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.

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.

• Authors: Babu Kunadian, Andrew G C Sutton, Kunadian Vijayalakshmi, Andrew R Thornley, Janine C Gray, Ever D Grech, James A Hall, Alun A Harcombe, Robert A Wright, Roger H Smith, Jerry J Murphy, Ananthaiah Shyam-Sundar, Michael J Stewart, Adrian Davies, Nicholas J Linker, Mark A de Belder
• Journal: American heart journal (Am Heart J) Vol. 153 Issue 5 Pg. 763-71 (May 2007) ISSN: 1097-6744 [Electronic] United States
• PMID: 17452151 (Publication Type: Comparative Study, Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Topics

• Comorbidity
• Female
• Follow-Up Studies
• Heart Failure (epidemiology)
• Humans
• Incidence
• Male
• Middle Aged
• Myocardial Infarction (mortality, therapy)
• Myocardial Revascularization (statistics & numerical data)
• Prospective Studies
• Recurrence
• Stents
• Stroke (epidemiology)
• Survival Analysis
• Thrombolytic Therapy (statistics & numerical data)
• Time Factors
• Treatment Failure
• United Kingdom (epidemiology)