Guideline adjudicated fibrinolytic failure: Incidence, findings, and management in a contemporary clinical trial

Buller, Christopher E.; Welsh, Robert C.; Westerhout, Cynthia M.; Webb, John G.; O'Neill, Blair; Gallo, Richard; Armstrong, Paul W.

doi:10.1016/j.ahj.2007.08.027

« Previous Next »American Heart Journal
Volume 155, Issue 1 , Pages 121-127, January 2008

Guideline adjudicated fibrinolytic failure: Incidence, findings, and management in a contemporary clinical trial

Christopher E. Buller, MD
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Reprint requests: Christopher E. Buller, MD, University of British Columbia, Diamond Ambulatory Care Centre, 9th Floor, 2775 Laurel Street, Vancouver, British Columbia, Canada V5Z 1M9
Robert C. Welsh, MD
- The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
Cynthia M. Westerhout, PhD
- The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
John G. Webb, MD
- University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
Blair O'Neill, MD
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
Richard Gallo, MD
- Institut de Cardiologie de Montreal, Universite de Montreal, Montreal, Quebec, Canada
Paul W. Armstrong, MD
- The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada

Received 12 June 2007; accepted 20 August 2007. published online 08 October 2007.

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.

Methods and 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.