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After Failed Fibrinolysis, Rescue PCI Is Best

Rescue PCI beat both repeat fibrinolysis and conservative care in the REACT trial.

What’s the best treatment strategy for acute-MI patients in whom fibrinolysis has failed? In this multicenter British trial, researchers randomized 427 such patients (mean age, 61) to undergo repeat fibrinolysis, conservative care (standard medical therapy), or coronary angiography followed by rescue PCI. Initial reperfusion failure (on 90-minute ECG) was defined as <50% ST-segment resolution in the lead showing the greatest initial ST-segment elevation.

For the entire cohort, the median time to first fibrinolytic treatment was 140 minutes from symptom onset and 27 minutes from presentation. The median additional delay to randomly assigned treatment was 84 minutes longer in the rescue-PCI group (39% of whom were transferred to other facilities) than in the repeat-fibrinolysis group (4.6 hours vs. 3.2 hours). Of the rescue-PCI group, 69% received stents and 43% received abciximab.

Incidence of the primary composite endpoint — death, recurrent MI, stroke, or severe heart failure (HF) at 6 months — was only 15.3% in the rescue-PCI group, but 29.8% in the conservative-care group and 31.0% in the repeat-fibrinolysis group (overall P=0.003). This difference was due to a significant advantage of rescue PCI in preventing recurrent MI (2.1% vs. 8.5% and 10.6%, respectively) and a nonsignificant mortality advantage (6.2% vs. 12.8% and 12.7%). Rates of stroke, severe HF, and major bleeding were similar among the groups. Notably, major bleeding was associated with no deaths in the rescue-PCI group, but with 3 and 5 deaths, respectively, in the other groups.

Comment: We now have clear evidence that rescue PCI is superior to conservative care and to repeat fibrinolysis in patients who do not initially achieve clinical reperfusion — evidence from a large study with high rates of stent and GPIIb/IIIa-inhibitor use among recipients of rescue PCI. The benefit emerged despite the need for transfer of many rescue-PCI patients and appeared to be independent of the time to PCI. Patients who do not achieve reperfusion with initial fibrinolysis should undergo rescue PCI whenever feasible.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology December 27, 2006

Citation(s):

Gershlick AH et al. for the REACT Trial Investigators. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005 Dec 29; 353:2758-68.

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