title: Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction.
abstract: BACKGROUND
  The appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction remains unclear. There are few data comparing emergency percutaneous coronary intervention (rescue PCI) with conservative care in such patients, and none comparing rescue PCI with repeated thrombolysis.
  
  
  METHODS
  We conducted 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), or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months.
  
  
  RESULTS
  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. There were no significant differences in mortality from all causes. Nonfatal bleeding, mostly at the sheath-insertion site, was more common with rescue PCI. At six months, 86.2 percent of the rescue-PCI group were free from revascularization, as compared with 77.6 percent of the conservative-therapy group and 74.4 percent of the repeated-thrombolysis group (overall P=0.05).
  
  
  CONCLUSIONS
  Event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment. Rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy.
authors.affiliation: Department of Cardiology, University Hospitals of Leicester, Leicester, United Kingdom. agershlick@aol.com
authors.forename: Anthony H
authors.initials: AH
authors.lastname: Gershlick
authors.forename: Amanda
authors.initials: A
authors.lastname: Stephens-Lloyd
authors.forename: Sarah
authors.initials: S
authors.lastname: Hughes
authors.forename: Keith R
authors.initials: KR
authors.lastname: Abrams
authors.forename: Suzanne E
authors.initials: SE
authors.lastname: Stevens
authors.forename: Neal G
authors.initials: NG
authors.lastname: Uren
authors.forename: Adam
authors.initials: A
authors.lastname: de Belder
authors.forename: John
authors.initials: J
authors.lastname: Davis
authors.forename: Michael
authors.initials: M
authors.lastname: Pitt
authors.forename: Adrian
authors.initials: A
authors.lastname: Banning
authors.forename: Andreas
authors.initials: A
authors.lastname: Baumbach
authors.forename: Man Fai
authors.initials: MF
authors.lastname: Shiu
authors.forename: Peter
authors.initials: P
authors.lastname: Schofield
authors.forename: Keith D
authors.initials: KD
authors.lastname: Dawkins
authors.forename: Robert A
authors.initials: RA
authors.lastname: Henderson
authors.forename: Keith G
authors.initials: KG
authors.lastname: Oldroyd
authors.forename: Robert
authors.initials: R
authors.lastname: Wilcox
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000517:prevention & control; D018592:Cross-Over Studies; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D011994:Recombinant Proteins / Q000627:therapeutic use; D055502:Secondary Prevention; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D017211:Treatment Failure
chemical_list: D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; C087896:reteplase; D010959:Tissue Plasminogen Activator