Abstract 3210: Early Invasive Management of Acute Coronary Syndromes without ST-elevation does not Improve Long-term Mortality: insights from the Randomized Trials with the most Recent Follow-up Data
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, by the necessarily open design MI and revascularisation/ recurrent ischemia are relatively weak endpoints. Since MI is both an entry criterion and an endpoint, it is difficult to evaluate, since it may be induced by intervention and, therefore, its definition in the trials is cumbersome. Thus, long-term mortality is the best outcome parameter to evaluate the above strategies. Recently, the very long follow-up data of 3 major trials RITA-3, FRISC-2 and ICTUS have been published.
Methods and Results We analyzed 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. F/U ranged from 6 months to 5 years with a total of 30,932 patients-years. RR for long-term mortality is for invasive versus conservative from completed follow-up data is 0.94 (95%CI 0.83–1.06, p = 0.32, 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. These findings should be mentioned in future guidelines.