Interventional versus conservative treatment in the acute non-ST-elevation coronary syndrome; the time course of patient management and disease events over one year in the RITA 3 trial

P A Poole-Wilson ^1*, S J Pocock ², K AA Fox ³, R A Henderson ⁴, D J Wheatley ⁵, D A Chamberlain ⁶, TRD Shaw ⁷ and T C Clayton ²

¹ Imperial College, United Kingdom
² LSHTM, United Kingdom
³ Edinburgh University, United Kingdom
⁴ Nottingham City Hospital, United Kingdom
⁵ Glasgow Royal Infirmary, United Kingdom
⁶ Hove, United Kingdom
⁷ Western General Hospital Edinburgh, United Kingdom

^* To whom correspondence should be addressed. E-mail: p.poole-wilson{at}imperial.ac.uk.

Accepted 15 March 2006

Abstract

Objective: To determine whether, in the acute non- ST-elevation coronary syndrome, the benefit from early invasive coronary intervention compared to a conservative strategy of later symptom guided intervention varies over time.

Methods: In RITA 3 (Randomised Intervention trial of unstable Angina 3) patients were randomly assigned to coronary angiography (median 2 days after randomisation) and appropriate intervention (n=895) or to a symptom guided conservative strategy (n=915).

Results: In the first week patients in both groups were at highest risk of death, MI (myocardial infarction) or refractory angina (incidence rate 40 times higher than in months 5 to 12 of follow-up). There were 22 MIs and 6 deaths in the intervention group (largely due to procedure related events, 14 MIs and 3 deaths) versus 17 MIs and 3 deaths in the conservative group. In the rest of the year there were an additional 12 versus 27 MIs respectively (treatment - time interaction p=0.021). Over one year in the intervention group there was a 43% reduction in refractory angina; 22% of patients underwent CABG and 35% underwent PCI only which reduced refractory angina but provoked some early MIs, whilst 43% were still on medical treatment mostly because of a favourable initial angiogram.

Conclusion: Any intervention policy needs to recognise the high risk of events in the first week, and the substantial minority of patients not needing intervention. Intervention may be best targeted at higher risk patients since the early hazards of the procedure are then offset by reduced subsequent events.

Keywords: acute coronary syndrome, coronary angiography, myocardial ischaemia, percutaneous coronary intervention

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