Elsevier

American Heart Journal

Volume 139, Issue 6, June 2000, Pages 1046-1053
American Heart Journal

Interventional Cardiology
Review of immediate angioplasty after fibrinolytic therapy for acute myocardial infarction: Insights from the RESCUE I, RESCUE II, and other contemporary clinical experiences,☆☆

https://doi.org/10.1067/mhj.2000.106624Get rights and content

Abstract

Background Prompt restoration of Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow improves survival in patients with acute ST-segment elevation myocardial infarction (MI). Fibrinolytic therapy fails to restore TIMI 3 flow within 90 minutes in 40% to 50% of patients. Because the results of percutaneous coronary intervention (PCI) for MI seem to be improving, a reevaluation of the role of PCI after fibrinolytic therapy for MI appears to be warranted. Methods and Results Data from all 9 randomized controlled trials (including new data from 4 trials) of rescue percutaneous transluminal coronary angioplasty (PTCA) versus conservative therapy after fibrinolytic therapy (1456 patients), 4 contemporary registries of PCI in this setting (977 patients), and other germane studies are reviewed. PTCA after failed fibrinolysis (TIMI 0 to 1 flow) appears to reduce early severe heart failure (3.8% vs 11.7%, P =.04) and improve survival over 1 year in patients with moderate to large MI (92% vs 87%, P =.001) and possibly reduces early repeat MI (4.3% vs 11.3%, P =.08). Assessment of the possible benefit of PTCA for TIMI 2 flow is hampered by the small number of patients randomly assigned. Repeat MI may be decreased and left ventricular functional recovery enhanced. PTCA early after successful fibrinolysis is nearly always technically successful and may reduce repeat MI and hospital length of stay. However, it must be recalled that randomized trials from the 1980s suggested increased mortality rates with PTCA after restoration of TIMI 2 to 3 flow with fibrinolysis. Data from contemporary randomized studies of stents and glycoprotein IIb/IIIa inhibitors suggest that PCI as performed today may yield better results than those reviewed. Conclusions These data suggest a probable benefit of rescue PTCA in several distinct scenarios and that the pivotal mid-1980s studies suggesting no benefit or harm for PTCA after fibrinolytic therapy may no longer be relevant. The role of mechanical intervention in the treatment of patients treated in these settings should be reassessed. (Am Heart J 2000;139:1046-53.)

Section snippets

Methods

In light of these changes and to provide additional new data, this report will attempt to summarize currently available data (through review of Medline and abstracts from Circulation, Journal of the American College of Cardiology, and European Heart Journal) on the clinical utility, or lack thereof, of rescue angioplasty.

Intervention for totally occluded vessels

Patients with occluded vessels visualized 90 minutes after administration of fibrinolytic therapy have a mortality rate that is more than twice that noted for patients with TIMI 3 flow (eg, 9.1% vs 4.3%, 30-day mortality rate in GUSTO I, P =.01).18 Only 4 small randomized controlled trials (RCTs)8, 9, 19, 20 (Table I) have critically analyzed whether or not PTCA, applied in a timely fashion, is beneficial to patients who are at such high risk.

. Randomized trials of intervention for patients with

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  • Cited by (0)

    Guest Editor for this manuscript was Christopher E. Buller, MD, Vancouver Hospital and Health Sciences Center, Vancouver, British Columbia, Canada.

    ☆☆

    Reprint requests: Stephen G. Ellis, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, F-25, Cleveland, OH 44195.E-mail: [email protected]

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