A randomized trial of coronary stenting versus balloon angioplasty as a rescue intervention after failed thrombolysis in patients with acute myocardial infarction.

OBJECTIVES This study was conducted to assess whether coronary stenting produces better results compared with balloon angioplasty in patients with acute myocardial infarction (AMI) after failed thrombolysis. BACKGROUND Little evidence exists on the value of rescue mechanical reperfusion after failed thrombolysis. METHODS This open-label, randomized study enrolled 181 patients with AMI referred for failed thrombolysis performed within the previous 24 h. The patients had to have a Thrombolysis In Myocardial Infarction (TIMI) flow grade of <or=2 in coronary angiography. Patients were randomly assigned to coronary stenting (90 patients) or coronary balloon angioplasty (91 patients). Salvage index (proportion of initial perfusion defect salvaged by rescue intervention), which was obtained by paired scintigraphic studies performed 7 to 10 days apart, was the primary end point of the trial. One-year clinical follow-up was assessed. RESULTS Myocardial salvage index (median [25th, 75th percentiles]) was significantly greater in the stent group than in the angioplasty group (0.35 [0.24, 0.56] vs. 0.25 [0.04, 0.43]; p = 0.005). Major bleeding occurred in four patients (4%) in the stent group and four patients (4%) in the angioplasty group. One-year mortality was 8% (7 patients) in the stent group versus 12% (11 patients) in the angioplasty group (relative risk, 0.6; 95% confidence interval 0.2 to 1.6; p = 0.35). CONCLUSIONS Patients with AMI and failed thrombolysis benefit from rescue mechanical reperfusion in terms of myocardial salvage. Coronary stenting is associated with a greater myocardial salvage in this setting compared with coronary balloon angioplasty.