January 13, 2006
By: Sahar Bedrood B.S. and Asher Kimchi M.D.
Leicester, UK - In patients who have had a
myocardial infarction, intravenous thrombolysis is
the first-line treatment, but primary percutaneous
coronary intervention (PCI) is increasingly being
used to restore flow to arteries. Until this study,
by Anthony Gershlick M.B, B.S. et al from the
University Hospitals of Leicester in the United
Kingdom, appropriate treatment for patients in whom
reperfusion fails to occur after
thrombolytic therapy for acute myocardial
infarction remained unclear. The study, published in
the December 29, 2005 issue of The New England
Journal of Medicine, found event-free survival
after failed thrombolytic therapy was
significantly higher with rescue PCI than with
repeated thrombolysis or conservative
treatment.
The study consisted of 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), which
consisted of standard therapy for myocardial
infraction other than thrombolysis or PCI, or rescue
PCI (144 patients). The primary end point was
a composite of death, reinfarction,
stroke, or severe heart failure within
six months.
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.
The study of the three therapeutic options after
failed thrombolytic therapy found that rescue PCI
was associated with a statistically significant
reduction in the incidence of major adverse
cardiac and cerebrovascular events, as
compared with either repeated thrombolysis or
conservative management. This information
can be used to determine appropriate treatment in
patients with failed thrombolytic therapy after
myocardial infarction.
Co-authors: Anthony H. Gershlick, M.B., B.S.,
Amanda Stephens-Lloyd, R.N., M.Sc., Sarah Hughes,
R.N., B.A., Keith R. Abrams, Ph.D., Suzanne E.
Stevens, M.Sc., Neal G. Uren, M.D., Adam de Belder,
M.D., John Davis, M.B., B.S., Michael Pitt, M.B.,
B.S., Adrian Banning, M.D., Andreas Baumbach, M.D.,
Man Fai Shiu, M.D., Peter Schofield, M.D., Keith D.
Dawkins, M.D., Robert A. Henderson, M.D., Keith G.
Oldroyd, M.D., Robert Wilcox, M.D., for the REACT
Trial Investigators
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