Boston, MA - Acute MI patients who fail to respond to thrombolysis will live longer, with fewer repeat events, if they receive rescue angioplasty instead of repeat thrombolysis, results from the Rescue Angioplasty versus Conservative Treatment or Repeat Thrombolysis (REACT) trial suggest. Final results of the trial, first reported by heartwire at the 2004 American Heart Association Scientific Sessions, are now published in the New England Journal of Medicine [1].

Called a "labor of love" last year by lead investigator Dr Anthony H Gershlick (Leicester University Hospital, UK), the British Heart Foundation-sponsored REACT study was plagued by slow enrollment, taking over four years, then halted after investigators had enrolled only 427 of the 450 necessary to achieve statistical power. Slow enrollment stemmed in part from a lack of equipoise over the best strategy for failed thrombolysis, with many operators opting for rescue PCI, despite no solid evidence supporting this approach.

With the publication of the REACT results, physicians already convinced of the value of rescue angioplasty can use it with an easy mind. "These results indicate that rescue PCI, with transfer to a tertiary site if required, should be considered for patients in whom thrombolysis for myocardial infarction with ST-segment elevation fails to achieve reperfusion," Gershlick et al write.

To heartwire, Gershlick commented that, in his opinion, one year after they were first released, the REACT results have already changed clinical practice. "There is no doubt that, previously, while physicians had felt that rescue PCI was 'right' in the setting of failed thrombolysis, the evidence for it was weak, and therefore if a patient presented to a community hospital with no interventional facilities, it could be considered justified treating them conservatively or with repeat lytic, based on some older data suggesting repeat lytic was perhaps better than doing nothing."

Now, he says, it has become common for physicians to look for failed lysis on the 90-minute ECG and to act on it when they see it, something that was not always done in the past. "It appears no longer acceptable to sit on patients with failed lysis once this is diagnosed," Gershlick commented, adding that, at his own institution, he and his colleagues have seen their rates of both rescue angioplasty and successful reperfusion increase since the REACT results were unveiled last year.