Rescue angioplasty for failed thrombolysis in older patients: Insights from the REACT trial

Background Thrombolysis remains the first-line therapy in a substantial proportion of patients presenting with ST elevation myocardial infarction. The optimal treatment for patients in whom there is failure of reperfusion following thrombolysis is unclear. The Rescue Angioplasty versus Conservative Treatment or Repeat Thrombolysis (REACT) trial demonstrated, in 427 randomly assigned patients with failed reperfusion following thrombolysis, that event-free survival rates were significantly improved with rescue angioplasty compared with either repeat thrombolysis or conservative treatment. However, the safety and efficacy of rescue angioplasty among older patients remains uncertain. Methods and results We aimed to determine whether rescue angioplasty was safe and effective in an older population, by evaluating the primary and secondary clinical outcomes among the 105 patients ≥ 70 years of age in the REACT trial. We observed an increased overall 6-month event rate among older patients. The relative benefit of rescue angioplasty versus repeat thrombolysis or conservative treatment was maintained, and the absolute benefit actually increased in this older age group compared with the study population as a whole. There was no adverse impact of advanced age on bleeding complications. Repeat thrombolysis was no more effective than conservative therapy. Conclusions Rescue angioplasty is the preferred management strategy for failed thrombolysis, even for patients ≥ 70 years of age.