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

Abstract

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.

Percutaneous Coronary Intervention After Successful Fibrinolytic Therapy for ST-Segment Elevation Myocardial Infarction

“…Fibrinolytic therapy is the alternative to primary PCI, but bleeding complications occur in some patients, and as many as 40% are ultimately resistant to infarct artery reperfusion (4). Among selected patients who fail to reperfuse with fibrinolytic therapy, a strategy of emergent transfer to a PCI hospital for rescue PCI has emerged as the standard of care (5). Thus, the definitive goal in contemporary reperfusion therapy is early, complete, and sustained reperfusion, which for decades has been known to result in better short-and long-term outcomes (6).…”

A busca de marcadores da reperfusão no infarto agudo do miocárdio: um é pouco, dois é bom, três seria ótimo!

“…Damonte et al 8 , com base em experiências prévias, exploram um marcador quantitativo de sucesso do procedimento, a regressão do supradesnivelamento do segmento ST, e suas implicações nos desfechos clínicos 9,10 . Essa mensuração, relativamente simples e de fácil obtenção, é o marcador de sucesso do tratamento recomendado na prática vigente, em especial para aqueles submetidos a fibrinólise, que não têm o auxílio da angiografia coronária imediata para a verificação da patência do vaso 11 .…”

The Only Better Alternative to Rescue Percutaneous Coronary Intervention Is Primary Percutaneous Coronary Intervention

“…In this issue of the Journal, Carver et al (11) report on the long-term results of the REACT trial. Briefly, the REACT trial included 427 patients, 21 to 85 years of age, with STEMI within 6 h of symptom onset and 90-min electrocardiographic criteria (Ͻ50% ST-segment resolution in the lead with previous maximal ST-segment elevation) for failed thrombolysis.…”

“…Of note, the most important finding of this study was a significant reduction in long-term mortality: 11.2% for rescue PCI, 22.4% for conservative therapy, and 22.3% for repeat thrombolysis. Also, of importance but not unexpected was the finding that repeat thrombolysis did not offer any benefit compared with conservative therapy (11).…”

“…This is because not all randomized trials on rescue PCI were able to show such a clear advantage from this form of therapy as did the REACT trial. We performed a meta-analysis using data on mortality at the longest available follow-up obtained from the most recent updated reports on 6 existing trials: the trial of Belenkie et al (14), the MERLIN trial (15), the REACT trial (11), the RESCUE (Randomized Comparison of Rescue Angioplasty With Conservative Management of Patients With Early Failure of Thrombolysis for Acute Anterior Myocardial Infarction) 1 and 2 trials (16), as well as the TAMI (Thrombolysis and Angioplasty in Myocardial Infarction) trial (16). As shown in Figure 1, in the pooled sample of 908 patients, there was a nonsignificant, slightly more than 25% risk reduction in 1-to 4-year mortality from rescue PCI.…”