ST elevation myocardial infarction rescue percutaneous coronary intervention
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| ICD-10 | I21-I22 |
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| ICD-9 | 410 |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Vijayalakshmi Kunadian M.B.B.S., M.D., M.R.C.P
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Definition
Rescue percutaneous coronary intervention (RPCI) also referred to as salvage PCI is performed in order to restore coronary artery blood flow when there is evidence of failed reperfusion following the administration of a fibrinolytic agent.
Background
Primary percutaneous coronary intervention (PPCI) is the optimal treatment for patients presenting with an acute myocardial infarction (MI) if it is available in a timely fashion and can be performed by highly skilled interventional cardiologists. However, worldwide, fibrinolytic therapy continues to be used as the first line therapy in 30-70% of the population for the management of this condition [1;2]. Fibrinolytic therapy has, however, a number of limitations. For instance, TIMI grade 3 flow is restored in only 54% of patients [3]. Of these, around 5-10% of patients experience reocclusion of the infarct related artery following initial successful reperfusion using fibrinolytic therapy.
Previous ST elevation myocardial infarction (STEMI) trials have suggested full reperfusion of the infarct artery (TIMI grade 3 flow) is associated with improved clinical outcomes [4]. Therefore restoration of coronary artery blood flow and myocardial perfusion by percutaneous coronary intervention (PCI) when a fibrinolytic agent has failed to restore complete flow appears to be a reasonable strategy.
Clinical trials
Although reports have been available since the mid 1980s regarding the use of rescue angioplasty, these data may now be mostly of historical interest as there have been significant developments in angioplasty techniques and in adjunctive pharmacotherapy. Preliminary studies on rescue angioplasty were first performed as part of large fibrinolytic trials. In the TAMI-5 trial, the benefit of rescue angioplasty was assessed among those who had fibrinolysis using TPA, urokinase and combination of both fibrinolytics. Among those who underwent rescue angioplasty for failed fibrinolysis, there was a trend towards increased patency rates of the infarct arteries on predischarge angiography compared to those who had delayed procedures (95% vs. 90%, p=0.065), improvement in regional wall motion abnormality in the infarct artery territory (p=0.004) and more patients were free from adverse events (67% vs. 55%, p=0.004) [5].
Rescue angioplasty however, is faced with logistical hurdle of requiring transfer of patients to a PCI center. The feasibility of transfer of patients was studied by Vermeer et al [6]. Patients were randomized to treatment with alteplase, fibrinolysis and transfer for rescue PTCA and primary PTCA. There was no significant difference in mortality between the three groups and the transport of patients was not associated with significant problems [7].
These initial studies led to randomized trials to evaluate the potential benefit of rescue angioplasty compared with conservative management. An initial randomized study of rescue angioplasty was performed by Ellis et al (RESCUE I) to determine the benefit of rescue angioplasty versus a conservative strategy for patients aged 21-79 years with failed reperfusion using fibrinolytic agents [8]. This study included 151 patients with anterior myocardial infarction from 20 centers. Patients were randomized to rescue balloon angioplasty (n=78) or conservative therapy consisting of aspirin, heparin and vasodilators (n=73) following coronary angiography if the infarct related artery was occluded. Balloon angioplasty was technically successful in 92% of patients. Although there was no difference in the resting ejection fraction between the two groups, there was a significant improvement in the exercise ejection fraction with rescue angioplasty (43±15% vs. 38±13% with the conservative therapy, p=0.04). There was also benefit observed in terms of reduction in combined heart failure or death using the rescue strategy compared to the conservative strategy (6% vs. 17%, p=0.05). However, rescue angioplasty was not associated with a difference in death (5% vs. 10%, p=0.18) or heart failure (1% vs. 7%, p=0.11). This study had a number of limitations including the relatively small study sample size which consisted of patients with only anterior infarcts undergoing intervention in the left anterior descending artery. Patients with previous myocardial infarction and left main stem diseases were excluded from the study. Stents and glycoprotein IIb/IIIa inhibitors were not used in this study. This study was followed later by two small randomized studies which demonstrated a potential benefit of the rescue strategy [9;10].
In addition to these small randomized trials, the TIMI study group evaluated the benefit of rescue angioplasty in the TIMI (Thrombolysis In Myocardial Infarction) trials (TIMI 10B-14) [11] in a non-randomized analysis. In an analysis of 1938 patients from TIMI 10B-14 studies, the investigators demonstrated that rescue angioplasty was associated with a reduction in 30-day mortality compared to conservative strategy (6% vs. 17%, p=0.01). Combined death and repeat myocardial infarction was also reduced in the rescue group (8% vs. 19%, p=0.01). Although in contrast to the RESCUE I study, abciximab was used in 45% of patients in the rescue group, this analysis is limited by the fact that this was not randomized. All patients who had acute myocardial infarction and were treated with fibrinolytic therapy (TNK or tPA) underwent coronary angiography at 90 minutes. If the infarct artery demonstrated TIMI 0/1 flow, rescue angioplasty was performed and if there was TIMI 2/3 flow adjunctive angioplasty was performed. Delayed angioplasty was performed among patients who presented >150 minutes after symptom onset. There was no difference in the outcome between the adjunctive and delayed PCI groups.
These data were subsequently followed by another sub-analysis from the TIMI 10B trial which provided outcome information for up to two years among patients undergoing rescue angioplasty compared to those who undergo medical therapy. In this analysis, rescue angioplasty was associated with improved mortality which extended to two years (p=0.03). Stents were used in 21% of patients who underwent rescue PCI and 3.1% of patients received glycoprotein IIb/IIIa inhibitor [12]. In addition, this study also demonstrated that regardless of whether patients underwent rescue or adjunctive PCI and achieved TIMI grade 3 flow, the presence of TIMI myocardial perfusion grade 2/3 was associated with improved mortality.
In 2004, a moderate sized randomized study of patients undergoing rescue PCI versus conservative therapy for failed reperfusion using fibrinolytic therapy was published [13]. The MERLIN trial (Middlesbrough Early Revascularization to Limit Infarction) consisted of 307 patients who were randomized to rescue PCI (n=153) and conservative therapy (n=154). There was no mortality benefit at 30 days for rescue PCI compared to conservative treatment (9.8% vs. 11%, p=0.7). However, there were differences in the composite secondary endpoints which consisted of death, reinfarction, stroke, subsequent revascularization and heart failure with a favorable outcome observed in the rescue group compared to the conservative group (37.3% vs. 50%, p=0.02). This difference was mainly due to an increase in subsequent revascularization in the conservative group compared to the rescue group (20.1% vs. 6.5%, p=0.01). In contrast, in the rescue angioplasty group, 4.6% of patients had a stroke or transfusion compared to 0.6% in the conservative group, p=0.03. Similar results were observed at 1 year and 3 year follow-up [14;15]. It should be noted that stenting (50.3%) and glycoprotein IIb/IIIa inhibitors (3.3%) were used infrequently in the MERLIN trial.
Subsequent to the MERLIN trial, the REACT (Rescue Angioplasty vs. Conservative or repeat Thrombolysis) trial (another UK trial) results were published [16]. The REACT trial randomized 427 patients into three different groups. In addition to the conservative (n=141) and the rescue arms (n=144), the REACT trial had a repeat lysis arm (n=142). This study demonstrated that the event free survival (freedom from death, reinfarction, stroke or severe heart failure) was significantly greater in the rescue PCI group (84.6%) compared to the conservative group (70.1%) and the repeat lysis group (68.7%), p=0.004. Non fatal bleeding events were more common in the rescue PCI arm. Freedom from repeat revascularization was lower in the conservative group (77.6%) and the repeat lysis group (74.4%) compared to the rescue group (86.2%), p=0.05.
A sub-analysis from the REACT trial studied patients who were ≥70 years of age. The 6-month event free survival was significantly better among those who underwent rescue PCI compared to repeat lysis and conservative treatments (77.2% vs. 49.5% vs. 51.7%, p=0.031). There was also a trend towards reduced mortality and improved survival among those who had rescue PCI compared to repeat lysis and conservative treatment (87.5% vs. 69.4% vs. 69%, p=0.123). There was no increase in the incidence of minor or major bleeding events among the elderly in all three groups. This study suggests that rescue PCI in the elderly in the absence of cardiogenic shock might be a beneficial strategy [17].
A number of differences between the MERLIN and the REACT trials might explain the differences in outcomes between the two trials. First, MERLIN included patients who had <50% ST segment resolution at 60 minutes as opposed to 90 minutes in the REACT trial. Second, 96.4% of patients in the MERLIN trial received streptokinase (SK) and 60% of patients received SK in the REACT trial. Third, operators in the MERLIN trial used stents (50.3% vs. 68.5%) and glycoprotein IIb/IIIa inhibitors (3.3% vs. 43.4%) less frequently compared to the REACT trial.
Given the differences in the outcomes with rescue angioplasty among the randomized trials, three meta-analyses on rescue PCI have been performed. While the studies had different inclusion and exclusion criteria, overall rescue PCI was associated with a reduction in mortality and heart failure at 30 days. Rescue PCI was also associated with reduced reinfarction. These benefits however, occur at a risk of an increased risk of stroke and bleeding events [18-20].
Rescue PCI in the setting of cardiogenic shock
Randomized studies excluded patients in cardiogenic shock, a group of patients that might derive particular benefit. To this end, a prospective analysis consisted of patients who underwent primary PCI (n=65) and rescue PCI (n=59) in the setting of cardiogenic shock. In this study, glycoprotein IIb/IIIa inhibitors were used in 42% of cases in the primary PCI group and 20% of cases in the rescue PCI group (p=0.01). TIMI flow grade 3 was achieved in 74% of cases in the primary PCI group and only in 56% of cases in the rescue PCI group (p=0.04). One year mortality was significantly increased in the rescue PCI group compared to the primary PCI group (71% vs. 49%, p=0.01). Among patients who were >70 years of age rescue PCI was associated with 100% mortality rate at one year compared to the primary PCI group (70%). This study demonstrates that rescue PCI in the setting of cardiogenic shock is not associated with favorable mortality outcomes [21].
Predictors of Failed Rescue PCI and 1-year Mortality
A recent study analyzed 440 patients undergoing coronary angiography for failed fibrinolysis. Of these, 318 patients underwent rescue PCI. Rescue PCI was successful in 77% of cases (no in-lab death or emergency coronary artery bypass surgery and TIMI 3 flow). A successful procedure was associated with lower 1-year mortality compared to a failed procedure (14% vs. 43%). Older patients, diabetics, anterior infarcts, inter-hospital transfers, not current smokers and those in cardiogenic shock were likely to have a failed procedure. One year mortality was associated with older age (>75 years), cardiogenic shock and <TIMI 3 flow at the completion of the procedure [22].
Comparison with early transfer for PCI following pharmacotherapy
In situations where it is not always possible to transport patients to a PPCI center, in addition to a strategy of rescue PCI, the concept of a pharmaco-invasive strategy has been tested. While rescue PCI is performed when there is failed reperfusion with fibrinolytic therapy, facilitated PCI involves pretreatment with a fibrinolytic, glycoprotein IIb/IIIa inhibitor or a combination of both fibrinolytic and glycoprotein IIb/IIIa inhibitor in order to improve the outcomes of subsequent planned percutaneous coronary intervention.
In a recent study, Di Mario and co-workers demonstrated that immediate transfer for PCI following the administration of half dose fibrinolytic and a full dose abciximab among patients with acute ST elevation myocardial infarction was associated with improved clinical outcomes when compared to a conservative watchful waiting strategy in the CARESS-in-AMI trial (Combined Abciximab Reteplase Stent Study in Acute Myocardial Infarction) [23]. A total of 600 patients treated with half dose reteplase, full dose abciximab, aspirin and heparin were randomized to either immediate transfer for PCI or transfer only in case of failed reperfusion (rescue group) or clinical deterioration. A total of 255 patients in the immediate transfer group underwent PCI and 91 patients in the conservative group underwent PCI for failed reperfusion. The 30-day mortality was lower in the immediate transfer group compared to the conservative group (4.4% vs. 10.7, p=0.004). There was no increase in bleeding events in the early PCI group (3.4% vs. 2.3%, p=0.47). Thus, early PCI after fibrinolytic administration is a better strategy than a watchful waiting conservative strategy.
This study has been characterized as testing the hypothesis that facilitated PCI would improve PCI outcomes. However come it is important to note that the study is not truly a study of a facilitated PCI strategy. The CARESS-in-AMI study determines whether early PCI improves pharmacotherapy outcomes. This study determines whether immediate transfer for PCI following the administration of half dose lytic and abciximab improves outcomes in the setting where a primary PCI facility is not readily available compared with a conservative strategy where rescue PCI is performed only in the setting of evidence of failed reperfusion or clinical deterioration. In order to test a facilitated PCI strategy, all patients would undergo PCI, and they would be randomized to receive either pharmacotherapy or placebo before the PCI. This would determine whether patients benefit from pre PCI pharmacotherapy.
Recommendations
Based on the evidences from the rescue PCI trials, the 2007 focused update of the American College of Cardiology/American Heart Association 2004 guidelines on the management of patients with ST elevation myocardial infarction provides a Class I indication for performing rescue angioplasty among patients who have failed fibrinolysis and have cardiogenic shock (among patients <75 years of age) [level of evidence B], severe heart failure and or pulmonary edema (level of evidence B) and hemodynamically compromising ventricular arrhythmias (level of evidence C) [24].
Conclusions
Rescue PCI is associated with improved mortality and heart failure compared to conservative treatment. In small studies, the benefit of this therapy in elderly patients with cardiogenic shock is not clear.
References
- Eagle KA, Goodman SG, Avezum A, Budaj A, Sullivan CM, Lopez-Sendon J (2002) Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet 359:373-377
- Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 343:311-322 (1994)
- Cannon CP, Gibson CM, McCabe CH, Adgey AA, Schweiger MJ, Sequeira RF, Grollier G, Giugliano RP, Frey M, Mueller HS, Steingart RM, Weaver WD, Van de WF, Braunwald E (1998) TNK-tissue plasminogen activator compared with front-loaded alteplase in acute myocardial infarction: results of the TIMI 10B trial. Thrombolysis in Myocardial Infarction (TIMI) 10B Investigators. Circulation 98:2805-2814
- Anderson JL, Karagounis LA, Califf RM (1996) Metaanalysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction. Am J Cardiol 78:1-8
- Califf RM, Topol EJ, Stack RS, Ellis SG, George BS, Kereiakes DJ, Samaha JK, Worley SJ, Anderson JL, Harrelson-Woodlief L, . (1991) Evaluation of combination thrombolytic therapy and timing of cardiac catheterization in acute myocardial infarction. Results of thrombolysis and angioplasty in myocardial infarction--phase 5 randomized trial. TAMI Study Group. Circulation 83:1543-1556
- Vermeer F, Oude Ophuis AJ, vd Berg EJ, Brunninkhuis LG, Werter CJ, Boehmer AG, Lousberg AH, Dassen WR, Bar FW (1999) Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study. Heart 82:426-431
- Califf RM, Topol EJ, Stack RS, Ellis SG, George BS, Kereiakes DJ, Samaha JK, Worley SJ, Anderson JL, Harrelson-Woodlief L, . (1991) Evaluation of combination thrombolytic therapy and timing of cardiac catheterization in acute myocardial infarction. Results of thrombolysis and angioplasty in myocardial infarction--phase 5 randomized trial. TAMI Study Group. Circulation 83:1543-1556
- Ellis SG, Da Silva ER, Heyndrickx G, Talley JD, Cernigliaro C, Steg G, Spaulding C, Nobuyoshi M, Erbel R, Vassanelli C, . (1994) Randomized comparison of rescue angioplasty with conservative management of patients with early failure of thrombolysis for acute anterior myocardial infarction. Circulation 90:2280-2284
- Belenkie I, Traboulsi M, Hall CA, Hansen JL, Roth DL, Manyari D, Filipchuck NG, Schnurr LP, Rosenal TW, Smith ER, . (1992) Rescue angioplasty during myocardial infarction has a beneficial effect on mortality: a tenable hypothesis. Can J Cardiol 8:357-362
- Ellis SG, Da Silva ER, Spaulding CM, Nobuyoshi M, Weiner B, Talley JD (2000) Review of immediate angioplasty after fibrinolytic therapy for acute myocardial infarction: insights from the RESCUE I, RESCUE II, and other contemporary clinical experiences. Am Heart J 139:1046-1053
- Schweiger MJ, Cannon CP, Murphy SA, Gibson CM, Cook JR, Giugliano RP, Changezi HU, Antman EM, Braunwald E (2001) Early coronary intervention following pharmacologic therapy for acute myocardial infarction (the combined TIMI 10B-TIMI 14 experience). Am J Cardiol 88:831-836
- Gibson CM, Cannon CP, Murphy SA, Marble SJ, Barron HV, Braunwald E (2002) Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction. Circulation 105:1909-1913
- Sutton AG, Campbell PG, Graham R, Price DJ, Gray JC, Grech ED, Hall JA, Harcombe AA, Wright RA, Smith RH, Murphy JJ, Shyam-Sundar A, Stewart MJ, Davies A, Linker NJ, de Belder MA (2004) 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. J Am Coll Cardiol 44:287-296
- Sutton AG, Campbell PG, Graham R, Price DJ, Gray JC, Grech ED, Hall JA, Harcombe AA, Wright RA, Smith RH, Murphy JJ, Shyam-Sundar A, Stewart MJ, Davies A, Linker NJ, de Belder MA (2005) One year results of the Middlesbrough early revascularisation to limit infarction (MERLIN) trial. Heart 91:1330-1337
- Kunadian B, Sutton AG, Vijayalakshmi K, Thornley AR, Gray JC, Grech ED, Hall JA, Harcombe AA, Wright RA, Smith RH, Murphy JJ, Shyam-Sundar A, Stewart MJ, Davies A, Linker NJ, de Belder MA (2007) Early invasive versus conservative treatment in patients with failed fibrinolysis--no late survival benefit: the final analysis of the Middlesbrough Early Revascularisation to Limit Infarction (MERLIN) randomized trial. Am Heart J 153:763-771
- Gershlick AH, Stephens-Lloyd A, Hughes S, Abrams KR, Stevens SE, Uren NG, de BA, Davis J, Pitt M, Banning A, Baumbach A, Shiu MF, Schofield P, Dawkins KD, Henderson RA, Oldroyd KG, Wilcox R (2005) Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 353:2758-2768
- Alp NJ, Gershlick AH, Carver A, Stevens SE, Wilcox R (2007) Rescue angioplasty for failed thrombolysis in older patients: Insights from the REACT trial. Int J Cardiol
- Patel TN, Bavry AA, Kumbhani DJ, Ellis SG (2006) A meta-analysis of randomized trials of rescue percutaneous coronary intervention after failed fibrinolysis. Am J Cardiol 97:1685-1690
- Collet JP, Montalescot G, Le MM, Borentain M, Gershlick A (2006) Percutaneous coronary intervention after fibrinolysis: a multiple meta-analyses approach according to the type of strategy. J Am Coll Cardiol 48:1326-1335
- Wijeysundera HC, Vijayaraghavan R, Nallamothu BK, Foody JM, Krumholz HM, Phillips CO, Kashani A, You JJ, Tu JV, Ko DT (2007) Rescue angioplasty or repeat fibrinolysis after failed fibrinolytic therapy for ST-segment myocardial infarction: a meta-analysis of randomized trials. J Am Coll Cardiol 49:422-430
- Kunadian B, Vijayalakshmi K, Dunning J, Thornley AR, Sutton AG, Muir DF, Wright RA, Hall JA, de Belder MA (2007) Should patients in cardiogenic shock undergo rescue angioplasty after failed fibrinolysis: comparison of primary versus rescue angioplasty in cardiogenic shock patients. J Invasive Cardiol 19:217-223
- Kunadian B, Vijayalakshmi K, Dunning J, Sutton AG, Muir DF, Wright RA, Hall JA, de Belder MA (2008) Rescue angioplasty after failed fibrinolysis foracute myocardial infarction: Predictors of a failed procedure and 1-year mortality. Catheter Cardiovasc Interv 71:138-145
- Di Mario C, Dudek D, Piscione F, Mielecki W, Savonitto S, Murena E, Dimopoulos K, Manari A, Gaspardone A, Ochala A, Zmudka K, Bolognese L, Steg PG, Flather M (2008) Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. Lancet 371:559-568
- Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC, Jr., Anbe DT, Kushner FG, Ornato JP, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW (2008) 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 117:296-329