title: 10-Year Mortality Outcome of a Routine Invasive Strategy Versus a Selective Invasive Strategy in Non-ST-Segment Elevation Acute Coronary Syndrome: The British Heart Foundation RITA-3 Randomized Trial.
abstract: BACKGROUND
  The RITA-3 (Third Randomised Intervention Treatment of Angina) trial compared outcomes of a routine early invasive strategy (coronary arteriography and myocardial revascularization, as clinically indicated) to those of a selective invasive strategy (coronary arteriography for recurrent ischemia only) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). At a median of 5 years' follow-up, the routine invasive strategy was associated with a 24% reduction in the odds of all-cause mortality.
  
  
  OBJECTIVE
  This study reports 10-year follow-up outcomes of the randomized cohort to determine the impact of a routine invasive strategy on longer-term mortality.
  
  
  METHODS
  We randomized 1,810 patients with NSTEACS to receive routine invasive or selective invasive strategies. All randomized patients had annual follow-up visits up to 5 years, and mortality was documented thereafter using data from the Office of National Statistics.
  
  
  RESULTS
  Over 10 years, there were no differences in mortality between the 2 groups (all-cause deaths in 225 [25.1%] vs. 232 patients [25.4%]: p = 0.94; and cardiovascular deaths in 135 [15.1%] vs. 147 patients [16.1%]: p = 0.65 in the routine invasive and selective invasive groups, respectively). Multivariate analysis identified several independent predictors of 10-year mortality: age, previous myocardial infarction, heart failure, smoking status, diabetes, heart rate, and ST-segment depression. A modified post-discharge Global Registry of Acute Coronary Events (GRACE) score was used to calculate an individual risk score for each patient and to form low-risk, medium-risk, and high-risk groups. Risk of death within 10 years varied markedly from 14.4 % in the low-risk group to 56.2% in the high-risk group. This mortality trend did not depend on the assigned treatment strategy.
  
  
  CONCLUSIONS
  The advantage of reduced mortality of routine early invasive strategy seen at 5 years was attenuated during later follow-up, with no evidence of a difference in outcome at 10 years. Further trials of contemporary intervention strategies in patients with NSTEACS are warranted. (Third Randomised Intervention Treatment of Angina trial [RITA-3]; ISRCTN07752711).
authors.affiliation: Trent Cardiac Centre, Nottingham University Hospitals, Nottingham, United Kingdom. Electronic address: robert.henderson@nuh.nhs.uk.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Henderson
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Christopher
authors.initials: C
authors.lastname: Jarvis
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Tim
authors.initials: T
authors.lastname: Clayton
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Pocock
authors.affiliation: University of Edinburgh, Edinburgh, United Kingdom.
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D002423:Cause of Death; D015897:Comorbidity; D017023:Coronary Angiography / Q000379:methods; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality; D004562:Electrocardiography / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D017063:Outcome Assessment, Health Care; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000401:mortality; D012307:Risk Factors; D013995:Time; D006113:United Kingdom / Q000453:epidemiology
keywords: NSTEMI; long-term mortality; revascularization; unstable angina