A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction: the Middlesbrough Early Revascularization to Limit INfarction (MERLIN) trial.
OBJECTIVE
We sought to compare emergency coronary angiography with or without rescue percutaneous coronary intervention (PCI) with conservative treatment in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction (STEMI).


BACKGROUND
Most patients with STEMI receive fibrinolytic therapy and aspirin. The management of failed fibrinolysis is unclear.


METHODS
A total of 307 patients with STEMI and failed fibrinolysis were randomized to emergency coronary angiography with or without rescue PCI or conservative treatment.


RESULTS
Thirty-day all-cause mortality was similar in the rescue and conservative groups (9.8% vs. 11%, p = 0.7, risk difference [RD] 1.2%, 95% confidence interval [CI] -5.8 to 8.3). The composite secondary end point of death/re-infarction/stroke/subsequent revascularization/heart failure occurred less frequently in the rescue group (37.3% vs. 50%, p = 0.02, RD 12.7%, 95% CI 1.6 to 23.5), driven by less subsequent revascularization (6.5% vs. 20.1%, p < 0.01, RD 13.6%, 95% CI 6.2 to 21.4). Re-infarction and clinical heart failure were less common in the rescue group (7.2% vs. 10.4%, p = 0.3, RD 3.2%, 95% CI -3.3 to 9.9; and 24.2% vs. 29.2%, p = 0.3, RD 5.7%, 95% CI -4.3 to 15.6, respectively). Strokes and transfusions were more common in the rescue group (4.6% vs. 0.6%, p = 0.03, RD 3.9%, 95% CI 0.5 to 8.6; and 11.1% vs. 1.3%, p < 0.001, RD 9.8%, 95% CI 4.9 to 19.9, respectively). Left ventricular function at 30 days was the same in the two groups.


CONCLUSIONS
Rescue angioplasty did not improve survival by 30 days, but improved event-free survival, almost completely due to a reduction in subsequent revascularization. Rescue angioplasty was associated with more strokes and more transfusions and did not result in preservation of left ventricular systolic function at 30 days.
Sutton
Andrew G C
AG
The James Cook University Hospital, Middlesbrough, UK.
Campbell
Philip G
PG
Graham
Richard
R
Price
Dallas J A
DJ
Gray
Janine C
JC
Grech
Ever D
ED
Hall
James A
JA
Harcombe
Alun A
AA
Wright
Robert A
RA
Smith
Roger H
RH
Murphy
Jerry J
JJ
Shyam-Sundar
Ananthaiah
A
Stewart
Michael J
MJ
Davies
Adrian
A
Linker
Nicholas J
NJ
de Belder
Mark A
MA
D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D003326:Coronary Circulation; D018572:Disease-Free Survival; D004562:Electrocardiography; D004630:Emergencies; D005260:Female; D006333:Heart Failure / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012008:Recurrence; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D015996:Survival Rate; D015912:Thrombolytic Therapy; D017211:Treatment Failure