Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina.
BACKGROUND
Current guidelines suggest that, for patients at moderate risk of death from unstable coronary-artery disease, either an interventional strategy (angiography followed by revascularisation) or a conservative strategy (ischaemia-driven or symptom-driven angiography) is appropriate. We aimed to test the hypothesis that an interventional strategy is better than a conservative strategy in such patients.


METHODS
We did a randomised multicentre trial of 1810 patients with non-ST-elevation acute coronary syndromes (mean age 62 years, 38% women). Patients were assigned an early intervention or conservative strategy. The antithrombin agent in both groups was enoxaparin. The co-primary endpoints were a combined rate of death, non-fatal myocardial infarction, or refractory angina at 4 months; and a combined rate of death or non-fatal myocardial infarction at 1 year. Analysis was by intention to treat.


RESULTS
At 4 months, 86 (9.6%) of 895 patients in the intervention group had died or had a myocardial infarction or refractory angina, compared with 133 (14.5%) of 915 patients in the conservative group (risk ratio 0.66, 95% CI 0.51-0.85, p=0.001). This difference was mainly due to a halving of refractory angina in the intervention group. Death or myocardial infarction was similar in both treatment groups at 1 year (68 [7.6%] vs 76 [8.3%], respectively; risk ratio 0.91, 95% CI 0.67-1.25, p=0.58). Symptoms of angina were improved and use of antianginal medications significantly reduced with the interventional strategy (p<0.0001).


CONCLUSIONS
In patients presenting with unstable coronary-artery disease, an interventional strategy is preferable to a conservative strategy, mainly because of the halving of refractory or severe angina, and with no increased risk of death or myocardial infarction.
Fox
K A A
KA
Cardiovascular Research, Department of Medical and Radiological Sciences, Royal Infirmary, Edinburgh EH3 9YW, UK. k.a.a.fox@ed.ac.uk
Poole-Wilson
P A
PA
Henderson
R A
RA
Clayton
T C
TC
Chamberlain
D A
DA
Shaw
T R D
TR
Wheatley
D J
DJ
Pocock
S J
SJ
D000787:Angina Pectoris / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D017225:Atherectomy, Coronary; D002316:Cardiotonic Agents / Q000627:therapeutic use*; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000150:complications / Q000401:mortality / Q000628:therapy*; D023381:Endpoint Determination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D012307:Risk Factors; D006113:United Kingdom
D002316:Cardiotonic Agents