Abstract 2804: Early Invasive Management of Acute Coronary Syndromes without ST-elevation: Relation between Rate of Invasive Therapies and Very Long-term Mortality in the Randomized Trials
Background Randomized trials evaluating an early invasive against a conservative strategy show a benefit over a conservative approach in the composite of death, MI and revascularisation/recurrent ischemia. However, the rate of invasive therapies differed significantly in the trials. Moreover, there were also large differences in the rate of invasive therapies in the invasive versus the conservative arms (cross-over rate) in the different studies. Therefore we studied the differences in rate of invasive therapy in the study arms of the above trials, and correlated them with the benefit of the invasive therapy with regard to the very long-term mortality as recently published.
Methods and Results We analyzed very long-term mortality (30,932 patient-years) in the 9 trials carried out between 1996 and 2004, which randomized 10,558 patients with non-ST-elevation acute coronary syndromes to an early invasive or an ischemia-guided conservative strategy. Differences in the revascularization rate between the invasive and conservative strategies in the trials ranged between 10% and 39%. There was no relation of the differences in revascularization between invasive and conservative strategies and the benefit on mortality whatsoever (see figure⇓).
Conclusion Although most trials on non ST-elevation ACS reported a reduction in the composite of death, MI and revascularisation/ recurrent ischemia, an early invasive strategy does not lead to improved survival on the very long-term. There seems no relation between the difference in revascularisation rate and benefit on the very long term, which may explain the lack of efficacy of early intervention on very long-term mortality.