Transfer for Failure of Fibrinolytic Therapy Several trials in the stent era and several meta-analyses have examined the role of PCI for fibrinolytic failure346,355 357,364 (Online Data Supplement 4). These studies report a trend toward a lower mortality rate and significantly lower rates of recurrent MI and HF among patients treated with rescue PCI for failed fibrinolysis. For example, in the REACT (Rapid Early Action for Coronary Treatment) study,355 who failed to demonstrate evidence of reperfusion at 90 min- utes by ECG criteria were randomized to 1 of 3 treatment arms: rescue PCI, conservative care, or repeat fibrinolytic therapy. The primary endpoint, a composite of death, rein- farction, stroke, or severe HF at 6 months, was significantly lower among patients randomized to rescue PCI than among those randomized to conservative care or repeat fibrinolysis (event-free survival rate: 84.6% versus 70.1% versus 68.7%, P=0.004). The benefit was driven primarily by a reduction in reinfarction; there was no significant survival benefit. Minor bleeding was significantly higher among patients ran- domized to rescue PCI; however, there were no differences in major bleeding among the 3 groups. Other studies have reported higher rates of periprocedural bleeding and stroke in patients undergoing rescue PCI than in patients treated The benefit of transferring a patient for PCI of a persistently occluded infarct artery likely would jus- tify these risks if cardiogenic shock, significant hypotension, severe HF, or ECG evidence of an extensive area of myo- cardial jeopardy (including an anterior infarction or inferior infarction with either right ventricular [RV] involvement or anterior precordial ST depression) is present. In these cir- cumstances, the benefits are greatest if PCI is initiated early after fibrinolytic failure. 