Rescue Angioplasty after Failed Thrombolytic Therapy for Acute Myocardial Infarction
Anthony H. Gershlick, M.B., B.S., Amanda Stephens-Lloyd, R.N., M.Sc., Sarah Hughes, R.N., B.A., Keith R. Abrams, Ph.D., Suzanne E. Stevens, M.Sc., Neal G. Uren, M.D., Adam de Belder, M.D., John Davis, M.B., B.S., Michael Pitt, M.B., B.S., Adrian Banning, M.D., Andreas Baumbach, M.D., Man Fai Shiu, M.D., Peter Schofield, M.D., Keith D. Dawkins, M.D., Robert A. Henderson, M.D., Keith G. Oldroyd, M.D., Robert Wilcox, M.D., for the REACT Trial Investigators
Background The appropriate treatment for patients in whom reperfusionfails to occur after thrombolytic therapy for acute myocardialinfarction remains unclear. There are few data comparing emergencypercutaneous coronary intervention (rescue PCI) with conservativecare in such patients, and none comparing rescue PCI with repeatedthrombolysis.
Methods We conducted a multicenter trial in the United Kingdominvolving 427 patients with ST-segment elevation myocardialinfarction in whom reperfusion failed to occur (less than 50percent ST-segment resolution) within 90 minutes after thrombolytictreatment. The patients were randomly assigned to repeated thrombolysis(142 patients), conservative treatment (141 patients), or rescuePCI (144 patients). The primary end point was a composite ofdeath, reinfarction, stroke, or severe heart failure withinsix months.
Results The rate of event-free survival among patients treatedwith rescue PCI was 84.6 percent, as compared with 70.1 percentamong those receiving conservative therapy and 68.7 percentamong those undergoing repeated thrombolysis (overall P=0.004).The adjusted hazard ratio for the occurrence of the primaryend point for repeated thrombolysis versus conservative therapywas 1.09 (95 percent confidence interval, 0.71 to 1.67; P=0.69),as compared with adjusted hazard ratios of 0.43 (95 percentconfidence interval, 0.26 to 0.72; P=0.001) for rescue PCI versusrepeated 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 allcauses. Nonfatal bleeding, mostly at the sheath-insertion site,was more common with rescue PCI. At six months, 86.2 percentof the rescue-PCI group were free from revascularization, ascompared with 77.6 percent of the conservative-therapy groupand 74.4 percent of the repeated-thrombolysis group (overallP=0.05).
Conclusions Event-free survival after failed thrombolytic therapywas significantly higher with rescue PCI than with repeatedthrombolysis or conservative treatment. Rescue PCI should beconsidered for patients in whom reperfusion fails to occur afterthrombolytic 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.
Rescue Angioplasty after Thrombolysis
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.
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