Rescue angioplasty in the thrombolysis in myocardial infarction (TIMI) 4 trial
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C M Gibson1, C P Cannon, R M Greene
1Department of Medicine, the Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Insights
Rescue percutaneous transluminal coronary angioplasty (PTCA) improves blood flow after failed thrombolysis for acute myocardial infarction. However, the overall strategy of rescue PTCA showed similar adverse outcomes compared to no intervention.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Management
Background:
- Thrombolysis is a primary treatment for acute myocardial infarction (AMI).
- Failed thrombolysis necessitates reperfusion strategies to restore coronary blood flow.
- Rescue percutaneous transluminal coronary angioplasty (PTCA) is an option for occluded arteries post-thrombolysis.
Purpose of the Study:
- To evaluate the angiographic and clinical outcomes of rescue PTCA.
- To compare outcomes in patients receiving rescue PTCA versus those with patent arteries after thrombolysis.
- To assess the safety and efficacy of rescue PTCA performed 90 minutes after initial thrombolysis for AMI.
Main Methods:
- Analysis of data from the Thrombolysis in Myocardial Infarction (TIMI) 4 trial.
- Comparison of patients with patent arteries versus those with occluded arteries after thrombolysis.
- Non-randomized assessment of rescue PTCA in patients with occluded arteries at 90 minutes post-thrombolysis.
Main Results:
- Successful rescue PTCA significantly improved coronary blood flow (corrected TIMI frame count) and TIMI grade 3 flow compared to patent arteries after thrombolysis.
- In-hospital adverse outcomes were higher in failed rescue PTCA (83%) versus successful rescue PTCA (29%).
- The overall incidence of adverse events for the rescue PTCA strategy was similar to that of no PTCA (35% vs 35%) and tended to be higher than patent arteries (35% vs 23%).
Conclusions:
- Successful rescue PTCA restores superior coronary blood flow compared to successful thrombolysis alone.
- The overall strategy of rescue PTCA, encompassing both successes and failures, did not demonstrate a significant reduction in adverse events compared to no intervention.
- Rescue PTCA should be carefully considered given its outcomes in the context of overall adverse event rates.
Abstract:
Rescue percutaneous transluminal coronary angioplasty (PTCA) has been used to establish reperfusion after failed thrombolysis, and the goal of this study was to examine the angiographic and clinical outcomes after rescue PTCA performed for an occluded artery 90 minutes after thrombolysis. Four hundred two patients with acute myocardial infarction were randomized to receive either anistreplase (APSAC), recombinant tissue plasminogen activator, or their combination in the Thrombolysis in Myocardial Infarction (TIMI) 4 trial. The angiographic and clinical outcomes of patients with a patent artery 90 minutes after thrombolysis were compared with those of patients with an occluded artery treated in a nonrandomized fashion with either rescue or no rescue PTCA. At 90 minutes, the number of frames required to opacify standard landmarks (corrected TIMI frame count) was significantly lower (i.e., flow was faster) after successful rescue PTCA (27 +/- 11) than that in patent arteries after successful thrombolysis (39 +/- 20, p < 0.001), and the incidence of TIMI grade 3 flow was correspondingly higher after successful rescue PTCA (87% vs 65%, p = 0.002). In-hospital adverse outcomes (death, recurrent acute myocardial infarction, severe congestive heart failure, cardiogenic shock or an ejection fraction <40%) occurred in 29% of successful rescue PTCAs and in 83% of failed rescue PTCAs (p = 0.01). Among all patients in whom rescue PTCA was performed (successes and failures combined), 35% of patients experienced an adverse outcome, which was the same as the 35% incidence observed in patients not undergoing rescue PTCA (p = NS) and tended to be higher than the 23% incidence observed in patients with patent arteries (p = 0.07). Although successful rescue PTCA for an occluded artery at 90 minutes results in restoration of flow that is superior to that of successful thrombolysis, the incidence of adverse events for the strategy of rescue PTCA as a whole was the same as that of undertaking no PTCA.