title: 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.
abstract: 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.
authors.affiliation: The James Cook University Hospital, Middlesbrough, UK.
authors.forename: Andrew G C
authors.initials: AG
authors.lastname: Sutton
authors.forename: Philip G
authors.initials: PG
authors.lastname: Campbell
authors.forename: Richard
authors.initials: R
authors.lastname: Graham
authors.forename: Dallas J A
authors.initials: DJ
authors.lastname: Price
authors.forename: Janine C
authors.initials: JC
authors.lastname: Gray
authors.forename: Ever D
authors.initials: ED
authors.lastname: Grech
authors.forename: James A
authors.initials: JA
authors.lastname: Hall
authors.forename: Alun A
authors.initials: AA
authors.lastname: Harcombe
authors.forename: Robert A
authors.initials: RA
authors.lastname: Wright
authors.forename: Roger H
authors.initials: RH
authors.lastname: Smith
authors.forename: Jerry J
authors.initials: JJ
authors.lastname: Murphy
authors.forename: Ananthaiah
authors.initials: A
authors.lastname: Shyam-Sundar
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Stewart
authors.forename: Adrian
authors.initials: A
authors.lastname: Davies
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Linker
authors.forename: Mark A
authors.initials: MA
authors.lastname: de Belder
mesh_terms: 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