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Previous Volume 353:2758-2768 December 29, 2005 Number 26 Next

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ABSTRACT

Background The appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remains unclear. There are few data comparing emergency percutaneous coronary intervention (rescue PCI) with conservative care in such patients, and none comparing rescue PCI with repeated thrombolysis.

Methods We conducted a multicenter trial in the United Kingdom involving 427 patients with ST-segment elevation myocardial infarction in whom reperfusion failed to occur (less than 50 percent ST-segment resolution) within 90 minutes after thrombolytic treatment. The patients were randomly assigned to repeated thrombolysis (142 patients), conservative treatment (141 patients), or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months.

Results The rate of event-free survival among patients treated with rescue PCI was 84.6 percent, as compared with 70.1 percent among those receiving conservative therapy and 68.7 percent among those undergoing repeated thrombolysis (overall P=0.004). The adjusted hazard ratio for the occurrence of the primary end point for repeated thrombolysis versus conservative therapy was 1.09 (95 percent confidence interval, 0.71 to 1.67; P=0.69), as compared with adjusted hazard ratios of 0.43 (95 percent confidence interval, 0.26 to 0.72; P=0.001) for rescue PCI versus repeated thrombolysis and 0.47 (95 percent confidence interval, 0.28 to 0.79; P=0.004) for rescue PCI versus conservative therapy. There were no significant differences in mortality from all causes. Nonfatal bleeding, mostly at the sheath-insertion site, was more common with rescue PCI. At six months, 86.2 percent of the rescue-PCI group were free from revascularization, as compared with 77.6 percent of the conservative-therapy group and 74.4 percent of the repeated-thrombolysis group (overall P=0.05).

Conclusions Event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment. Rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy.

Source Information

From the Department of Cardiology, University Hospitals of Leicester, Leicester (A.H.G., A.S.-L., S.H.); the Departments of Health Sciences (K.R.A.) and Cardiovascular Sciences (S.E.S.), University of Leicester, Leicester; the Department of Cardiology, Royal Infirmary Edinburgh, Edinburgh (N.G.U.); Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton (A. de Belder); the Department of Cardiology, North Staffordshire Hospital, Stoke-on-Trent (J.D.); the Department of Cardiology, Heartlands Hospital, Birmingham (M.P.); the Department of Cardiology, John Radcliffe Hospital, Oxford (A. Banning); the Department of Cardiology, Bristol Royal Infirmary, Bristol (A. Baumbach); the Department of Cardiology, Walsgrave Hospital, Coventry (M.F.S.); the Department of Cardiology, Papworth Hospital, Cambridge (P.S.); Wessex Cardiac Unit, Southampton General Hospital, Southampton (K.D.D.); Trent Cardiac Centre, Nottingham City Hospital, Nottingham (R.A.H.); the Department of Cardiology, Western Infirmary, Glasgow (K.G.O.); and the Department of Cardiovascular Medicine, Queens Medical Centre, Nottingham (R.W.) — all in the United Kingdom.

Address reprint requests to Dr. Gershlick at the University Hospitals of Leicester, Groby St., Leicester LE3 9QP, United Kingdom, or at agershlick{at}aol.com.

Full Text of this Article

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Owen A., Aziz S., Ramsdale D., Sharma S., Bhambi B., Nyitray W., Viswanathan G. N., Sankar S., Gershlick A. H., Stephens-Lloyd A., Wilcox R.
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N Engl J Med 2006; 354:1639-1641, Apr 13, 2006. Correspondence

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