Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial

Fox, Keith A.A.; Poole‐Wilson, Philip A.; Henderson, Robert A.; Clayton, Tim; Chamberlain, D A; Shaw, T. R. D.; Wheatley, David J.; Pocock, Stuart J.

doi:10.1016/s0140-6736(02)09894-x

Cited by 768 publications

(371 citation statements)

References 19 publications

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“…14 In non-ST-segment elevation ACS, regardless of the presence of HF, three recent trials have provided consistent evidence of the benefit of early revascularization. [15][16][17] Given the high mortality rate of patients with HF and ACS, this group would be expected to derive an even greater benefit from revascularization. Importantly, patients with HF who underwent revascularization had lower cumulative 6-month mortality rates that those who did not, even after adjustment for baseline differences.…”

Section: Discussionmentioning

confidence: 99%

Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes

Steg

Dabbous²,

Feldman³

et al. 2004

Circulation

476

129

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Background— Few data are available on the impact of heart failure (HF) across all types of acute coronary syndromes (ACS). Methods and Results— The Global Registry of Acute Coronary Events (GRACE) is a prospective study of patients hospitalized with ACS. Data from 16 166 patients were analyzed: 13 707 patients without prior HF or cardiogenic shock at presentation were identified. Of these, 1778 (13%) had an admission diagnosis of HF (Killip class II or III). HF on admission was associated with a marked increase in mortality rates during hospitalization (12.0% versus 2.9% [with versus without HF], P <0.0001) and at 6 months after discharge (8.5% versus 2.8%, P <0.0001). Of note, HF increased mortality rates in patients with unstable angina (defined as ACS with normal biochemical markers of necrosis; mortality rates: 6.7% with versus 1.6% without HF at admission, P <0.0001). By logistic regression analysis, admission HF was an independent predictor of hospital death (odds ratio, 2.2; P <0.0001). Admission HF was associated with longer hospital stay and higher readmission rates. Patients with HF had lower rates of catheterization and percutaneous cardiac intervention, and fewer received β-blockers and statins. Hospital development of HF (versus HF on presentation) was associated with an even higher in-hospital mortality rate (17.8% versus 12.0%, P <0.0001). In patients with HF, in-hospital revascularization was associated with lower 6-month death rates (14.0% versus 23.7%, P <0.0001; adjusted hazard ratio, 0.5; 95% CI, 0.37 to 0.68, P <0.0001). Conclusions— In this observational registry, heart failure was associated with reduced hospital and 6-month survival across all ACS subsets, including patients with normal markers of necrosis. More aggressive treatment of these patients may be warranted to improve prognosis.

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Section: Discussionmentioning

confidence: 99%

Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes

Steg

Dabbous²,

Feldman³

et al. 2004

Circulation

476

129

View full text Add to dashboard Cite

show abstract

“…Patients with CKD have accelerated atherosclerosis and an increased risk of myocardial infarction, with cardiovascular disease remaining the most common cause of death 3. Based on previous seminal studies,4, 5, 6 the 2014 American College of Cardiology/American Heart Association (ACC/AHA) and the 2015 European Society of Cardiology guidelines recommend an urgent invasive strategy in high‐risk patients presenting with non–ST‐segment–elevation myocardial infarction (NSTEMI) 7, 8. However, CKD patients are often denied invasive coronary angiography and percutaneous coronary intervention (PCI) because of concerns about acute kidney injury accelerating their progression to dialysis 9, 10.…”

Section: Introductionmentioning

confidence: 99%

Non–ST‐Segment–Elevation Myocardial Infarction Among Patients With Chronic Kidney Disease: A Propensity Score–Matched Comparison of Percutaneous Coronary Intervention Versus Conservative Management

Bhatia

Arora

Bhatia

et al. 2018

JAHA

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BackgroundChronic kidney disease (CKD) remains an independent predictor of cardiovascular morbidity and mortality. CKD complicates referral for percutaneous coronary intervention (PCI) in non–ST‐segment–elevation myocardial infarction (NSTEMI) patients because of the risk for acute kidney injury and the need for dialysis, with American College of Cardiology/American Heart Association guidelines underscoring the limited data on these patients.Methods and ResultsUsing the National Inpatient Sample to analyze hospitalizations in the United States from 2004 to 2014, we sought to assess PCI utilization and in‐hospital outcomes in NSTEMI admissions with CKD. NSTEMI admissions were identified by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) code 410.7. CKD admissions were identified by ICD‐9‐CM code 585. Propensity score–matched cohorts of patients with NSTEMI were matched for age, sex, comorbidities, race, median household income, primary payer status, and hospital characteristics. Of 4 488 795 hospitalizations for NSTEMI, 31% underwent PCI. Overall, 89% of admissions had no CKD. In addition, 32% of NSTEMI admissions with no CKD and 23%, 14%, and 22% with CKD stages 3, 4, and 5 underwent PCI, respectively. Hospitalized NSTEMI patients with CKD stages 4 and 5 had 41% and 20% less likelihood, respectively, of undergoing PCI compared with those with no CKD. Among hospitalized NSTEMI patients with no CKD or CKD stage 3, 4, or 5, PCI‐treated groups had 63%, 57%, 39%, and 59% lower likelihood, respectively, of all‐cause, in‐hospital mortality compared with propensity score–matched medically managed groups.Conclusions PCI use decreased among hospitalized NSTEMI patients as CKD severity increased, and all‐cause, in‐hospital mortality was greater for NSTEMI patients admitted with more severe CKD regardless of treatment strategy.

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“…In five large, randomized trials (Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital [VANQWISH] ), a routine, early invasive strategy (early angiography followed by revascularization, depending on angiographic findings) was compared with a "conservative" strategy (angiography and subsequent revascularization only if medical therapy failed or substantial residual ischemia was documented). [2][3][4][5][6] An early invasive strategy was shown to be beneficial in the FRISC II, TACTICS-TIMI 18, and RITA-3 studies, especially in subgroups of patients at high risk, such as those presenting with an elevated cardiac troponin level. As a result, recent guidelines of the American College of Cardiology-American Heart Association and the European Society of Cardiology recommend an early invasive approach in high-risk patients with acute coronary syndromes without ST-segment elevation.…”

mentioning

confidence: 99%

Early Invasive versus Selectively Invasive Management for Acute Coronary Syndromes

et al. 2005

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Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial

Cited by 768 publications

References 19 publications

Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes

Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes

Non–ST‐Segment–Elevation Myocardial Infarction Among Patients With Chronic Kidney Disease: A Propensity Score–Matched Comparison of Percutaneous Coronary Intervention Versus Conservative Management

Early Invasive versus Selectively Invasive Management for Acute Coronary Syndromes

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