Longer-term follow-up of patients recruited to the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) trial.

OBJECTIVES

To evaluate the longer-term outcomes for rescue percutaneous coronary intervention (R-PCI).

BACKGROUND

Thrombolysis remains an important, commonly used reperfusion therapy, yet failure to achieve complete reperfusion occurs relatively frequently. A number of recent trials have focused on the management of patients with thrombolytic failure, including the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) trial, which demonstrated a significant 6-month benefit favoring R-PCI. However, longer-term maintenance of benefit for R-PCI has not been demonstrated.

METHODS

Rates of the primary composite end point (major adverse cardiac and cerebrovascular events) to 1 year and mortality to a median of 4.4 years in 427 patients included in the 3 randomized arms of the REACT trial (repeat lysis, conservative therapy, and R-PCI) were analyzed.

RESULTS

One-year event-free survival for patients randomized to R-PCI was 81.5%, compared with 64.1% for repeat thrombolysis and 67.5% for conservative therapy (overall p = 0.004). Adjusted hazard ratio was 0.44 (95% confidence interval [CI]: 0.28 to 0.71; p = 0.0008) for R-PCI versus repeat thrombolysis and 0.51 (95% CI: 0.32 to 0.83; p = 0.007) for R-PCI versus conservative therapy. Adjusted hazard ratio for longer-term (median 4.4 years) overall mortality for R-PCI versus repeat thrombolysis was 0.41 (95% CI: 0.22 to 0.75; p = 0.004) and 0.43 (95% CI: 0.23 to 0.79; p = 0.006) for R-PCI versus conservative therapy. There was no difference in either analysis between repeat thrombolysis and conservative strategies.

CONCLUSIONS

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.