a leading cause of cardiovascular death worldwide. Percutaneous coronary intervention (PCI) has replaced fibrinolysis as the standard of care, yet the magnitude of benefit, durability, and safety trade-offs of modern PCI techniques remain incompletely quantified.

Methods: The study strictly adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines. Eligible designs: randomised controlled trials and comparative observational studies. Risk of bias assessed with RoB 2, ROBINS-I, and Newcastle-Ottawa Scale.

Results: Thirty-three studies (21 RCTs, 12 non-RCTs) with >320,000 patients met criteria. Compared with stand-alone fibrinolysis, primary PCI significantly reduced death-containing composites (RR 0.85; 95% CI 0.75–0.96; I²=0%; P=0.011), with benefit sustained to 16 years. In contemporary registries with PCI delay <60 minutes, benefit was larger (OR 0.38; 95% CI 0.32–0.44; P<0.001). Primary PCI was not superior to a pharmacoinvasive strategy when timely PCI was unavailable (RR 1.20; 95% CI 0.98–1.48; P=0.077). Complete revascularisation reduced cardiovascular death or myocardial infarction (HR 0.71; 95% CI 0.54–0.91; P=0.008). Radial access reduced mortality (OR 0.64; 95% CI 0.41–0.98; P=0.041) and major bleeding (4.4–5.8%). Routine thrombus aspiration conferred no mortality benefit and increased stroke (HR 1.66; 95% CI 1.10–2.51; P=0.015). Everolimus-eluting stents reduced the device-oriented composite at 10 years (HR 0.72; 95% CI 0.55–0.93). In cardiogenic shock, culprit-lesion-only PCI reduced death or renal-replacement therapy (RR 0.83; 95% CI 0.71–0.96). Reperfusion delay showed a monotonic relationship with mortality; prognostic models achieved AUC 0.709–0.959.

Discussion: The benefit of PCI in STEMI is not a single effect but a family of effects whose magnitude depends critically on time, comparator, anatomical target, and haemodynamic status. The advantage of primary PCI over fibrinolysis is durable to 16 years, driven predominantly by prevention of re-infarction and cardiac death. This advantage is time-dependent and is abolished once PCI delay exceeds ~2 hours, restoring the pharmacoinvasive strategy to legitimacy. The most striking safety findings: routine thrombectomy causes harm without benefit, whereas radial access delivers benefit largely by preventing access-site bleeding and acute kidney injury.

Conclusion: Primary PCI performed with system delay <2 hours is the most effective reperfusion strategy for STEMI, with superiority persisting to 16 years. Complete revascularisation, transradial access, and new-generation drug-eluting stents should be regarded as integral components of contemporary primary PCI, whereas routine thrombus aspiration and immediate multivessel intervention in cardiogenic shock should be avoided. Health systems with PCI delay >2 hours should implement a pharmacoinvasive pathway.