title: Early invasive versus conservative treatment in patients with failed fibrinolysis--no late survival benefit: the final analysis of the Middlesbrough Early Revascularisation to Limit Infarction (MERLIN) randomized trial.
abstract: BACKGROUND
  Early (30 days) and midterm (6 months) clinical outcomes in trials comparing rescue angioplasty (rescue percutaneous coronary intervention [rPCI]) with conservative treatment of failed fibrinolysis complicating ST-segment elevation myocardial infarction have shown variable results. Whether early rPCI confers late (up to 3 years) clinical benefits is not known.
  
  
  METHODS
  The MERLIN trial compared rPCI and a conservative strategy in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction. Three hundred seven patients with electrocardiographic evidence of failure to reperfuse at 60 minutes were included. Patients in cardiogenic shock were excluded. Thirty-day and 1-year results have been reported. Results of 3 years of follow-up are presented.
  
  
  RESULTS
  Three-year mortality in the conservative arm and rPCI, respectively, was 16.9% versus 17.6% (P = .9, relative difference [RD] -0.8, 95% CI [-9.3 to 7.8]). Death rates were similar (3.9% vs 3.2%) between 1- and 3-year follow-up, respectively. The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularization, or heart failure was significantly higher in the conservative arm (64.3% vs 49%, P = .01, RD 15.3, 95% CI [4.2-26]). There was no significant difference in the rate of reinfarction (0.7% vs 0.7%) or heart failure (1.3% vs 2.7%) between 1 and 3 years between the conservative and rPCI arms, respectively. The incidence of subsequent unplanned revascularization at 3 years was significantly higher in the conservative arm (33.8% vs 14.4%, P < .01, RD 19.4, 95% CI [10-28.7]), most of which occurred within 1 year; the rates between 1 and 3 years were 3.9% in the conservative arm versus 2% in the rPCI arm. There was a trend toward fewer strokes in the conservative arm at 3 years (conservative arm 2.6% vs rPCI 6.5%, P = .1, RD -3.9%, 95% CI [-9.4 to 0.8]), with similar stroke rates (1.3% vs 1.3%) between 1- and 3-year follow-up.
  
  
  CONCLUSIONS
  Rescue angioplasty did not confer a late survival advantage at 3 years. The composite end point occurred less often in the rPCI arm mainly because of fewer unplanned revascularization procedures in the early phase of follow-up. The highest risk of clinical events in patients with failed reperfusion is in the first year, beyond which the rate of clinical events is low.
authors: The James Cook University Hospital, Middlesbrough, UK. babukunadian@aol.com
authors: Babu
authors: B
authors: Kunadian
authors: Andrew G C
authors: AG
authors: Sutton
authors: Kunadian
authors: K
authors: Vijayalakshmi
authors: Andrew R
authors: AR
authors: Thornley
authors: Janine C
authors: JC
authors: Gray
authors: Ever D
authors: ED
authors: Grech
authors: James A
authors: JA
authors: Hall
authors: Alun A
authors: AA
authors: Harcombe
authors: Robert A
authors: RA
authors: Wright
authors: Roger H
authors: RH
authors: Smith
authors: Jerry J
authors: JJ
authors: Murphy
authors: Ananthaiah
authors: A
authors: Shyam-Sundar
authors: Michael J
authors: MJ
authors: Stewart
authors: Adrian
authors: A
authors: Davies
authors: Nicholas J
authors: NJ
authors: Linker
authors: Mark A
authors: MA
authors: de Belder
mesh_terms: D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012008:Recurrence; D015607:Stents; D020521:Stroke / Q000453:epidemiology; D016019:Survival Analysis; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D013997:Time Factors; D017211:Treatment Failure; D006113:United Kingdom / Q000453:epidemiology