Aggressive Therapy Best for Chest Pain

Large, ongoing British study finds it would save lives

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By Amanda Gardner
HealthDay Reporter

WEDNESDAY, Sept. 7, 2005 (HealthDay News) -- A British study has reconfirmed the value of more aggressive therapy for patients with chest pain indicating the presence of acute coronary syndrome.

Writing in the Sept. 8 online issue of The Lancet, the researchers found that acting quickly in patients with acute coronary syndrome reduced the long-term risk of death or nonfatal heart attacks. The benefit was seen mainly in high-risk patients.

"Taking an aggressive course was superior to a conservative one," said Dr. Samin Sharma, director of interventional cardiology at Mount Sinai Medical Center in New York City.

"This is an important and well-done and well-analyzed study," added Dr. Thomas Ryan, professor of medicine at Boston University School of Medicine and a past president of the American Heart Association. "I think it will have its impact on the way organized cardiology, such as the American Heart Association and the American College of Cardiology, makes their guidelines."

Acute coronary syndrome causes chest pains as a result of insufficient blood supply to the heart.

According to the American Heart Association, the term "acute coronary syndrome" actually covers a range of conditions, including unstable angina and heart attack, which are major causes of emergency medical care and hospitalization in the United States.

It has not been clear, however, what the best long-treatment for the condition is.

"If a patient was having chest pain, in the past there were two approaches," Sharma explained. "One was to take them to the catheterization lab directly, and the second was to stabilize them first and then take them to the cath lab a few days later."

For this trial, the British Heart Foundation's RITA 3 trial, researchers compared an interventional strategy of early angiography (imaging of blood vessels) followed by revascularization (replacing or repairing the blood vessels) with a conservative strategy which involved an initial wait-and-see period.

One-year follow-up data, which showed similar rates of death or heart attack, have already been published.

Almost 2,000 patients with acute coronary syndrome from 45 hospitals in England and Scotland were randomized to receive either early intervention or the more conservative approach.

After five years of follow-up, patients who had received the more aggressive interventional strategy had fewer deaths or nonfatal heart attacks than patients in the conservative group. This translated to 3.5 deaths or heart attacks prevented for every 100 patients treated.

The study is the first large-scale trial to compare the long-term outcome of these two approaches.

According to the study authors, the findings lend support for national and international guidelines to identify which patients are at highest risk so as to employ a more aggressive strategy.

Ryan agreed. "The best strategy seems to be to take high-risk patients and certainly give them intervention and, for low-risk patients, you can probably afford to hold off on [the] intervention," he said. "The sicker you are, the more benefit you get in the long run."

More information

The American Heart Association has more on acute coronary syndrome.

SOURCES: Samin Sharma, M.D., director, interventional cardiology, Mount Sinai Medical Center, New York City; Thomas J. Ryan, M.D., professor, medicine, Boston University School of Medicine; Sept. 8, 2005, The Lancet

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