2,457 patients from 58 Scandinavian centers who had unstable symptomatic coronary artery disease were divided into 2 groups. Group 1 consisted of 1222 patients who underwent an invasive strategy were compared to 1235 patients (Group 2) who were treated noninvasively. The mortality rate at the end of one year was 2.2% in the invasive group compared to 3.9 % in the noninvasively treated group. The 1.7 % difference between the 2 groups calculates out to 60 patients who would have to undergo an invasive form of treatment to benefit one patient. Similarly, the frequency of a heart attack was 9% in the invasive group vs. 12% in the noninvasive group. This calculates out to 35 patients that would have to be invasively treated to benefit one patient. This is the only study that has shown any benefit from aggressive interventional treatment and the difference is too small to be considered clinically significant. Certainly it would be hard to justify operating on 60 patients just to benefit one.
(3A) http://www.ncbi.nlm.nih.gov/pubmed/16980115
5 year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non-ST-elevation acute coronary syndrome: a follow-up study.Lagerqvist B, Husted S, Kontny F, Ståhle E, Swahn E, Wallentin L; Fast Revascularisation during InStability in Coronary artery disease (FRISC-II) Investigators.
Department of Cardiology and Uppsala Clinical Research Center, University Hospital, S-751 85 Uppsala, Sweden.
FINDINGS: At 5 years the groups differed in terms of the primary composite endpoint of death,
myocardial infarction, or both (invasive 217, 19.9 %; noninvasive 270, 24.5 %; risk ratio 0.81; 95% CI 0.69-0.95; p=0.009).
5-year mortality was 117 (9.7%) in the invasive group compared with 124 (10.1%)in the noninvasive group (0.95; 0.75 -1.21; p=0.693).
Rates of myocardial infarction were 141 (12.9 %) in the invasive and 195 (17.7%) in the non-invasive group (0.73; 0.60-0.89; p=0.002).
The benefit of the invasive strategy was confined to male patients, non-smokers, and patients with two or more risk indicators.
INTERPRETATION: The 5-year outcome of this trial indicates sustained benefit of an early invasive strategy in patients with non-ST-elevation acute coronary syndrome at moderate to high risk.
(4) http://circ.ahajournals.org/cgi/content/full/98/19/2017
(Circulation. 1998;98:2017-2023.)
Intensive Medical Therapy Versus Coronary Angioplasty for Suppression of Myocardial Ischemia in Survivors of an Acute Myocardial Infarction
(5) http://content.nejm.org/cgi/content/abstract/338/25/1785
Outcome In Patients with Acute Non-Q Wave Myocardial Infarction Randomly Assigned to An Invasive As Compared with a Conservative Management Strategy
William E. Boden, M.D., Robert A. O'Rourke, M.D., Michael H. Crawford, M.D., Alvin S. Blaustein, M.D., Prakash C. Deedwania, M.D., Robert G. Zoble, M.D., Ph.D., Laura F. Wexler, M.D., Robert E. Kleiger, M.D., Carl J. Pepine, M.D., David R. Ferry, M.D., Bruce K. Chow, M.S., Philip W. Lavori, Ph.D., for The Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators
Conclusions Most patients with non–Q-wave myocardial infarction do not benefit from routine, early invasive management consisting of coronary angiography and revascularization. A conservative, ischemia-guided initial approach is both safe and effective.
Not only do most patients not benefit from aggressive invasive treatment after their heart attack, but it is harmful.
(6) http://www.ncbi.nlm.nih.gov/pubmed/9645886
Twenty-two Year Follow-up in the VA Cooperative Study of Coronary artery bypass surgery for Stable Angina
Am J Cardiol. 1998 Jun 15;81(12):1393-
In total, there were twice as many bypass procedures performed in the group assigned to surgery without any long-term survival or symptomatic benefit
(7) http://content.onlinejacc.org/cgi/content/abstract/32/3/596
A Prospective Randomized Trial of Triage Angiography in Acute Coronary Syndromes Ineligible for Trombolytic Therapy. Results of the Medicine Versus Angiography in Thrombolytic Exclusion (MATE) Trial. McCullough PA, O'Neill WW, Graham M, et al. Journal of the American College of Cardiology. 1998; 32: 596-605.
The endpoint of a repeat heart attack or death at 21 months was seen in 14% of those undergoing revascularization versus 12% of the medically treated patients.
Long-term follow-up at a median of 21 months revealed no significant differences in the endpoints of late revascularization, recurrent myocardial infarction, or all-cause mortality.
Conclusions. Despite more frequent early revascularization after triage angiography,
we found no long-term benefit in cardiac outcomes compared
with conservative medical therapy with revascularization prompted by recurrent ischemia.
(8) http://circ.ahajournals.org/cgi/content/full/96/3/748
Danish Multicenter Randomized Study of Invasive Versus Conservative Treatment In Patients
With Inducible Ischemia After Thrombolysis In Acute Myocardial Infarction. DANAMI) Madsen JK, Grande P, Saunamaki K, et al. Circulation. 1997; 96: 748-755.
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