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Rescue Angioplasty after Failed Thrombolytic Therapy for Patients with Acute Myocardial Infarction Results in Higher Survival Rate

January 13, 2006

By: Sahar Bedrood B.S. and Asher Kimchi M.D.

Leicester, UK - In patients who have had a myocardial infarction, intravenous thrombolysis is the first-line treatment, but primary percutaneous coronary intervention (PCI) is increasingly being used to restore flow to arteries. Until this study, by Anthony Gershlick M.B, B.S. et al from the University Hospitals of Leicester in the United Kingdom, appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remained unclear. The study, published in the December 29, 2005 issue of The New England Journal of Medicine, found event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment.

The study consisted of 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), which consisted of standard therapy for myocardial infraction other than thrombolysis or PCI, or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months.

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.

The study of the three therapeutic options after failed thrombolytic therapy found that rescue PCI was associated with a statistically significant reduction in the incidence of major adverse cardiac and cerebrovascular events, as compared with either repeated thrombolysis or conservative management. This information can be used to determine appropriate treatment in patients with failed thrombolytic therapy after myocardial infarction.

Co-authors: 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

 


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