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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.
J Am Coll Cardiol. 2010 Jun 01; 55(22):2435-45.JACC

Abstract

OBJECTIVES

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+Show Affiliations

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>No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Review

Language

eng

PubMed ID

20359842

Citation

Fox, Keith A A., et al. "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." Journal of the American College of Cardiology, vol. 55, no. 22, 2010, pp. 2435-45.
Fox KA, Clayton TC, Damman P, et al. 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. J Am Coll Cardiol. 2010;55(22):2435-45.
Fox, K. A., Clayton, T. C., Damman, P., Pocock, S. J., de Winter, R. J., Tijssen, J. G., Lagerqvist, B., & Wallentin, L. (2010). 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. Journal of the American College of Cardiology, 55(22), 2435-45. https://doi.org/10.1016/j.jacc.2010.03.007
Fox KA, et al. 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. J Am Coll Cardiol. 2010 Jun 1;55(22):2435-45. PubMed PMID: 20359842.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - 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. AU - Fox,Keith A A, AU - Clayton,Tim C, AU - Damman,Peter, AU - Pocock,Stuart J, AU - de Winter,Robbert J, AU - Tijssen,Jan G P, AU - Lagerqvist,Bo, AU - Wallentin,Lars, AU - ,, Y1 - 2010/03/30/ PY - 2010/02/10/received PY - 2010/03/04/revised PY - 2010/03/11/accepted PY - 2010/4/3/entrez PY - 2010/4/3/pubmed PY - 2010/6/16/medline SP - 2435 EP - 45 JF - Journal of the American College of Cardiology JO - J Am Coll Cardiol VL - 55 IS - 22 N2 - OBJECTIVES: 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. SN - 1558-3597 UR - https://www.unboundmedicine.com/medline/citation/20359842/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_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0735-1097(10)00994-0 DB - PRIME DP - Unbound Medicine ER -