Invasive Therapy Doesn't Cut Deaths in Acute Coronary Syndrome

Patient's risk profile should determine best treatment, one expert says

FRIDAY, March 9, 2007 (HealthDay News) -- Early invasive therapies that open blocked heart arteries don't reduce the number of deaths or heart attacks in patients with acute coronary syndrome, Dutch researchers report.

Acute coronary syndrome describes a group of symptoms that point to heart trouble; typically the problem is an insufficient supply of blood to the heart muscle.

"Cardiologists have been arguing over the best approach for non-ST elevation acute coronary syndrome for over 10 years," said Dr. Byron Lee, an assistant professor of cardiology at the University of California, San Francisco.

"There continues to be conflicting data, some supporting the invasive approach and some supporting a more conservative approach," Lee said. "Although cardiologists typically have a personal bias, perhaps they should let the patient decide what they would prefer, since neither approach has been shown to be clearly superior."

In the Dutch study, Dr. Robbert de Winter, from the Academic Medical Centre Amsterdam, and colleagues did a four-year follow-up on 1,200 acute coronary syndrome patients who were randomly selected to undergo early invasive therapy (angioplasty or coronary bypass) or have aggressive drug therapy.

Their report is published in the March 10 issue of The Lancet.

After four years, the researchers found that among patients who had early invasive therapy, 30 percent had died or had a heart attack, compared with 26 percent of the patients who did not undergo early invasive therapy.

In addition, more patients in the early invasive therapy group had heart attacks (18.3 percent), than among patients who did not have early invasive therapy (12.3 percent).

Moreover, the rates of death or heart attack were not different between the groups, (14.3 percent among patients in the early invasive therapy group and 11.2 percent among patients in the other group). At four years, there was no statistical difference in death from any cause (7.9 percent vs. 7.7 percent) or cardiovascular mortality (4.5 percent vs. 5 percent) between the groups.

"An early invasive strategy prevents rehospitalization, but no reduction in death or myocardial infarction was recorded," the authors concluded. The Dutch team believes that the aggressive drug therapy given to both groups explains why there is little difference between treatment options.

Another expert doesn't think this study can be used to change current practice guidelines.

"The small size of the study makes it interesting but not a definitive study," said Dr. Christopher P. Cannon, a professor of medicine at Harvard Medical School.

Cannon noted that current guidelines call for assessing a patient's overall risk before determining which treatment is best.

"The current practice is to follow an invasive approach for medium- and high-risk patients and a conservative approach for lower-risk patients," he said. "That will stand as the appropriate strategy, despite the findings in this paper."

More information

For more information on acute coronary syndrome, visit the American Heart Association.

SOURCES: Christopher P. Cannon, M.D., professor, medicine, Harvard Medical School, Boston; Byron Lee, M.D., assistant professor, cardiology, University of California, San Francisco; March 10, 2007, The Lancet
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