5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart
K A A Fox1, P Poole-Wilson, T C Clayton
1Centre for Cardiovascular Science, Department of Medical and Radiological Sciences, University of Edinburgh, Edinburgh EH16 4SB, UK. k.a.a.fox@ed.ac.uk
Insights
An early invasive strategy for non-ST-elevation acute coronary syndrome significantly reduces long-term risk of death or myocardial infarction, particularly in high-risk patients. This approach improves outcomes over 5 years compared to conservative management.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- The long-term efficacy of an interventional strategy versus a conservative approach in non-ST-elevation acute coronary syndrome (NSTE-ACS) remains unclear.
- This study evaluates the 5-year outcomes of routine angiography and revascularization compared to ischemia-driven angiography in NSTE-ACS patients.
Purpose of the Study:
- To compare the long-term (5-year) effectiveness of an early interventional strategy against a conservative strategy for patients with non-ST-elevation acute coronary syndrome.
- To determine if routine angiography and subsequent revascularization improves patient outcomes compared to symptom-driven procedures.
Main Methods:
- A multicenter randomized trial involving 1810 patients with NSTE-ACS, randomly assigned to early intervention (n=895) or conservative strategy (n=915).
- Both groups received optimal medical treatment; the interventional group underwent coronary arteriography within 72 hours, with management guided by findings.
- The primary outcome was a composite of death or non-fatal myocardial infarction, assessed via intention-to-treat analysis with masked independent adjudication.
Main Results:
- At 5-year median follow-up, the intervention group had a lower rate of death or non-fatal myocardial infarction (16.6%) compared to the conservative group (20.0%) (OR 0.78, p=0.044).
- Benefits were most pronounced in high-risk patients, with an odds ratio of 0.44 for death or non-fatal myocardial infarction in the highest risk subgroup (p=0.004).
- Rates of cardiovascular death or myocardial infarction were also significantly reduced in the intervention group (OR 0.74, p=0.030).
Conclusions:
- A routine invasive strategy in NSTE-ACS patients leads to a significant long-term reduction in the risk of death or non-fatal myocardial infarction.
- The benefits of the interventional strategy are primarily observed in patients identified as high-risk.
- These findings support current guidelines emphasizing robust risk stratification for acute coronary syndrome management.
Background:
The long-term outcome of an interventional strategy in patients with non-ST-elevation acute coronary syndrome is unknown. We tested whether an interventional strategy (routine angiography followed by revascularisation) was better than a conservative strategy (ischaemia-driven or symptom-driven angiography) over 5 years' follow-up.
Methods:
In a multicentre randomised trial, 1810 patients (from 45 hospitals in England and Scotland, UK) with non-ST-elevation acute coronary syndrome were randomly assigned to receive an early intervention (n=895) or a conservative strategy (n=915) within 48 h of the index episode of cardiac pain. In each group, the aim was to provide the best medical treatment, and also to undertake coronary arteriography within 72 h in the interventional strategy with subsequent management guided by the angiographic findings. Analysis was by intention to treat and the primary outcome (composite of death or non-fatal myocardial infarction) had masked independent adjudication. RITA 3 has been assigned the International Standard Randomised Control Trial Number ISRCTN07752711.
Findings:
At 1-year follow-up, rates of death or non-fatal myocardial infarction were similar. However, at a median of 5 years' follow-up (IQR 4.6-5.0), 142 (16.6%) patients with intervention treatment and 178 (20.0%) with conservative treatment died or had non-fatal myocardial infarction (odds ratio 0.78, 95% CI 0.61-0.99, p=0.044), with a similar benefit for cardiovascular death or myocardial infarction (0.74, 0.56-0.97, p=0.030). 234 (102 [12%] intervention, 132 [15%] conservative) patients died during follow-up (0.76, 0.58-1.00, p=0.054). The benefits of an intervention strategy were mainly seen in patients at high risk of death or myocardial infarction (p=0.004), and for the highest risk group, the odds ratio of death or non-fatal myocardial infarction was 0.44 (0.25-0.76).
Interpretation:
In patients with non-ST-elevation acute coronary syndrome, a routine invasive strategy leads to long-term reduction in risk of death or non-fatal myocardial infarction, and this benefit is mainly in high-risk patients. The findings provide support for national and international guidelines in the need for more robust risk stratification in acute coronary syndrome.
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