Heart attack treatment - REACT

The clinical question

A STEMI heart attack is caused by a complete blockage in one of the coronary arteries that supply blood to the heart. People having this type of heart attack usually have an emergency surgical procedure to reopen the artery, known as angioplasty. However, angioplasty may not be always be available quickly enough. These patients are given ‘clot-busting’ drugs to try to remove the blockage without surgery.

But clot-busting drugs don’t always work. So with BHF funding, Professor Anthony Gershlick and his team at the University of Leicester designed the ‘Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis’ (REACT) trial to find out how best to treat heart attack patients who don’t respond to clot-busting treatment. 

What did the study involve?

From 1999 to 2004, the REACT trial recruited 427 STEMI heart attack patients, across 35 UK hospitals, who had received unsuccessful clot-busting therapy. Participants were randomised to either:

• Receive more clot-busting drugs, known as ‘repeat thrombolysis’.

• Receive surgical treatment, known as ‘rescue angioplasty’.

• Receive standard medical therapy, without clot-busting drugs or angioplasty.

Participants were followed up for up to 4 years after treatment.

What did the study show?

• Participants who received rescue angioplasty were more likely to survive than those in the other two groups, at 6 months and 4 years after treatment.

• The rescue angioplasty group were less likely to have had a further heart attack or a stroke at 1 year after treatment.

• Repeat thrombolysis did not seem to offer any further benefit to patients compared with standard medical care.  

• Rescue angioplasty is safe and beneficial for STEMI patients over 70 years old, who may be more likely to experience complications from the procedure than younger patients. 

Why is the study important?

The results of REACT were incorporated into UK, European and USA guidelines for the treatment of STEMI heart attack patients. It is now recommended that if a patient has not responded to clot-busting drugs, they receive surgical treatment to open the blocked artery. 

Professor Gershlick received a British Cardiovascular Intervention Society Lifetime Achievement Career Award in January 2017 for his contributions to this field. When interviewed by the European Heart Journal following this award, he highlighted the REACT trial as being the work he is most proud of:

In the UK and many other countries, it is now standard practice to treat STEMI heart attack patients with immediate angioplasty and stenting - within 90 minutes of first medical contact (primary angioplasty). But there are still parts of the world where people may not have immediate access to a hospital able to carry out these procedures, known as a ‘PCI centre’.

Following on from REACT, Professor Gershlick together with an international team designed and carried out the STREAM trial. This trial recruited STEMI patients who were unable to undergo angioplasty within 1 hour of medical contact. The team showed that giving clot-busting drugs followed by angioplasty (for example, after transfer to a PCI centre) was equal to treating with primary angioplasty. These findings were also incorporated into international guidelines. 

Study details

"Rescue angioplasty versus conservative treatment or repeat thrombolysis (REACT) trial."
Award reference:  RG/1998005/10496
Principal Investigator: Professor Anthony Gershlick, University of Leicester
Trial registration number: ISRCTN31931021

Publication details

Gershlick AH, Stephens-Lloyd A, Hughes S, et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med. 2005;353(26):2758-68.