Emergency 'rescue' percutaneous transluminal coronary angioplasty after failed thrombolysis with streptokinase. Early and late results

Although thrombolytic therapy has been a major advance in the treatment of acute myocardial infarction, in at least 25% of patients the artery remains occluded after administration. In these patients, the strategy of 'rescue' or 'salvage' angioplasty is frequently used although follow-up data are limited. Sixty-three patients underwent percutaneous transluminal coronary angioplasty (PTCA) after thrombolytic therapy for acute myocardial infarction. The decision to proceed with PTCA was based on physician preference and not a specific research protocol. In 34 of these selected patients, PTCA was performed as a rescue procedure because the infarct-related artery remained occluded (group 1); in 29 of these patients, it was performed to treat a severe but subtotal residual stenosis (group 2). PTCA successfully restored patency in 71% of group 1 and in 90% of group 2. Group 1 patients had a significantly worse baseline ejection fraction than did those in group 2 (47 ± 13% vs. 58 ± 13%, p = 0.0015). Group 1 patients also had a significantly worse predismissal ejection fraction (36 ± 13% vs. 50 ± 14%, p = 0.00004). During initial hospitalization, 14 (22%) patients underwent coronary bypass surgery. In-hospital mortality was low in each group (3% in group 1 and 0% in group 2). During a mean follow-up of 4 years, 89% of group 1 patients remained alive as compared with 97% of group 2 patients. This excellent 4-year survival rate, despite the depressed predismissal ejection fraction in patients undergoing rescue PTCA, raises the issue of whether acute reperfusion has a beneficial effect aside from any impact on myocardial salvage and preservation of left ventricular function.