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ISCHAEMIC HEART DISEASE
Rescue angioplasty: should we or shouldn’t we? ▸
Although primary percutaneous coronary intervention (PCI) is a proven therapeutic approach in ST elevation myocardial infarction (STEMI) and is used increasingly, intravenous thrombolysis remains the first line treatment in 30–70% of cases worldwide. However, thrombolysis results in a grade 3 flow, according to the thrombolysis in myocardial infarction (TIMI) classification system, in only 60% of patients, even with current fibrin specific agents. To date, it has been unclear how best to treat the remaining patients, in whom thrombolysis has not worked. In a randomised trial involving 427 patients with STEMI of < 6 hours’ duration treated with thrombolysis, in whom reperfusion failed to occur (< 50% ST segment resolution) within 90 minutes, patients were randomly assigned to repeated thrombolysis (142 patients), conservative treatment (141 patients), 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%, as compared with 70.1% among those receiving conservative treatment and 68.7% 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 treatment was 1.09 (95% confidence interval (CI) 0.71 to 1.67; p = 0.69), as compared with adjusted hazard ratios of 0.43 (95% CI 0.26 to 0.72; p = 0.001) for rescue PCI versus repeated thrombolysis and 0.47 (95% 0.28 to 0.79; p = 0.004) for rescue PCI versus conservative treatment. There were no significant differences in mortality from all causes. Non-fatal bleeding, mostly at the sheath insertion site, was more common with rescue PCI, although mortality related to bleeding was higher in the other two groups. At six months, 86.2% of the rescue PCI group were free from revascularisation, as compared with …