Guideline adjudicated fibrinolytic failure: incidence, findings, and management in a contemporary clinical trial.
BACKGROUND
Rescue percutaneous coronary intervention (PCI) is efficacious after clinical failure of fibrinolytic therapy and is recommended for those with persistent ischemia, hemodynamic, or electrical instability. We sought to describe the frequency of fibrinolytic failure (rescue eligibility) as well as the patient characteristics associated with rescue eligibility, rescue referral, and PCI.


RESULTS
Eligibility, indication, and referral for guideline-based rescue PCI were adjudicated in 221 patients enrolled in the WEST trial. WEST treated patients at earliest medical contact and used a tenectaplase/enoxaparin regimen. Ninety patients (41%) were adjudicated with acute myocardial infarction as rescue eligible of whom 68 were referred for rescue PCI. Baseline characteristics did not predict rescue eligibility or referral. Emergency angiography before PCI performed a median of 82 minutes (interquartile range 50-99) after rescue referral showed TIMI flow grade 2 or 3 in 34 (50%). Percutaneous coronary intervention was adjudicated as successful in 58 of 60 attempts. Procedures began approximately 45 minutes sooner in patients initially admitted to PCI-capable hospitals. Compared to those with clinically successful fibrinolytic therapy, rescue eligible patients demonstrated higher median peak creatine phosphokinase (1889 [1243-3746] vs 999 [440-2048], P < .01) and 30-day median NT-proBNP levels (748 [391-1916] vs 431 [153-1016], P < .01).


CONCLUSIONS
Rescue eligibility determined by guideline criteria is common after contemporary fibrinolysis and is not predicted by conventional baseline characteristics. Half of rescue-referred patients are patent at angiography: although contemporary PCI success rates are high, rescue eligibility is associated with larger infarctions.
Buller
Christopher E
CE
University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada. cbuller@interchange.ubc.ca
Welsh
Robert C
RC
Westerhout
Cynthia M
CM
Webb
John G
JG
O'Neill
Blair
B
Gallo
Richard
R
Armstrong
Paul W
PW
D000368:Aged; D000465:Algorithms; D015906:Angioplasty, Balloon, Coronary / Q000379:methods* / Q000401:mortality; D017023:Coronary Angiography; D023903:Coronary Restenosis / Q000517:prevention & control; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005500:Follow-Up Studies; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011336:Probability; D012016:Reference Values; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D016879:Salvage Therapy; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods*; D017211:Treatment Failure; D014654:Vascular Patency / Q000502:physiology
D005343:Fibrinolytic Agents