Abstract / Summary
Introduction and objectives: Persistent microvascular obstruction and incomplete myocardial reperfusion remain major challenges in ST-segment elevation myocardial infarction (STEMI) despite timely primary percutaneous coronary intervention (pPCI).Adjunctive intracoronary fibrinolysis has re-emerged as a potential strategy to improve tissue-level reperfusion, but the effect of low-dose prourokinase remains uncertain.Methods: We performed a systematic review and meta-analysis of randomized controlled trials evaluating adjunctive intracoronary low-dose prourokinase during pPCI in adults with STEMI.CENTRAL, LILACS, MEDLINE/PubMed, trial registries, and citation sources were searched from inception through 12 January 2026.Risk of bias was assessed using RoB 2. Random-effects meta-analyses were conducted using risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (95%CIs).Results: Six randomized trials including 1328 patients were eligible.Compared with control, adjunctive intracoronary low-dose prourokinase significantly improved complete ST-segment resolution (RR, 1.28; 95%CI, 1.12-1.46;P < .001)and final TIMI grade 3 flow (RR, 1.08; 95%CI, 1.03-1.14;P = .002).Furthermore, it was associated with a lower corrected TIMI frame count and reduced peak cardiac biomarker levels.No clear difference was observed in 30-day major adverse cardiovascular events (MACE), although a signal toward lower 6-month MACE was observed in 3 trials (RR, 0.59; 95%CI, 0.38-0.92;P = .02).Safety evidence for major bleeding was limited to 2 trials and remained imprecise.Conclusions: Adjunctive intracoronary low-dose prourokinase appears to improve myocardial reperfusion.However, current evidence is insufficient to confirm clinical benefit or exclude a clinically meaningful increase in major bleeding; larger contemporary trials are needed to determine whether these benefits translate into meaningful clinical advantages.PROSPERO CRD420261284192.