title: 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.
abstract: OBJECTIVE
  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 an 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 strategy), 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.
authors.affiliation: British Heart Foundation Professor of Cardiology, Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. k.a.a.fox@ed.ac.uk <k.a.a.fox@ed.ac.uk>
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
authors.forename: Tim C
authors.initials: TC
authors.lastname: Clayton
authors.forename: Peter
authors.initials: P
authors.lastname: Damman
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Pocock
authors.forename: Robbert J
authors.initials: RJ
authors.lastname: de Winter
authors.forename: Jan G P
authors.initials: JG
authors.lastname: Tijssen
authors.forename: Bo
authors.initials: B
authors.lastname: Lagerqvist
authors.forename: Lars
authors.initials: L
authors.lastname: Wallentin
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D002423:Cause of Death; D001026:Coronary Artery Bypass / Q000379:methods; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009204:Myocardial Revascularization / Q000379:methods / Q000401:mortality; D018579:Patient Selection; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011336:Probability; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012720:Severity of Illness Index; D015607:Stents; D016019:Survival Analysis; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors
chemical_list: D010975:Platelet Aggregation Inhibitors