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CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION

Longer-Term Follow-Up of Patients Recruited to the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) Trial

Amanda Carver, MSc, BA (Hons), RN^_*,_*, Suzanne Rafelt, BSc (Hons), MSc, Anthony H. Gershlick, BSc, MB, BS, Kathryn L. Fairbrother, BA, RN, Sarah Hughes, BA (Hons), RN, Robert Wilcox, BSc, DM^|| for the REACT Investigators

^_* Queensland Health, Brisbane, Queensland, Australia
Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
Department of Academic Cardiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
Cardio-Respiratory Directorate, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
^|| University Hospital, Nottingham, United Kingdom

Manuscript received September 10, 2008; revised manuscript received March 23, 2009, accepted March 24, 2009.

^_* Reprint requests and correspondence: Ms. Amanda Carver, Population Health, Office of the Chief Health Officer, Queensland Health, Citilink Business Centre, Campbell Street, Herston, Brisbane 4001, Queensland, Australia (Email: amanda.carver{at}bigpond.com).

Objectives: To evaluate the longer-term outcomes for rescue percutaneous coronary intervention (R-PCI).

Background: Thrombolysis remains an important, commonly used reperfusion therapy, yet failure to achieve complete reperfusion occurs relatively frequently. A number of recent trials have focused on the management of patients with thrombolytic failure, including the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) trial, which demonstrated a significant 6-month benefit favoring R-PCI. However, longer-term maintenance of benefit for R-PCI has not been demonstrated.

Methods: Rates of the primary composite end point (major adverse cardiac and cerebrovascular events) to 1 year and mortality to a median of 4.4 years in 427 patients included in the 3 randomized arms of the REACT trial (repeat lysis, conservative therapy, and R-PCI) were analyzed.

Results: One-year event-free survival for patients randomized to R-PCI was 81.5%, compared with 64.1% for repeat thrombolysis and 67.5% for conservative therapy (overall p = 0.004). Adjusted hazard ratio was 0.44 (95% confidence interval [CI]: 0.28 to 0.71; p = 0.0008) for R-PCI versus repeat thrombolysis and 0.51 (95% CI: 0.32 to 0.83; p = 0.007) for R-PCI versus conservative therapy. Adjusted hazard ratio for longer-term (median 4.4 years) overall mortality for R-PCI versus repeat thrombolysis was 0.41 (95% CI: 0.22 to 0.75; p = 0.004) and 0.43 (95% CI: 0.23 to 0.79; p = 0.006) for R-PCI versus conservative therapy. There was no difference in either analysis between repeat thrombolysis and conservative strategies.

Conclusions: Rescue PCI, previously shown to be superior in the short term to both repeat thrombolysis and conservative therapy, maintains benefit in terms of long-term mortality. This strategy for failed lysis should be mandated as part of thrombolytic-based ST-segment elevation myocardial infarction protocols.

Key Words: ST-segment elevation myocardial infarction • failed thrombolysis • rescue percutaneous coronary intervention

Abbreviations and Acronyms   AMI = acute myocardial infarction   CABG = coronary artery bypass grafting   CI = confidence interval   CVA = cerebrovascular accident   ECG = electrocardiograph   HR = hazard ratio   MACCE = major adverse cardiac and cerebrovascular events   PCI = percutaneous coronary intervention   P-PCI = primary percutaneous coronary intervention   re-AMI = recurrent acute myocardial infarction   R-PCI = rescue percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction

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