Myocardial infarction: no clear benefit from rescue angioplasty following failed thrombolysis.

Clinical bottom line (level 1b-)

  1. Patients with an anterior myocardial infarction treated with thrombolysis and subsequently found to have an occluded infarct vessel, who received angioplasty compared with conservative treatment were not clearly less likely to die, develop severe heart failure or require revascularisation.
Ellis et al: Circulation 1994; 90 (5): 2280-2284
Expires March 2003

The study

Unblinded ?concealed randomised trial without intention-to-treat
Setting: 20 acute hospitals, USA, Brazil and Europe

151 patients (aged 21 to 79; mean 59, 82% male) who had
  • an acute myocardial infarction (ST elevation of 2 mm or more in at least 2 precordial leads
  • thrombolysis
  • angiography within 6 hours of onset of chest pain, and reduced flow (TIMI flow grade 0 or 1) in left anterior descending artery at least 90 minutes after thrombolysis


Excluded if
  • aged < 21, > 79
  • cardiogenic shock
  • prior myocardial infarction
  • left main coronary artery stenosis 50% or more


Note:
  • Patients were stratified for investigational site and time from onset of chest pain to randomisation, before being randomised.


Control Group: (n = 73, 73 analysed): conservative management
Experimental Group: (n = 78, 78 analysed): rescue angioplasty
All patients received aspirin, iv nitrates, and subcutaneous heparin for at least three days. Heart failure was treated with digitalis, diuretics and ACE inhibitors if possible.
100% followed for 30 days

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
PTCA or CABG required in hospital 30 days 10
(13.7%)		 7
(8.97%)		 34%
(-63% to 74%)		 4.72%
(-5.40% to 14.9%)		 21
(NNT = 7 to infinity;
NNH = 19 to infinity)
severe heart failure 30 days 5
(6.85%)		 1
(1.28%)		 81%
(-56% to 98%)		 5.57%
(-0.742% to 11.9%)		 18
(NNT = 8 to infinity;
NNH = 140 to infinity)
death 30 days 7
(9.59%)		 4
(5.13%)		 47%
(-75% to 84%)		 4.46%
(-3.88% to 12.8%)		 22
(NNT = 8 to infinity;
NNH = 26 to infinity)

Citation

  1. Ellis SG, Ribeiro da Silva E, Heyndrickx G, et al: Randomized comparison of rescue angioplasty with conservative management of patients with early failure of thrombolysis for acute anterior myocardial infarction (RESCUE). Circulation 1994; 90 (5): 2280-2284
Search Terms: reference from review article
Contributor: Chris Ball and Clare Wotton, February 2000
Reviewer:

Clinical Question.
Patient myocardial infarction
Intervention or Exposure rescue angioplasty following failed thrombolysis
Comparison conservative therapy
Outcome death, severe heart failure, need for revascularisation (PTCA or CABG)