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Early invasive versus conservative treatment in patients with failed fibrinolysis-no late survival benefit: The final analysis of the Middlesbrough Early Revascularisation to Limit Infarction (MERLIN) randomized trial

Lookup NU author(s): Dr Vijay Kunadian, Dr Janine Gray, Dr James Hall, Dr Alun Harcombe, Professor Jeremy Murphy, Dr Ananthaiah Shyam-Sundar, Dr Adrian Davies, Dr Nicholas Linker, Dr Mark De Belder

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Abstract

Background: Early (30 days) and midterm (6 months) clinical outcomes in trials comparing rescue angioplasty (rescue percutaneous coronary intervention [rPCI]) with conservative treatment of failed fibrinolysis complicating ST-segment elevation myocardial infarction have shown variable results. Whether early rPCI confers late (up to 3 years) clinical benefits is not known. Methods: The MERLIN trial compared rPCI and a conservative strategy in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction. Three hundred seven patients with electrocardiographic evidence of failure to reperfuse at 60 minutes were included. Patients in cardiogenic shock were excluded. Thirty-day and 1-year results have been reported. Results of 3 years of follow-up are presented. Results: Three-year mortality in the conservative arm and rPCI, respectively, was 16.9% versus 17.6% (P = .9, relative difference [RD] -0.8, 95% CI [-9.3 to 7.8]). Death rates were similar (3.9% vs 3.2%) between 1- and 3-year follow-up, respectively. The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularization, or heart failure was significantly higher in the conservative arm (64.3% vs 49%, P = .01, RD 15.3, 95% CI [4.2-26]). There was no significant difference in the rate of reinfarction (0.7% vs 0.7%) or heart failure (1.3% vs 2.7%) between 1 and 3 years between the conservative and rPCI arms, respectively. The incidence of subsequent unplanned revascularization at 3 years was significantly higher in the conservative arm (33.8% vs 14.4%, P < .01, RD 19.4, 95% CI [10-28.7]), most of which occurred within 1 year; the rates between 1 and 3 years were 3.9% in the conservative arm versus 2% in the rPCI arm. There was a trend toward fewer strokes in the conservative arm at 3 years (conservative arm 2.6% vs rPCI 6.5%, P = .1, RD -3.9%, 95% CI [-9.4 to 0.8]), with similar stroke rates (1.3% vs 1.3%) between 1- and 3-year follow-up. Conclusions: Rescue angioplasty did not confer a late survival advantage at 3 years. The composite end point occurred less often in the rPCI arm mainly because of fewer unplanned revascularization procedures in the early phase of follow-up. The highest risk of clinical events in patients with failed reperfusion is in the first year, beyond which the rate of clinical events is low. © 2007 Mosby, Inc. All rights reserved.


Publication metadata

Author(s): Kunadian B, Sutton AGC, Vijayalakshmi K, Thornley AR, Gray JC, Grech ED, Hall JA, Harcombe AA, Wright RA, Smith RH, Murphy JJ, Shyam-Sundar A, Stewart MJ, Davies A, Linker NJ, de Belder MA

Publication type: Article

Publication status: Published

Journal: American Heart Journal

Year: 2007

Volume: 153

Issue: 5

Pages: 763-771

ISSN (print): 0002-8703

ISSN (electronic): 1097-6744

Publisher: Mosby, Inc.

URL: http://dx.doi.org/10.1016/j.ahj.2007.02.021

DOI: 10.1016/j.ahj.2007.02.021

PubMed id: 17452151


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