Contribution of stenting to the results of rescue PTCA

Angiographic and Long-Term Outcomes of “Rescue” Stenting versus PTCA in Failed Thrombolysis in Acute Myocardial Infarction

Percutaneous transluminal coronary angioplasty (PTCA), when performed early after clinically failed thrombolysis, improves acute infarct-artery patency in up to 90% of cases. Limited data are available regarding the role of rescue stenting in this setting. From January 1995 to December 1999, the authors studied all consecutive patients treated with rescue PTCA or rescue stenting within 12 hours of onset of chest pain and clinically failed thrombolytic therapy at their institution. Baseline demographic characteristics, infarct-related artery location, lesion class, left ventricular function, and incidence of multivessel disease were similar between groups (23 patients in each group). Preprocedural TIMI flow 0 was more common in PTCA patients (p=0.025). Quantitative coronary analysis revealed similar incidence of calcification, thrombus burden, minimal lumen diameter (MLD), and lesion length between groups. Post-procedural TIMI 3 flow was more common in stent patients; however, this was not statistically significant (p=0.18). Greater final MLD (p<0.001), less residual stenosis (p<0.001), and a trend toward larger reference vessel diameter (p=0.13) were observed in favor of stent patients. At 6-month follow-up, there was no difference in the incidence of death, myocardial infarction, or readmission for unstable angina between groups. More stent patients (60% vs 27%, p=0.06) were angina free as compared to PTCA patients. Despite similar in-hospital clinical outcomes, the study suggests better angiographic results and 6-month morbidity with rescue stenting.

Management of failed thrombolysis after acute myocardial infarction: An overview of current treatment options

Thrombolytic therapy remains the most commonly administered revascularization strategy for patients with ST-elevation myocardial infarctions (STEMI). However, many patients fail to have patent arteries or ST-segment resolution after these therapies. Multiple strategies have been examined to treat these patients with "failed thrombolysis." We examined the existing medical literature regarding treatment of failed thrombolysis including strategies testing repeat thrombolytic therapy and rescue percutaneous coronary intervention. Additional, we reviewed the literature regarding the efficacy of transferring patient for rescue percutaneous intervention and coronary stenting. The impact of contemporary antiplatelet strategies, cardiogenic shock, and coronary bypass surgery was examined. Overall, the management of patients with acute STEMI in whom thrombolytic therapy failed remains a challenging problem. As a result, many different strategies are currently in use. Among these therapeutic interventions, rescue PCI with coronary stenting appears to be superior when it is done in a timely manner by an experienced center.

One year results of the Middlesbrough early revascularisation to limit infarction (MERLIN) trial

OBJECTIVE

To report one year results of the MERLIN (Middlesbrough early revascularisation to limit infarction) trial, a prospective randomised trial comparing the strategy of coronary angiography and urgent revascularisation with conservative treatment in patients with failed fibrinolysis complicating ST segment elevation myocardial infarction (STEMI). The 30 day results have recently been published. At the planning stage of the trial, it was determined that follow up of trial patients would continue annually to three years to determine whether late benefit occurred.

SUBJECTS

307 patients who received a fibrinolytic for STEMI but failed to reperfuse early according to previously described ECG criteria and did not develop cardiogenic shock.

METHODS

Patients were randomly assigned to receive either emergency coronary angiography with a view to proceeding to urgent revascularisation (rescue percutaneous coronary intervention (rPCI) arm) or continued medical treatment (conservative arm). The primary end point was all cause mortality at 30 days. The secondary end points included the composite end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure at 30 days. The same end points were evaluated at one year and these results are presented.

RESULTS

All cause mortality at one year was similar in the conservative arm and the rPCI arm (13.0% v 14.4%, p = 0.7, risk difference (RD) -1.4%, 95% confidence interval (CI) -9.3 to 6.4). The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure was significantly higher in the conservative arm (57.8% v 43.1%, p = 0.01, RD 14.7%, 95% CI 3.5% to 25.5%). This was driven almost exclusively by a significantly higher incidence of subsequent unplanned revascularisation in the conservative arm (29.9% v 12.4%, p < 0.001, RD 17.5%, 95% CI 8.5% to 26.4%). Reinfarction and clinical heart failure were numerically, but not statistically, more common in the conservative arm (14.3% v 10.5%, p = 0.3, RD 3.8%, 95% CI -3.7 to 11.4, and 31.2% v 26.1%, p = 0.3, RD 5.0%, 95% CI -5.1 to 15.1). There was a strong trend towards fewer strokes in the conservative arm (1.3% v 5.2%, p = 0.06, RD -3.9%, 95% CI -8.9 to 0.06).

CONCLUSION

At one year of follow up, there was no survival advantage in the rPCI arm compared with the conservative arm. The incidence of the composite secondary end point was significantly lower in the rPCI arm, but this was driven almost entirely by a highly significant reduction in the incidence of further revascularisation.

The evolving role of rescue therapy for acute myocardial infarction

Coronary reperfusion for acute ST-elevation myocardial infarction can be accomplished with fibrinolytic therapy or with percutaneous coronary intervention (PCI). Primary PCI provides more effective and sustained early reperfusion than fibrinolytic therapy, but is only available in a minority of hospitals worldwide. There is a lack of a definite method for identification of patients who have inadequate reperfusion after fibrinolysis. Transfer of patients after fibrinolysis for diagnostic angiography and possible rescue therapy is safe and feasible. Rescue PCI with the use of stents and antiplatelet therapy decreases cardiovascular mortality and morbidity compared with conservative therapy. Increasing use of primary PCI and forming networks to transfer patients to centers that offer primary PCI may decrease the need for rescue therapy in the future.

Delayed Post-Myocardial Infarction Invasive Measures, Helpful or Harmful?

BACKGROUND

In patients who have experienced acute myocardial infarction (MI), primary percutaneous coronary intervention (PCI) has been shown to be of benefit in terms of clinical outcomes. However, the value of performing routine PCI in patients with early MI (ie, an MI occurring > 12 h to < or = 7 days before patient presentation) or recent MI (ie, an MI occurring > or = 8 days to < 30 days before patient presentation) has not been established. The purposes of this prospective observational study were to evaluate the impact of PCI on outcomes, and to delineate the predictors of lack of response to reperfusion and the prognostic determinants in patients with this clinical condition.

METHODS AND RESULTS

A total of 377 consecutive unselected patients who had experienced early or recent MI underwent PCI. Successful reperfusion (ie, Thrombolysis in Myocardial Infarction flow grade 3 of the infarct-related artery [IRA]) was achieved in 90.2% of patients. By multiple stepwise logistic regression analysis, high-burden thrombus formation (odds ratio [OR], 15.53; 95% confidence interval [CI], 6.09 to 39.60; p < 0.0001) in the IRA, early PCI (ie, < or = 3 days) [OR, 4.10; 95% CI, 1.79 to 7.36; p = 0.0008], advanced congestive heart failure (CHF) [OR, 4.10; 95% CI, 1.70 to 9.91; p = 0.002], and diabetes (OR, 3.03; 95% CI, 1.03 to 7.06; p = 0.010) were independent predictors for lack of response to reperfusion. The 30-day mortality rate was 6.8%. The only variables that were independently related to the 30-day mortality rate were advanced CHF (OR, 29.85; 95% CI, 7.84 to 113.7; p < 0.0001), lack of response to reperfusion (OR, 7.57; 95% CI, 2.29 to 25.07; p = 0.0009), early PCI (OR, 4.81; 95% CI, 1.60 to 14.41; p = 0.005), and multivessel disease (OR, 9.22; 95% CI, 1.63 to 52.04; p = 0.0119). The surviving 351 patients were discharged from the hospital and followed-up for a mean (+/- SD) 38.9 +/- 14.2 months. Coronary angiographic follow-up was performed in 285 patients (81.2%). Restenosis of the IRA was found in 101 patients (35.4%). Reinterventions of the IRA were required in 69 patients (24.2%). Follow-up measurements of left ventricular ejection fraction (LVEF) showed significantly more improvement than the initial LVEF (59.3 +/- 13.8% vs 50.4 +/- 13%; p < 0.0001). The total cumulative mortality rate after hospital discharge was 6.5% for the entire group. Only advanced CHF (OR, 3.46; 95% CI, 1.26 to 9.52; p = 0.016) and old age (ie, > or = 70 years of age) [OR, 4.41; 95% CI, 1.59 to 12.24; p = 0.004] were independent predictors of long-term mortality.

CONCLUSION

The performance of PCI on > or = day 4 in patients after they had experienced an MI was safe and had a high rate of success. The clinical benefits of a relative low mortality rate associated with successful PCI for patients with early and recent MI was maintained during the long-term follow-up. However, patients with advanced CHF along with old age continued to have a poor prognosis.

Rescue coronary stenting with heparin-coated Jostents for failed thrombolysis in acute myocardial infarction

The aim of the present study was to assess the procedural safety and in-hospital and long-term effectiveness of heparin-coated Jostents after failed thrombolysis in acute myocardial infarction. We prospectively analyzed the acute and long-term clinical and angiographic outcomes of 35 consecutive patients treated with heparin-coated Jostents for thrombolytic failure. Rescue coronary stenting was successful in 34 of 35 patients (97%). Thrombolysis in Myocardial Infarction flow grade 3 was obtained in 31 patients (88.5%). The only patient with procedural failure died from cardiogenic shock a day after the procedure. One patient (2.8%) underwent an emergency coronary bypass operation because of angiographic evidence of stent thrombosis with re-infarction. During in-hospital follow-up, 2 patients (5.7%) underwent an elective coronary bypass operation after successful stent implantation of the infarct-related artery because of existing severe multivessel coronary artery disease. Minor bleeding complications at the vascular access site occurred in 3 (8.6%) patients. No cerebrovascular or any other major bleeding complication occurred. One patient (2.1%) underwent repeat coronary angioplasty for restenosis and an elective coronary artery bypass operation was performed in one patient (2.8%) during the 294 +/- 150 days follow-up. The rate of target vessel revascularization was 14.3% and the event-free survival rate was 80%. Twenty-six patients (90%) had angiographic follow-up at six months, and stent restenosis was found in 5 (19.2%). This study demonstrates that heparin-coated Jostents are sale, with low in-hospital and long-term mortality rates for the treatment of failed thrombolysis in acute myocardial infarction. The angiographic restenosis and target vessel revascularization rates of this registry are also acceptable.

Failure of thrombolysis: experience with a policy of early angiography and rescue angioplasty for electrocardiographic evidence of failed thrombolysis

OBJECTIVE

To assess the outcome of a policy of emergency coronary angiography with or without rescue angioplasty in patients with acute myocardial infarction and ECG evidence of failed reperfusion after thrombolysis.

DESIGN

A cohort study.

SETTING

Regional cardiothoracic unit.

PATIENTS

197 patients with acute myocardial infarction fulfilling a simple ECG criterion of failed reperfusion.

INTERVENTIONS

Emergency coronary angiography proceeding to rescue angioplasty for inadequate antegrade flow.

MAIN OUTCOME MEASURES

Hospital mortality for all 197 patients; incidence of successful and failed rescue angioplasty; need for additional revascularisation in those receiving rescue angioplasty compared with those not treated in this way.

RESULTS

197 patients had emergency angiography for ECG evidence of failed reperfusion; 156 patients received immediate rescue angioplasty. Overall hospital mortality for those undergoing rescue angioplasty was 11.5%. Rescue angioplasty achieved TIMI 2 (11) or TIMI 3 (124) in 135 patients, who had a hospital mortality of 5.9%. Failure to achieve at least TIMI 2 flow following rescue angioplasty occurred in 21 patients, with a hospital mortality of 48%. In the 41 patients in whom immediate rescue angioplasty was not performed, reinfarction or requirement for revascularisation occurred in 37%. Reinfarction occurred in three patients (1.9%) who had immediate rescue angioplasty. Hospital mortality for the whole cohort was 10.7%.

CONCLUSIONS

A policy of emergency coronary angiography proceeding to rescue angioplasty where appropriate reduces mortality in a high risk group to a level less than expected for patients with acute myocardial infarction and ECG evidence of failed reperfusion. Unsuccessful rescue angioplasty is associated with a high mortality.