Long-Term Outcome of a Routine Versus Selective Invasive Strategy in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome A Meta-Analysis of Individual Patient Data
2010 (English)In: Journal of the American College of Cardiology, ISSN 0735-1097, E-ISSN 1558-3597, Vol. 55, no 22, 2435-2445 p.Article in journal (Refereed) Published
OBJECTIVES: This study was designed to determine: 1) whether a routine invasive (RI) strategy reduces the long-term frequency of cardiovascular death or nonfatal myocardial infarction (MI) using a meta-analysis of individual patient data from all randomized studies with 5-year outcomes; and 2) whether the results are influenced by baseline risk. BACKGROUND: Pooled analyses of randomized trials show early benefit of routine intervention, but long-term results are inconsistent. The differences may reflect differing trial design, adjunctive therapies, and/or limited power. This meta-analysis (n = 5,467 patients) is designed to determine whether outcomes are improved despite trial differences. METHODS: Individual patient data, with 5-year outcomes, were obtained from FRISC-II (Fragmin and Fast Revascularization during Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Randomized Trial of a Conservative Treatment Strategy Versus an Interventional Treatment Strategy in Patients with Unstable Angina) trials for a collaborative meta-analysis. A Cox regression analysis was used for a multivariable risk model, and a simplified integer model was derived. RESULTS: Over 5 years, 14.7% (389 of 2,721) of patients randomized to RI strategy experienced cardiovascular death or nonfatal MI versus 17.9% (475 of 2,746) in the selective invasive (SI) strategy (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.71 to 0.93; p = 0.002). The most marked treatment effect was on MI (10.0% RI strategy vs. 12.9% SI), and there were consistent trends for cardiovascular deaths (HR: 0.83, 95% CI: 0.68 to 1.01; p = 0.068) and all deaths (HR: 0.90, 95% CI: 0.77 to 1.05). There were 2.0% to 3.8% absolute reductions in cardiovascular death or MI in the low and intermediate risk groups and an 11.1% absolute risk reduction in highest risk patients. CONCLUSIONS: An RI strategy reduces long-term rates of cardiovascular death or MI and the largest absolute effect in seen in higher-risk patients.
Place, publisher, year, edition, pages
2010. Vol. 55, no 22, 2435-2445 p.
acute coronary syndrome, percutaneous coronary intervention, interventional strategy
Medical and Health Sciences
IdentifiersURN: urn:nbn:se:uu:diva-124695DOI: 10.1016/j.jacc.2010.03.007ISI: 000278026600003PubMedID: 20359842OAI: oai:DiVA.org:uu-124695DiVA: diva2:317887