Management and outcomes of patients transferred for rescue coronary angioplasty in acute myocardial infarction.

BACKGROUND: Rescue coronary angioplasty (PTCA), though recommended by the guidelines, is not regularly performed after failed lysis in patients with ST-elevation acute myocardial infarction (AMI), and data from large contemporary studies are not available. The outcomes of a recent series of consecutive patients in our Center are presented. METHODS: Between August 2000 and November 2003, 270 patients with AMI < 12 hours were referred to our cath lab for emergency PTCA: 117 (43%) for rescue PTCA after failed lysis, and 153 for primary or facilitated PTCA. The baseline, procedural and outcome data of all patients were prospectively collected, analyzed on an "intention-to-treat" basis and compared. Cineangiographic data were reviewed by three angiographers who were unaware of the clinical data. RESULTS: No significant differences were found between rescue PTCA and primary/facilitated PTCA patients as to: age, female gender, diabetes, hypertension, previous AMI, time from pain onset to the first emergency room admission, heart rate at admission, systolic blood pressure, number of leads with ST-segment elevation, total ST-segment deviation, collateral flow to the infarct-related artery, initial TIMI 2-3 flow, and three-vessel disease. Patients with rescue PTCA, as compared to primary/facilitated PTCA, had a longer time from pain onset to the cath lab (336 +/- 196 vs 229 +/- 155 min, p = 0.0001) and more frequently had an anterior AMI (52 vs 38%, p = 0.027), a higher Killip class (1.5 +/- 0.98 vs 1.26 +/- 0.7, p = 0.02), shock (11 vs 5%, p = 0.073), and intra-aortic balloon pump use (17 vs 8%, p = 0.048); fewer patients were in Killip class 1 (74 vs 85%, p = 0.043). PTCA was performed immediately in 78 vs 95% of patients (p = 0.0001); 8 vs 3 patients had PTCA of the infarct-related artery and 8 vs 1 had bypass surgery later during hospitalization. Patients with rescue PTCA, as compared to primary/facilitated PTCA, had a final TIMI 3 flow in 62 vs 76% of cases (p = 0.017), > or = 70% ST-segment resolution in 36 vs 50% (p = 0.086), and both of the latter in 24 vs 45% (p = 0.006); the overall hospital mortality was 12 vs 6.5%, and 5.8 vs 3.4% when patients in shock on admission were not considered; reinfarction and stroke occurred in 0.9 vs 1.3% and in 2.6 vs 0% of the patients respectively. CONCLUSIONS: Due to referral, rescue PTCA patients were admitted to the cath lab later after the onset of infarction, and had a higher risk profile, as compared to primary/facilitated PTCA patients; both recanalization and reperfusion were less satisfactory, as were the outcomes. Thrombolysis is often ineffective but, as long as it remains a widespread treatment, efforts should be made to improve reperfusion and survival in these patients, possibly by an earlier referral for rescue PTCA.