A new study on Rescue Angioplasty after Failed Thrombolytic Therapy for Acute Myocardial Infarction

Management of acute myocardial infarction has continued to evolve over the years. Thrombolysis, and later primary PCI has improved the results. There are many areas which are not clear like the appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy. This study published in NEJM compares rescue PCI with repeated thrombolysis.

This is a multicenter trial in the United Kingdom involving 427 patients with ST-segment elevation myocardial infarction in whom reperfusion failed to occur (less than 50 percent ST-segment resolution) within 90 minutes after thrombolytic treatment. The patients were randomly assigned to repeated thrombolysis (142 patients), conservative treatment (141 patients), or rescue PCI (144 patients). The primary end point was a composite of death, reinfarction, stroke, or severe heart failure within six months.

The rate of event-free survival among patients treated with rescue PCI was 84.6 percent, as compared with 70.1 percent among those receiving conservative therapy and 68.7 percent among those undergoing repeated thrombolysis. There were no significant differences in mortality from all causes. Nonfatal bleeding, mostly at the sheath-insertion site, was more common with rescue PCI. At six months, 86.2 percent of the rescue-PCI group were free from revascularization, as compared with 77.6 percent of the conservative-therapy group and 74.4 percent of the repeated-thrombolysis group.

The study concludes that event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment and recommends that rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy.

Effect of Intensive Diabetes Treatment on Cardiovascular Disease in Patients with Type 1 Diabetes

This is an interesting study published in this week's issue of NEJM. Hitherto, we have been concerned mainly about the increased cardiovascular risk in Type 2 diabetics. There are few studies on type 1 diabetics.

Previously, it had been shown that intensive diabetes therapy aimed at achieving near normoglycemia reduces the risk of microvascular and neurologic complications of type 1 diabetes. This study whether the use of intensive therapy as compared with conventional therapy during the Diabetes Control and Complications Trial (DCCT) affected the long-term incidence of cardiovascular disease.

It was found that intensive treatment reduced the risk of any cardiovascular disease event by 42% and the risk of nonfatal myocardial infarction, stroke, or death from cardiovascular disease by 57%. The decrease in glycosylated hemoglobin values during the DCCT was significantly associated with most of the positive effects of intensive treatment on the risk of cardiovascular disease. Microalbuminuria and albuminuria were also associated with a significant increase in the risk of cardiovascular disease.

The study concludes that intensive diabetes therapy has long-term beneficial effects on the risk of cardiovascular disease in patients with type 1 diabetes. One more reason for intensive therapy for Type 1 Diabetes!