ACUTE MYOCARDIAL INFARCTION: CLINICAL RESEARCH
A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction
The Middlesbrough Early Revascularization to Limit INfarction (MERLIN) trial
Andrew G. C. Sutton, MA, MB, MRCP*,
Philip G. Campbell, MB, MRCP*,
Richard Graham, MB, MRCP*,
Dallas J. A. Price, MB, MRCP*,
Janine C. Gray, BSc(Hons), PhD ,
Ever D. Grech, MD, MRCP, FACC*,
James A. Hall, MA, MD, FRCP*,
Alun A. Harcombe, MD, MRCP*,
Robert A. Wright, MD, FRCP*,
Roger H. Smith, BSc(Hons), MB, FRCP ,
Jerry J. Murphy, MB, BS, DM, FRCP ,
Ananthaiah Shyam-Sundar, MB, BS, MD, DM, FRCP,
Michael J. Stewart, MD, FRCP*,
Adrian Davies, BSc, MB, BS, FRCP*,
Nicholas J. Linker, BSc, MD, FRCP, FESC* and
Mark A. de Belder, MA, MD, FRCP*,*
* The James Cook University Hospital, Middlesbrough, UK
University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
University Hospital of North Tees, Stockton-on-Tees, UK
Darlington Memorial Hospital, Darlington, United Kingdom
Manuscript received October 20, 2003;
revised manuscript received December 5, 2003,
accepted December 10, 2003.
* Reprint requests and correspondence: Dr. Mark A. de Belder, Cardiothoracic Division, The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW Teesside, United Kingdom.
mark.debelder{at}stees.nhs.uk
OBJECTIVES: We sought to compare emergency coronary angiography with or without rescue percutaneous coronary intervention (PCI) with conservative treatment in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction (STEMI).
BACKGROUND: Most patients with STEMI receive fibrinolytic therapy and aspirin. The management of failed fibrinolysis is unclear.
METHODS: A total of 307 patients with STEMI and failed fibrinolysis were randomized to emergency coronary angiography with or without rescue PCI or conservative treatment.
RESULTS: Thirty-day all-cause mortality was similar in the rescue and conservative groups (9.8% vs. 11%, p = 0.7, risk difference [RD] 1.2%, 95% confidence interval [CI] –5.8 to 8.3). The composite secondary end point of death/re-infarction/stroke/subsequent revascularization/heart failure occurred less frequently in the rescue group (37.3% vs. 50%, p = 0.02, RD 12.7%, 95% CI 1.6 to 23.5), driven by less subsequent revascularization (6.5% vs. 20.1%, p < 0.01, RD 13.6%, 95% CI 6.2 to 21.4). Re-infarction and clinical heart failure were less common in the rescue group (7.2% vs. 10.4%, p = 0.3, RD 3.2%, 95% CI –3.3 to 9.9; and 24.2% vs. 29.2%, p = 0.3, RD 5.7%, 95% CI –4.3 to 15.6, respectively). Strokes and transfusions were more common in the rescue group (4.6% vs. 0.6%, p = 0.03, RD 3.9%, 95% CI 0.5 to 8.6; and 11.1% vs. 1.3%, p < 0.001, RD 9.8%, 95% CI 4.9 to 19.9, respectively). Left ventricular function at 30 days was the same in the two groups.
CONCLUSIONS: Rescue angioplasty did not improve survival by 30 days, but improved event-free survival, almost completely due to a reduction in subsequent revascularization. Rescue angioplasty was associated with more strokes and more transfusions and did not result in preservation of left ventricular systolic function at 30 days.
|
Abbreviations and Acronyms
| | CABG | = coronary artery bypass graft surgery | | LV | = left ventricular | | MERLIN | = Middlesbrough Early Revascularization to Limit INfarction trial | | PCI | = percutaneous coronary intervention | | RD | = risk difference | | RWMI | = regional wall motion index | | STEMI | = ST-segment elevation myocardial infarction | | TIMI | = Thrombolysis In Myocardial Infarction |
|
This article has been cited by other articles:
|
|
|
|
 
A. Carver, S. Rafelt, A. H. Gershlick, K. L. Fairbrother, S. Hughes, R. Wilcox, and for the REACT Investigators
Longer-Term Follow-Up of Patients Recruited to the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) Trial.
J. Am. Coll. Cardiol.,
July 7, 2009;
54(2):
118 - 126.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Ndrepepa, A. Schomig, and A. Kastrati
The Only Better Alternative to Rescue Percutaneous Coronary Intervention Is Primary Percutaneous Coronary Intervention.
J. Am. Coll. Cardiol.,
July 7, 2009;
54(2):
127 - 129.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J J Edmond, C P Juergens, and J K French
The pharmaco-invasive approach to STEMI: when should fibrinolytic-treated patients go to the "cath lab"?
Postgrad. Med. J.,
June 1, 2009;
85(1004):
331 - 334.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J J Edmond, C P Juergens, and J K French
The pharmaco-invasive approach to STEMI: when should fibrinolytic-treated patients go to the "cath lab"?
Heart,
March 1, 2009;
95(5):
358 - 361.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Dudek, T. Rakowski, A. Dziewierz, and P. Kleczynski
PCI after lytic therapy: when and how?
Eur. Heart J. Suppl.,
December 1, 2008;
10(suppl_J):
J15 - J20.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. W. Stone
Angioplasty Strategies in ST-Segment-Elevation Myocardial Infarction: Part II: Intervention After Fibrinolytic Therapy, Integrated Treatment Recommendations, and Future Directions
Circulation,
July 29, 2008;
118(5):
552 - 566.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. G. Goodman, V. Menon, C. P. Cannon, G. Steg, E. M. Ohman, and R. A. Harrington
Acute ST-Segment Elevation Myocardial Infarction: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Chest,
June 1, 2008;
133(6_suppl):
708S - 775S.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Testa, W.J. van Gaal, G.G.L. Biondi-Zoccai, A. Abbate, P. Agostoni, R. Bhindi, and A.P. Banning
Repeat thrombolysis or conservative therapy vs. rescue percutaneous coronary intervention for failed thrombolysis: systematic review and meta-analysis
QJM,
May 1, 2008;
101(5):
387 - 395.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Abbate, G. G.L. Biondi-Zoccai, D. L. Appleton, P. Erne, A. W. Schoenenberger, M. J. Lipinski, P. Agostoni, I. Sheiban, and G. W. Vetrovec
Survival and Cardiac Remodeling Benefits in Patients Undergoing Late Percutaneous Coronary Intervention of the Infarct-Related Artery: Evidence From a Meta-Analysis of Randomized Controlled Trials
J. Am. Coll. Cardiol.,
March 4, 2008;
51(9):
956 - 964.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
American College of Cardiology/American Heart Asso, Developed in Collaboration With the Canadian Cardi, Endorsed by the American Academy of Family Physici, 2007 Writing Group to Review New Evidence and Upda, E. M. Antman, M. Hand, P. W. Armstrong, E. R. Bates, L. A. Green, L. K. Halasyamani, et al.
2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction
J. Am. Coll. Cardiol.,
January 15, 2008;
51(2):
210 - 247.
[Full Text]
[PDF]
|
|
|
|
|
|
|
American College of Cardiology/American Heart Asso, 2007 Writing Group to Review New Evidence and Upda, S. B. King III, S. C. Smith Jr, J. W. Hirshfeld Jr, A. K. Jacobs, D. A. Morrison, and D. O. Williams
2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention
J. Am. Coll. Cardiol.,
January 15, 2008;
51(2):
172 - 209.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. M. Antman, M. Hand, P. W. Armstrong, E. R. Bates, L. A. Green, L. K. Halasyamani, J. S. Hochman, H. M. Krumholz, G. A. Lamas, C. J. Mullany, et al.
2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the Canadian Cardiovascular Society Endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee
Circulation,
January 15, 2008;
117(2):
296 - 329.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. B. King III, S. C. Smith Jr, J. W. Hirshfeld Jr, A. K. Jacobs, D. A. Morrison, D. O. Williams, 2005 WRITING COMMITTEE MEMBERS, S. C. Smith Jr, T. E. Feldman, J. W. Hirshfeld Jr, et al.
2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2007 Writing Group to Review New Evidence and Update the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention, Writing on Behalf of the 2005 Writing Committee
Circulation,
January 15, 2008;
117(2):
261 - 295.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. M. Wilson and J. T. Willerson
Myocardial Revascularization with Percutaneous Devices
Card. Surg. Adult,
January 1, 2008;
3(2008):
573 - 598.
[Full Text]
|
|
|
|
|
|
|
E. Eeckhout
RESCUE PERCUTANEOUS CORONARY INTERVENTION: DOES THE CONCEPT MAKE SENSE?
Heart,
May 1, 2007;
93(5):
632 - 638.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. C. Wijeysundera, R. Vijayaraghavan, B. K. Nallamothu, J. M. Foody, H. M. Krumholz, C. O. Phillips, A. Kashani, J. J. You, J. V. Tu, and D. T. Ko
Rescue Angioplasty or Repeat Fibrinolysis After Failed Fibrinolytic Therapy for ST-Segment Myocardial Infarction: A Meta-Analysis of Randomized Trials
J. Am. Coll. Cardiol.,
January 30, 2007;
49(4):
422 - 430.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J Kendall
The optimum reperfusion pathway for ST elevation acute myocardial infarction: development of a decision framework
Emerg. Med. J.,
January 1, 2007;
24(1):
52 - 56.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J.-P. Collet, G. Montalescot, M. Le May, M. Borentain, and A. Gershlick
Percutaneous Coronary Intervention After Fibrinolysis: A Multiple Meta-Analyses Approach According to the Type of Strategy
J. Am. Coll. Cardiol.,
October 3, 2006;
48(7):
1326 - 1335.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T S N Lo, I R Hall, R Jaumdally, P M Davison, K Dickinson, D J Hildick-Smith, and J Nolan
Transradial rescue angioplasty for failed thrombolysis in acute myocardial infarction: reperfusion with reduced vascular risk.
Heart,
August 1, 2006;
92(8):
1153 - 1154.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Kaul, W.-C. Chang, A. M. Lincoff, P. Aylward, A. Betriu, C. Bode, R. M. Califf, E. M. Ohman, V. Guetta, P. G. Steg, et al.
Optimizing use of revascularization and clinical outcomes in ST-elevation myocardial infarction: insights from the GUSTO-V trial
Eur. Heart J.,
May 2, 2006;
27(10):
1198 - 1206.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. R. Dixon, C. L. Grines, and W. W. O'Neill
The Year in Interventional Cardiology
J. Am. Coll. Cardiol.,
April 18, 2006;
47(8):
1689 - 1706.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C.-K. Wong, R. A.H. Stewart, W. Gao, J. K. French, C. Raffel, H. D. White, and for the Hirulog and Early Reperfusion or Occlusion
Prognostic differences between different types of bundle branch block during the early phase of acute myocardial infarction: insights from the Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial
Eur. Heart J.,
January 1, 2006;
27(1):
21 - 28.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. H. Gershlick, A. Stephens-Lloyd, S. Hughes, K. R. Abrams, S. E. Stevens, N. G. Uren, A. de Belder, J. Davis, M. Pitt, A. Banning, et al.
Rescue Angioplasty after Failed Thrombolytic Therapy for Acute Myocardial Infarction
N. Engl. J. Med.,
December 29, 2005;
353(26):
2758 - 2768.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. J. Cantor, F. Brunet, C. P. Ziegler, A. Kiss, and L. J. Morrison
Immediate angioplasty after thrombolysis: a systematic review
Can. Med. Assoc. J.,
December 6, 2005;
173(12):
1473 - 1481.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. J. Witt, R. D. Brown Jr., S. J. Jacobsen, S. A. Weston, B. P. Yawn, and V. L. Roger
A Community-Based Study of Stroke Incidence after Myocardial Infarction
Ann Intern Med,
December 6, 2005;
143(11):
785 - 792.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A de Belder
Should primary angioplasty be available for all patients with an ST elevation myocardial infarction?
Heart,
December 1, 2005;
91(12):
1509 - 1511.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A G C Sutton, P G Campbell, R Graham, D J A Price, J C Gray, E D Grech, J A Hall, A A Harcombe, R A Wright, R H Smith, et al.
One year results of the Middlesbrough early revascularisation to limit infarction (MERLIN) trial
Heart,
October 1, 2005;
91(10):
1330 - 1337.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. G. Steg, L. Francois, B. Iung, D. Himbert, P. Aubry, P. Charlier, H. Benamer, L. J. Feldman, and J.-M. Juliard
Long-term clinical outcomes after rescue angioplasty are not different from those of successful thrombolysis for acute myocardial infarction
Eur. Heart J.,
September 2, 2005;
26(18):
1831 - 1837.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. W. O'Neill, S. R. Dixon, and C. L. Grines
The year in interventional cardiology
J. Am. Coll. Cardiol.,
April 5, 2005;
45(7):
1117 - 1134.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Authors/Task Force Members, S. Silber, P. Albertsson, F. F. Aviles, P. G. Camici, A. Colombo, C. Hamm, E. Jorgensen, J. Marco, J.-E. Nordrehaug, et al.
Guidelines for Percutaneous Coronary Interventions: The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology
Eur. Heart J.,
April 2, 2005;
26(8):
804 - 847.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. G.C. Sutton and M. A. de Belder
Rescue angioplasty--the MERLIN trial
J. Am. Coll. Cardiol.,
March 1, 2005;
45(5):
806 - 807.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. L. Grines and W. O'Neill
Rescue angioplasty--the MERLIN trial: Reply
J. Am. Coll. Cardiol.,
March 1, 2005;
45(5):
807 - 808.
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Osman, A. Chit, and P. E. Glennon
Definition of failed lysis may have influenced outcome in the MERLIN trial
J. Am. Coll. Cardiol.,
March 1, 2005;
45(5):
808 - 808.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. G.C. Sutton and M. A. de Belder
Definition of failed lysis may have influenced outcome in the MERLIN trial: Reply
J. Am. Coll. Cardiol.,
March 1, 2005;
45(5):
808 - 809.
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. J. Gersh, G. W. Stone, H. D. White, and D. R. Holmes Jr
Pharmacological Facilitation of Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction: Is the Slope of the Curve the Shape of the Future?
JAMA,
February 23, 2005;
293(8):
979 - 986.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L Bhatia, G J Clesham, and D R Turner
Clinical implications of ST-segment non-resolution after thrombolysis for myocardial infarction
J R Soc Med,
December 1, 2004;
97(12):
566 - 570.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Benefit of Rescue Angioplasty After Failed Fibrinolysis Still Unclear
Journal Watch Emergency Medicine,
September 29, 2004;
2004(929):
6 - 6.
[Full Text]
|
|
|
|
