Early Intervention in Unstable CAD

For patients with non-ST elevation acute coronary syndromes, an early interventional strategy provides greater improvements in health-related quality of life (HRQOL) compared with a more conservative medical approach, new findings suggest.
The gains in HRQOL with angiography and revascularization, if indicated, appear to be largely due to improvements in angina grade, principal investigator Dr. Joseph Kim, from the London School of Hygiene & Tropical Medicine, told Reuters Health.
"And although these gains were small, they occurred without an increased risk of death or MI to patients," he emphasized.
The findings, from the third Randomized Intervention Trial of unstable Angina (RITA-3), are published in the January 18th Journal of the American College of Cardiology.
In the trial, 1810 patients with chest pain at rest and confirmed coronary artery disease were randomized to an early intervention strategy (i.e., maximal medical therapy plus early coronary arteriography with possible myocardial revascularization) or to a more conservative strategy (i.e., maximal medical therapy with symptom-provoked angiography and revascularization).
At four months, subjects in the early intervention arm had significantly better HRQOL based on responses to all four HRQOL instruments used in the study. At one year, the differences in HRQOL were still present but had narrowed and were not all statistically or clinically significant.
"It is likely that the observed attenuation in HRQOL scores at one year reflects those severely symptomatic patients in the conservative arm who crossed over and underwent revascularization and hence, were likely to have benefits in HRQOL," the authors suggest.
Employing an early interventional strategy in the management of patients with unstable CAD is controversial. The RITA-3 results suggest that early intervention "has the potential to reduce the occurrence of refractory angina, while also improving health-related quality of life," Dr. Kim told Reuters Health.
"However, these benefits should be balanced against the overall economic cost and clinical risk of performing an early intervention," he added.
In a statement, Dr. John Spertus, from the Mid America Heart Institute in Kansas City, Missouri, who was not involved in the trial, called it a "very thorough and well-conducted study" that amplifies earlier results on the benefits of early intervention over conservative therapy in patients with unstable CAD.
J Am Coll Cardiol 2005;45:221-228. source: reuters

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