Rescue percutaneous coronary interventions for failed fibrinolytic therapy in ST-segment elevation myocardial
Dennis T Ko1, Clare L Atzema, Linda R Donovan
1Division of Cardiology, Schulich Heart Centre, University of Toronto, Ontario, Canada. dennis.ko@ices.on.ca
Insights
Rescue percutaneous coronary intervention (PCI) significantly lowers long-term adverse outcomes for ST-segment elevation myocardial infarction (STEMI) patients who fail fibrinolysis. Despite benefits, this crucial reperfusion strategy is underused in clinical practice.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Fibrinolytic therapy is a primary reperfusion strategy for ST-segment elevation myocardial infarction (STEMI).
- Limited data exist on rescue percutaneous coronary intervention (PCI) use, its predictors, and long-term outcomes in STEMI patients with failed fibrinolysis.
Purpose of the Study:
- To analyze the utilization patterns of rescue PCI in STEMI patients experiencing failed fibrinolysis.
- To identify factors associated with rescue PCI use.
- To evaluate the impact of rescue PCI on long-term adverse outcomes.
Main Methods:
- Observational analysis of a population-based cohort of 2,953 STEMI patients in Ontario, Canada (2004-2005).
- Failed fibrinolysis defined as <50% ST-segment resolution at 60-90 minutes post-therapy.
- Primary endpoint: death or repeat acute coronary syndrome hospitalization at 4 years.
Main Results:
- 40.3% of fibrinolysis-treated STEMI patients (611/1517) failed therapy.
- Rescue PCI was used in 34.7% of these patients (212/611); conservative management in 61.1%; repeat fibrinolysis in 4.3%.
- Initial presentation to a PCI-capable hospital strongly predicted rescue PCI use (OR 3.7). Rescue PCI was associated with a 31% reduction in long-term adverse events (aHR 0.69), primarily driven by reduced mortality (HR 0.60).
Conclusions:
- Rescue PCI significantly reduces long-term adverse outcomes, including death, in STEMI patients with failed fibrinolysis.
- Despite proven benefits, rescue PCI remains substantially underutilized in current clinical practice.
Background:
Fibrinolytic therapy remains the reperfusion strategy of choice for many regions treating patients presenting with ST-segment elevation myocardial infarction (STEMI). However, limited data exist regarding the pattern of use of rescue percutaneous coronary intervention (PCI) in patients with STEMI who failed fibrinolysis, factors associated with its use, and its impact on long-term outcomes.
Methods:
Observational analysis of a population-based cohort was done, which included 2,953 patients with STEMI hospitalized from 2004 to 2005 in Ontario, Canada. Failed fibrinolysis was defined as <50% ST-segment resolution on follow-up electrocardiogram at 60 to 90 minutes after fibrinolysis. The main outcome of measure was death or repeat hospitalization for acute coronary syndrome at 4 years.
Results:
Among the 1,517 patients who received fibrinolytic therapy, 611 patients (40.3%) failed fibrinolysis. Of these, rescue PCI was performed in 212 patients (34.7%); conservative management, in 373 patients (61.1%); and repeat fibrinolysis, in 26 patients (4.3%). Initial presentation to a PCI hospital was the strongest predictor of rescue PCI use (odds ratio 3.7, 95% CI 2.2-6.0). At 4-year follow-up, the primary end point occurred in 24.5% of patients who received rescue PCI and 36.5% in patients with no rescue PCI (adjusted hazard ratio 0.69, 95% CI 0.49-0.96). This difference was attributable mainly to a significant reduction in death favoring rescue PCI patients (hazard ratio 0.60, 95% CI 0.38-0.94).
Conclusions:
Rescue PCI was associated with significantly lower risk of long-term adverse outcomes for patients with STEMI who failed fibrinolytic therapy. However, rescue PCI is substantially underused in clinical practice.
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