title: 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial.
abstract: 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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Centre for Cardiovascular Science, Department of Medical and Radiological Sciences, University of Edinburgh, Edinburgh EH16 4SB, UK. k.a.a.fox@ed.ac.uk
authors.forename: K A A
authors.initials: KA
authors.lastname: Fox
authors.forename: P
authors.initials: P
authors.lastname: Poole-Wilson
authors.forename: T C
authors.initials: TC
authors.lastname: Clayton
authors.forename: R A
authors.initials: RA
authors.lastname: Henderson
authors.forename: T R D
authors.initials: TR
authors.lastname: Shaw
authors.forename: D J
authors.initials: DJ
authors.lastname: Wheatley
authors.forename: R
authors.initials: R
authors.lastname: Knight
authors.forename: S J
authors.initials: SJ
authors.lastname: Pocock
mesh_terms: D000789:Angina, Unstable / Q000175:diagnosis / Q000628:therapy*; D002423:Cause of Death; D017023:Coronary Angiography; D004562:Electrocardiography; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D009204:Myocardial Revascularization