Rescue percutaneous coronary interventions for failed fibrinolytic therapy in ST-segment elevation myocardial infarction: a population-based study

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.