Review of immediate angioplasty after fibrinolytic therapy for acute myocardial infarction: Insights from the RESCUE I, RESCUE II, and other contemporary clinical experiences

Background Prompt restoration of Thrombolysis In Myocardial Infarction (TIM I) grade 3 flow improves survival in patients with acute ST-segment elevati on myocardial infarction (MI). Fibrinolytic therapy fails to restore TIMI 3 flow within 90 minutes in 40% to 50% of patients. Because the results of p ercutaneous coronary intervention (PCI) for MI seem to be improving, a reev aluation of the role of PCI after fibrinolytic therapy for MI appears to be warranted. Methods and Results Data from all 9 randomized controlled trials (including new data from 4 trials) of rescue percutaneous transluminal coronary angio plasty (PTCA) versus conservative therapy after fibrinolytic therapy (1456 patients), 4 contemporary registries of PCI in this setting (977 patients), and other germane studies are reviewed. PTCA after failed fibrinolysis (TI MI 0 to 1 flow) appears to reduce early severe heart failure (3.8% vs 11.7% , P = .04) and improve survival over 1 year in patients with moderate to la rge MI (92% vs 87%, P = .001) and possibly reduces early repeat MI (4.3% vs 1 1.3%, P = .08). Assessment of the possible benefit of PTCA for TIMI 2 fl ow is hampered by the small number of patients randomly assigned. Repeat MI may be decreased and left ventricular functional recovery enhanced. PTCA e arly after successful fibrinolysis is nearly always technically successful and may reduce repeat MI and hospital length of stay. However, ii must be r ecalled that randomized trials from the 1980s suggested increased mortality rates with PTCA after restoration of TIMI 2 to 3 flow with fibrinolysis. D ata from contemporary randomized studies of stents and glycoprotein IIb/III a inhibitors suggest that PCI as performed today may yield better results t han those reviewed. Conclusions These data suggest a probable benefit of rescue PTCA in several distinct scenarios and that the pivotal mid-1980s studies suggesting no be nefit or harm for PTCA after Fibrinolytic therapy may no longer be relevant . The role of mechanical intervention in the treatment of patients treated in these settings should be reassessed.