ATLANTA — A routine invasive strategy in patients with non–ST-segment elevation acute coronary syndrome results in significantly fewer cardiovascular deaths and nonfatal MIs over the subsequent 5 years than does a selective, symptom-driven revascularization approach, according to a meta-analysis of all pertinent clinical trials.
“The key result is that 5 years after the randomization there is a net absolute difference of 3.2% and a 19% relative risk reduction in cardiovascular death or MI in the routine invasive group,” Dr. Keith A.A. Fox observed in presenting the meta-analysis at the annual meeting of the American College of Cardiology.
The routine invasive strategy, consisting of early angiography with an eye toward revascularization, showed significant benefit in patients with non–ST-elevation acute coronary syndrome (NSTE-ACS). This finding constitutes a compelling argument for a change in the existing ACC/American Heart Association guidelines, which recommend a routine invasive strategy in NSTE-ACS patients with high-risk indicators, but state that in moderate- or low-risk patients the routine invasive or selective invasive approach is appropriate, said Dr. Fox, professor of cardiology at the University of Edinburgh, Scotland.
The meta-analysis, called the FIR Trial Collaboration, was conducted because the individual trials had inconsistent long-term findings. By combining individual patient data from the 5,467 patients who participated in the three trials, conclusive results emerged.
The 5-year cumulative rate of cardiovascular death or MI was 14.7% with a routine invasive strategy, compared with 17.9% with a selective invasive approach in which angiography was done only in patients with refractory angina or rest ischemia despite optimal medical therapy. The nonfatal MI rate was 10.0% with a routine invasive strategy, compared with 12.9% with a selective invasive approach, a statistically significant 23% relative risk reduction.
The absolute benefit of a routine invasive strategy was greatest in the 13% of patients who fell into the highest-risk group at baseline, but the strategy also showed significant advantages in the moderate- and low-risk groups. (See box.) The difference in outcomes between the two strategies increased steadily over time within all subgroups.
Disclosures: Meta-analysis funded by the British Heart Association and the host institutions for the three trials. Dr. Fox has been a consultant to Sanofi-Aventis and Bristol-Myers Squibb.
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Source Elsevier Global Medical News