Long-term clinical outcomes after rescue angioplasty are not different from those of successful thrombolysis for acute myocardial infarction

Philippe Gabriel Steg*, Laurent Francois, Bernard Iung, Dominique Himbert, Pierre Aubry, Patrick Charlier, Hakim Benamer, Laurent J. Feldman and Jean-Michel Juliard

Department of Cardiology, Hôpital Bichat-Claude Bernard, Assistance Publique—Hôpitaux de Paris, 46 rue Henri Huchard, 75877 Paris Cedex 18, France

Received 20 September 2004; revised 22 March 2005; accepted 22 April 2005; online publish-ahead-of-print 1 June 2005.

* Corresponding author. Tel: +33 1 40 25 86 68; fax: +33 1 40 25 88 65. E-mail address: gabriel.steg{at}bch.ap-hop-paris.fr

See page 1813 for the editorial comment on this article (doi:10.1093/eurheartj/ehi382)


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
Aims The long-term value of rescue percutaneous transluminal coronary angioplasty (PTCA) in patients with ST-segment elevation myocardial infarction who received thrombolytic therapy but failed to achieve early recanalization of the artery is still debated. This study aimed to compare long-term outcomes after successful thrombolysis vs. systematic attempted rescue PTCA.

Methods and results A total of 362 consecutive patients with STEMI hospitalized within 6 h of symptom onset and treated with intravenous thrombolytic therapy were studied. Of these, 345 underwent coronary angiography within 90 min. Sixty per cent of patients achieved TIMI 3 flow and were treated medically; the in-hospital death rate in this group was 4%. Nine per cent of patients had TIMI 2 flow and 31% TIMI 0–1 flow. In this latter group, rescue PTCA was attempted in 85.8% with a hospital death rate of 5.5% (20% with failed vs. 4% with successful rescue PTCA, P=0.03). Eight year actuarial survival without recurrent myocardial infarction was no different in patients who had successful thrombolytic therapy and in patients with attempted rescue PTCA [78 and 95% CI (71–85) vs. 78 and 95% CI (68–87), respectively, hazard ratio: 0.93 (0.52–1.65), P=0.80]. Total mortality, cardiac mortality, and other composite endpoints also did not differ between groups.

Conclusion Routine attempted rescue PTCA 90 min after thrombolytic therapy in patients with persistent occlusion of the infarct-related vessels achieves long-term clinical outcomes which do not differ from those obtained by successful thrombolysis.

Key Words: PTCA • Angioplasty • Thrombolysis • Myocardial infarction


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
If given in a timely manner, intravenous thrombolytic therapy for acute myocardial infarction can decrease the risk of mortality.1 This is achieved largely by reducing infarct size and preserving left ventricular function. Angiographic studies have consistently linked the full benefit of thrombolytic therapy to early (i.e. 60–90 min), complete (i.e. TIMI grade 3 angiographic flow), and sustained recanalization of the infarct-related artery. Yet, current thrombolytic regimens fail to achieve 90 min TIMI grade 3 patency in a large proportion of the patients treated, in the range of 30% with fibrin-specific agents and>50% for streptokinase.24 Early angiography experience has shown that patients with failed thrombolysis have consistently worse short- and long-term outcomes when compared with patients with successful thrombolysis.45 Mortality is highest in patients with TIMI 0–1 flow, intermediate in patients with TIMI 2 flow, and lowest in patients with TIMI 3 flow. Rescue angioplasty has been suggested as a method to treat such thrombolytic therapy ‘failures’, but very little evidence is available to prove that rescue angioplasty is indeed beneficial in patients with persistently occluded arteries early after thrombolysis.

The TAMI-5 (Thrombolysis and Angioplasty in Myocardial Infarction) trial6 randomized patients who had received thrombolytic therapy either to an ‘aggressive’ strategy of immediate angiography and rescue angioplasty of persistently occluded arteries or to a conventional therapy strategy. Composite clinical outcomes (death, stroke, re-infarction, re-occlusion, heart failure, and recurrent ischaemia) were superior and regional wall motion in the infarct region improved in the group treated aggressively. The main randomized clinical trial performed so far, the RESCUE (Randomized Evaluation of Salvage angioplasty with Combined Utilization of Endpoints) trial,7 encountered problems with enrolment, given the ethical issues related to randomization of patients in whom persistent occlusion of the infarct artery was demonstrated on angiography.8 Nevertheless, despite the small size of this study, there was a non-significant trend towards a reduction in the combined incidence of death and congestive heart failure (6.4 vs. 16.6%, P=0.055) with rescue angioplasty compared to conventional medical therapy in patients with an anterior myocardial infarction treated within 8 h of symptom onset. There have, however, been reports of catastrophic outcomes when rescue percutaneous transluminal coronary angioplasty (PTCA) fails to achieve successful recanalization of the infarct artery.3,4,8 More recently, the MERLIN (Middlesbrough Early Revascularization to Limit Infarction) trial found no difference in 30 day mortality between rescue and conservative treatment after suspected failure of thrombolysis,9 although this trial only examined short-term mortality and was small. Furthermore, some observational studies have found no benefit in terms of outcomes for rescue PTCA compared to thrombolytic therapy alone.1011 Little information is available regarding the long-term outcome of patients treated with rescue angioplasty. In one study involving a cohort of patients enrolled in a TIMI 10B (Thrombolysis In Myocardial Infarction 10B) substudy, individuals who underwent rescue percutaneous coronary intervention (PCI) had a reduced morbidity at 2 year follow-up. However, improved microvascular perfusion before PCI was also associated with improved long-term survival.12

The present report describes a cohort of consecutive patients with ST-segment elevation myocardial infarction admitted to the Coronary Care Unit of Hôpital Bichat within 6 h of symptom onset and treated with thrombolytic therapy. Since 1988, the routine policy of this institution has been to perform systematic 90 min angiography in all patients treated with thrombolytic therapy to identify those with failed recanalization (TIMI 0–1 flow) and perform immediate rescue PTCA.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
Between January 1988 and January 1998, 362 consecutive patients admitted for ST-segment elevation acute myocardial infarction within 6 h of symptom onset received intravenous thrombolytic therapy. Of these, 345 (95%) patients underwent 90 min coronary angiography (Figure 1). The remaining 17 patients did not undergo angiography because of renal failure (n=1), previous coronary artery bypass grafting (n=1), agitation (n=2), power shortage (n=1), morbid obesity (n=2), inclusion in a clinical trial precluding angiography (n=5), and cardiogenic shock (n=1). In two additional patients, angiography was attempted but was impossible via the femoral approach and was not pursued because the patients were clinically stable. Finally, two other patients underwent angiography beyond 90 min. Angiography was performed via the femoral approach using 6F or 4F catheters. The infarct-related artery was injected and flow graded according to the TIMI score. Patients with TIMI 3 flow did not undergo immediate angioplasty but were treated medically with intravenous heparin for at least 48 h (targeting an activated partial thromboplastin time >2.5), aspirin, and beta-blockers as appropriate (Figure 1B). Patients in this group were subsequently revascularized as judged appropriate. Patients with failed thrombolytic therapy, defined as angiographic TIMI 0–1 flow in the infarct-related artery, were treated with rescue PTCA (Figure 1B). In-hospital management of the patients was performed according to usual local practice, but all patients underwent a study of left ventricular function using echocardiography or radionuclide angiography before discharge from hospital.



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Figure 1 (A) Study design; and (B) flow chart of percutaneous transluminal coronary angioplasty use according to TIMI flow rate. STEMI, ST-segment elevation myocardial infarction.

 
Follow-up information was obtained either from the patient's cardiologist or by telephone or mail directly from the patient. Data were collected for death, re-infarction, congestive heart failure leading to hospitalization, new revascularizations, angina (Canadian Cardiovascular Society Classification), and congestive heart failure (New York Heart Association Classification). The reference date for follow-up was 1 January 2000. Of the 345 patients, nine (2.6%) were lost to follow-up (four were foreign residents, three were homeless patients, and two had incomplete addresses). The clinical and angiographic characteristics for the patients lost to follow-up were similar to those for whom follow-up data were available. The average length of follow-up for the rest of the cohort was 30±16 months.

Statistical analysis
Quantitative variables are expressed as means±standard deviations. Survival and event-free survival were computed using the Kaplan–Meier method. Event-free rates are represented with 95% confidence intervals (CI) and extend up to 10 years of follow-up. However, when comparing survival curves, data were not reported beyond 8 years of follow-up, if the number of patients at risk fell below 10. Univariate analysis comparing patient subsets used unpaired Student's t-tests for quantitative variables and {chi}2 for qualitative variables, using Yates's correction as appropriate. The comparison between treatment groups (rescue PTCA vs. TIMI 3 flow) following thrombolytic therapy of long-term survival without recurrent myocardial infarction was adjusted on variables known to predict long-term outcomes after thrombolysis, such as age, gender, infarct location, number of diseased vessels, and ejection fraction, using a multivariable Cox model. The assumption of proportional hazards was verified graphically. All statistical tests were two sided. A P-value <0.05 was considered significant. Analyses were performed using the SAS statistical Software (version 6.11, SAS Institute, Cary, MI, USA).


    Results
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
Data from 345 consecutive patients were analysed. The patients' clinical and angiographic characteristics are summarized in Table 1. In all patients, a diagnosis of myocardial infarction was subsequently confirmed by creatine kinase elevation at least twice above the upper limit of normal. The average delay between the onset of pain and the start of thrombolytic therapy was 170±75 min (range 30–360 min). The thrombolytic treatment used was recombinant tissue plasminogen activator (rtPA) in 66% of patients, streptokinase in 22%, a combination of rtPA and streptokinase in 8%, and anisoylated purified streptokinase activator complex in 4%. Thrombolytic therapy had been initiated in the pre-hospital setting in 53% of the cases.


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Table 1 Clinical and angiographic characteristics in patients with ST-segment elevation myocardial infarction
 
Emergency 90 min angiography identified the culprit artery in all patients: the left anterior descending artery was involved in 49% of patients, the right coronary artery in 38%, the left circumflex in 12%, and the left main stem in 1% (Table 1). Flow in the infarct vessel was graded as TIMI 3 in 60% of patients, TIMI 0–1 in 31%, and TIMI 2 in 9% (Figure 1B). Among the 208 patients with TIMI 3 flow, no immediate PTCA was performed but 147 (70.7%) underwent delayed PTCA of the infarct vessel later during the hospitalization. Among the 106 patients with TIMI 0–1 flow, rescue PTCA was attempted in 91 (85.8%) patients. In the remaining 15 patients with TIMI 0–1 flow, rescue PTCA was not attempted because the culprit vessel appeared to be small and unworthy of revascularization (always with a reference diameter <2 mm), because it converted to TIMI 2 flow during angiography, or because of enrolment in a clinical trial precluding emergency rescue PTCA (Figure 1B).7

Patients undergoing rescue PTCA received 5000 units of intravenous heparin. Only one patient received abciximab. Rescue PTCA achieved TIMI 3 flow in the infarct-related artery in 81 (89.0%) patients, TIMI 2 flow in 5 (5.5%), and TIMI 0–1 flow in 5 (5.5%). Stents were used in 4% of the procedures and GP IIb/IIIa intravenous antagonists in one patient.

In-hospital outcomes
Of the 345 patients, 15 (4.4%) died while in hospital. The death rate was 4.0% in patients with TIMI 3 flow (8 of 208) compared with 6.5% (2 of 31) in patients with TIMI 2 flow and 5.0% (5 of 106) in patients who presented with TIMI 0–1 flow in the infarct-related artery on angiography after thrombolytic therapy ({chi}2 test P=0.78). In this latter group of 106 patients with failed thrombolytic therapy and TIMI 0–1 flow, mortality was zero in the 15 patients in whom rescue PTCA was not attempted. In-hospital mortality in patients who underwent attempted rescue PTCA was 5.5% overall but was 20% in the 10 patients in whom it was attempted and failed and 3.7% in the 81 patients who underwent a successful rescue PTCA (P=0.03). With respect to bleeding, the rate of intracerebral bleeding was 1.6%, there were 2.8% other major bleeds and 3.0% access site bleedings. Seven per cent of the patients received a blood transfusion in hospital.

Long-term survival
Ten year actuarial survival was 81% (95% CI: 78–86%), and actuarial freedom from cardiac death was 85% (95% CI: 82–88%). Figure 2 displays long-term survival, freedom from cardiac death and from recurrent myocardial infarction, revascularization, or admission for congestive heart failure for the 345 patients.



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Figure 2 Ten year actuarial survival and actuarial freedom from cardiac death and long-term survival without recurrent myocardial infarction (MI), revascularization, or admission for congestive heart failure (CHF). Event-free rates are represented with 95% CIs.

 
Successful thrombolytic therapy vs. attempted rescue PTCA
From the 345 patient cohort, the 208 patients with successful thrombolytic therapy (defined as TIMI 3 flow after thrombolytic therapy on emergency angiography) were compared with the 91 patients with ‘attempted rescue PTCA’ (TIMI 0–1 flow on emergency angiography after thrombolytic therapy and attempted rescue PTCA). The baseline demographics of the two groups and in-hospital bleeding complications related to the two strategies are summarized in Table 2. Clinical outcomes after 8 years did not differ between the two groups (Table 3), regardless of the single or composite endpoint considered; for example, the unadjusted hazard ratio for cardiac death or for recurrent myocardial infarction was 0.93 (0.52–1.65) for successful thrombolysis when compared with attempted rescue PTCA (P=0.80, Figure 3A). Likewise, after 8 years, actuarial freedom from death, acute myocardial infarction, and revascularization was also no different in both groups: 64 (95% CI: 56–72%) vs. 60% (95% CI: 46–73%) for successful thrombolysis and attempted rescue PTCA patients, respectively, univariate P=0.73. Survival curves were almost superimposable between the two groups (Figure 3B, P=0.52). After adjusting on known predictors of long-term outcomes, the hazard ratio of long-term death or myocardial infarction after rescue PTCA compared with successful thrombolytic therapy was 0.9 (0.5–1.6), P=0.62 (Table 4).


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Table 2 Baseline characteristics and bleeding complications of patients who underwent successful thrombolytic therapy (i.e. TIMI 3 flow in the infarct related artery at 90 min angiography) or attempted rescue PTCA
 

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Table 3 Clinical outcomes up to 8 years in patients who underwent successful thrombolytic therapy vs. attempted rescue PTCA
 


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Figure 3 Comparison of long-term outcomes in patients with successful thrombolysis vs. attempted rescue angioplasty: (A) survival without myocardial infarction, (B) total survival. Event-free rates are represented with 95% CIs.

 

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Table 4 Adjusted hazard ratio of death or myocardial infarction in the 299 patients who underwent successful thrombolytic therapy or attempted rescue PTCA according to known predictor variables and to the initial treatment
 

    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
Rescue angioplasty has been suggested to be an effective treatment to palliate thrombolytic treatment failures, if performed in a timely fashion; however, only small-scale randomized trials have evaluated this approach. The RESCUE trial7 found a borderline difference favouring rescue angioplasty in terms of preventing death and congestive heart failure at 42 days in patients with anterior myocardial infarction and persistent occlusion of the left anterior descending artery documented by angiography 90 min after thrombolytic therapy but within 8 h of symptom onset. Although the reduction of the primary endpoint was of borderline significance, the magnitude of the benefit was large, with a reduction in the combined endpoint of death or severe congestive heart failure at 30 days from 16.6 to 6.4% (P=0.055).7 The TAMI-5 trial suggested a benefit in terms of combined clinical endpoints and regional wall motion of a strategy of emergency routine catheterization following thrombolysis to identify thrombolytic therapy failures and perform rescue angioplasty.6 In the SIAM III (The Southwest German Interventional Study in Acute Myocardial Infarction) study, a policy of immediate stenting after thrombolysis was superior to one of delayed intervention. However, this study addressed all patients after thrombolysis, not necessarily those who had failed thrombolysis.13 Hong et al.14 compared long-term outcomes following primary or rescue PCI in patients with acute myocardial infarction. The success rate was similar for both primary (94%) and rescue PCI (95%), and left ventricular function was improved on long-term follow-up in patients who underwent rescue PCI. Survival rates for both groups were similar at 1, 6, and 12 months. Miller et al.15 studied the impact of early angioplasty and treatment with abciximab on in-hospital and 30 day outcomes in patients who had failed thrombolysis. They reported that patients who received abciximab showed trends toward a lower 30 day mortality than patients who underwent angioplasty alone but were at greater risk of severe bleeding.

These trial results represent a small number of patients in a small number of studies4 because of difficulties with enrolment8 and limited follow-up information. There have been concerns that although successful rescue PTCA may be useful in improving clinical outcomes, failed rescue PTCA may be associated with catastrophic short-term outcomes.7,8,1618

The main finding of the present study, performed in a cohort of consecutive unselected patients, is that routine attempted rescue PTCA of occluded infarct-related vessels 90 min after intravenous thrombolytic therapy yields excellent long-term clinical outcome, which is not different from that obtained by successful thrombolysis (defined as TIMI 3 flow at 90 min angiography). This contrasts with the consistent finding in all patency studies performed after intravenous thrombolytic therapy of worse clinical outcomes and lower survival when TIMI flow in the infarct-related artery is 0–1 compared with TIMI 3 flow.16 The value of this result is enhanced given the unselected nature of the patient population which comprised consecutive patients treated with intravenous thrombolysis. There was no referral bias for angiography because emergency 90 min angiography was routinely performed in all patients undergoing thrombolysis (as is still the case in our institution). This is especially important in view of the difficulties in reliably identifying real-time patients in whom thrombolysis fails to recanalize the infarct-related artery, regardless of whether one uses simple clinical and electrocardiographic variables,19 biochemical methods,20 or computerized electrocardiographic methods.21 The group of patients with closed vessels who did not undergo rescue PCI, has excellent outcomes but was highly biased as many patients in that group were deemed not to warrant PCI in the first place because of a very low risk or small vessel. The poor in-hospital outcomes of the small group of patients in whom rescue PTCA was unsuccesful did not appear to offset the benefits afforded by successful rescue PTCA in the broader group of patients with failed thrombolysis. Therefore, because of these limitations related to the observational design, the current study should not be viewed as proving the superiority of rescue PCI vs. conservative management of failed lysis (which can only be established by randomized trials) but rather as showing the excellent outcome of an approach of emergency angiography after thrombolysis followed by routine rescue PCI in patients with an occluded infarct-related artery. The benefit of rescue PTCA may relate to salvage of ischaemic myocardium and limitation of infarct size, given that the average delay between symptom onset and recanalization of the infarct vessel was <5 h, and was in the same range as the time to angiographic demonstration of patency in the group of patients who underwent successful thrombolysis. However, it may also be related to the benefits of late recanalization (i.e. those related to an open infarct artery rather than limitation of infarct size). Indeed, experimental and observational clinical data suggest that late opening of the infarct vessel, beyond the time window compatible with myocardial salvage, may be beneficial through other mechanisms such as prevention of ventricular arrythmias,22 prevention of left ventricular remodelling (possibly through reduced apoptosis),23,24 reperfusion of an ischaemic but viable border zone, and maintenance of a channel for potential collateralization in the event of contralateral occlusion.25,26

The main limitations of this study are the relatively young age and small number of patients (although this still represents one of the largest single-centre cohorts of patients treated with rescue PTCA) and the fact that a fraction of the patients with persistent occlusion of the infarct-related artery did not undergo an attempt at rescue PTCA. However, this is due to the inclusion of consecutive patients in this cohort and represents the ‘real life’ application of a strategy of routine rescue PTCA in which some patients have to be treated medically because the infarct-related artery is either judged unsuitable for PTCA or emergency angiography cannot technically be performed. Despite the superimposable survival curves, the CIs of the long-term event hazard ratios indicate the possibility of a substantial difference in outcome, the demonstration of which would require a much larger cohort or a randomized trial. As this study looks at long-term outcomes, the use of stents and glycoprotein IIb/IIIa inhibitors reflects the practice pattern at the time patients were treated and, therefore, is not contemporary. However, improvements in PTCA technique and adjuvant therapy would be expected to translate into improved outcomes for rescue PTCA and, therefore, would in no way negate our results. In addition, even today, the use of glycoprotein IIb/IIIa agents for rescue PTCA in patients having received full dose lytic therapy is still not recommended because it may lead to excessive bleeding.27,28 Finally, this study did not address myocardial reperfusion at the tissue level because this cohort of patients was accumulated at a time when methods for evaluating tissue reperfusion based upon electrocardiographic2932 or angiographic criteria33 had not been standardized.


    Conclusions
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
In conclusion, routine application of rescue PTCA in patients with persistent occlusion (TIMI 0–1 flow in the infarct-related artery) 90 min after intravenous thrombolysis is associated with excellent long-term outcomes, which do not differ from those of patients with patent epicardial vessels. These results were obtained using the interventional techniques available in the early 1990s. They contrast sharply with the results from angiographic studies of thrombolysis, which have consistently demonstrated worse short- and long-term outcomes for patients with failed thrombolysis when compared with successful thrombolysis. We hope that advances in pharmacologic adjuvant therapy and interventional procedures will lead to further improvement in success rates and, therefore, long-term outcomes following rescue PTCA. Our data provide additional evidence in favour of a clinical benefit of routine rescue PTCA.


    Acknowledgement
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
The authors are indebted to Pr France Mentré for her expert statistical advice.


    References
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 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 

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