Rescue Angioplasty versus Conservative Therapy or Repeat Thrombolysis Trial

1. REACT: 6 month results Rescue Angioplasty versus Conservative Therapy or Repeat Thrombolysis Trial Presented at American Heart Association Scientific Sessions 2004 Presented by Dr. A. H. Gershlick

2. REACT: 6 month results 427 Acute MI patients with failed thrombolysis aspirin and thrombolytic therapy (60% received streptokinase) within 6 hours of chest pain onset, <50% resolution of ST changes on ECG at 90 minutes 42% anterior infarctions • Rescue PCI • Angiography with or without • Revascularization • n=144 • Conservative Treatment • IV Unfractionated Heparin • for 24 hours • n=141 • Repeat Thrombolysis • Accelerated tPA or reteplase • n=142 • Primary Endpoint: • Composite of death, reinfarction, CVA, or severe heart failure at 6 months Presented at AHA 2004

3. REACT: 6 month results Primary Composite Endpoint at 6 Months (Death, MI, CVA, or severe heart failure) • The primary composite endpoint of death, MI, CVA or severe heart failure at 6 months was significantly lower in the rescue PCI group compared with either the repeat thrombolysis group or the conservative management group p=0.002 p<0.001 Repeat Thrombolysis Conservative Management Rescue PCI Presented at AHA 2004

4. REACT: 6 month results Freedom from revascularization was significantly higher in the rescue PCI group compared with the repeat lysis group or the conservative group (overall p=0.05). Minor bleeding was significantly higher in the rescue PCI group (p<0.001), however, major bleeding did not significantly differ among groups. Minor Bleeding Events Freedom from Revascularization Conservative Management Repeat Thrombolysis Conservative Management Rescue PCI Repeat Thrombolysis Rescue PCI Presented at AHA 2004

5. REACT: Summary • Among patients with acute MI and failed reperfusion after thrombolytic therapy, treatment with rescue angiography was associated with a reduction in the primary composite endpoint of death, reinfarction, CVA, or severe HF at 6 months compared with both repeat thrombolysis or conservative management. • These six month results reiterate the trial’s preliminary 30-day results presented at the TCT meeting earlier this year. • The secondary positive endpoint of freedom from revascularization was also significantly higher in the rescue angiography group compared with either the thrombolytic or conservative management group • However, minor bleeding rates were significantly higher in the rescue PCI group • The REACT results support the results of the earlier, smaller RESCUE trial, which showed a trend toward lower death and heart failure with rescue PCI compared with conservative management. On the other hand, these results disagree with those of the recent MERLIN trial, which showed no difference between rescue angiography and conservative treatment strategies at 30 days. Hypotheses offered to explain the opposing outcomes of MERLIN and REACT include differences in initial thrombolysis (↑ streptokinase in MERLIN), concomitant medications (↑ GP IIb/IIIa inhibitors in REACT), and inclusion criteria (↑ time to rescue PCI in MERLIN)