RESCUE ANGIOPLASTY AFTER FAILED THROMBOLYSIS - TECHNICAL AND CLINICALOUTCOMES IN A LARGE THROMBOLYSIS TRIAL

Objectives. We sought to assess the angiographic outcome, complication rates and clinical features of percutaneous transluminal coronary ang ioplasty (PTCA) after failed thrombolysis for acute myocardial infarct ion. Background. ''Rescue angioplasty'' refers to mechanical reopening of an occluded infarct-related artery (IRA) after failed intravenous thrombolysis. Although the procedure is commonly performed, data descr ibing its technical and clinical outcome are sparse. Early reports sug gested that rescue PTCA is less often successful and produces more com plications than primary PTCA, Other reports have described beneficial effects of successful rescue PTCA but adverse outcomes when PTCA is un successful. Methods. Using data from the Global Utilization of Strepto kinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) angiographic substudy, we compared clinical and angiographi c outcomes of 198 patients selected for a rescue PTCA attempt with tho se of 266 patients with failed thrombolysis but managed conservatively and, for reference, with those of 1,058 patients with successful thro mbolysis. Results. Patients offered rescue PTCA had more impaired left ventricular function than those in whom closed vessels were managed c onservatively. Rescue successfully opened 88.4% of closed arteries, wi th 68% attaining Thrombolysis in Myocardial Infarction (TIMI) grade 3 how. The interventions did not increase catheterization laboratory or postprocedural complication rates. Multivariate analysis identified se vere heart failure to be a determinant of a failed rescue attempt. Suc cessful rescue PTCA resulted in superior left ventricular function and 30 day mortality outcomes, comparable to outcomes in patients with cl osed IRAs managed conservatively, but less favorable than in patients in whom thrombolytic therapy was initially successful. The mortality r ate after a failed rescue attempt was 30.4%; however, five of the seve n patients who died after failed rescue PTCA were in cardiogenic shock before the procedure. Conclusions. Rescue PTCA tends to be selected f or patients with clinical predictors of a poor outcome. It is effectiv e in restoring patency. Patients who die after a failed rescue attempt are often already in extremis before the angioplasty attempt. (C) 199 8 by the American College of Cardiology.