NonSTSegment Elevation Acute Coronary Syndromes

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In acute coronary syndromes without ST-segment elevation, there has been a long-standing debate about two competing treatment strategies.11 The conservative strategy reserves coronary angiography and revascularization for those patients who continue to have spontaneous or inducible myocardial ischemia despite maximal medical therapy. The invasive strategy, on the other hand, recommends coronary angi-ography and revascularization regardless of the primary success of medical treatment. Various studies have addressed this issue. A meta-analysis published in 2005 concluded that the invasive strategy, while increasing the risk of in-hospital death and MI (so-called early hazard), significantly reduced death and MI during the entire follow-up period, ranging from 6 months to 2 years in various studies, by 18% (95% confidence interval [CI], 2% to 42%).12 Supporting this analysis, the 5-year follow-up of RITA-3 revealed that the benefit of the invasive strategy with respect to death and MI continued to increase with time, compared with the conservative strategy.13 At 5 years after intervention, the incidence of death and MI was 20.0% in the conservative arm but 16.6% in the interventional arm (P = .04). Moreover, there was an increased survival benefit of the invasive strategy during the 5-year follow-up (88% vs. 85%) that almost reached statistical significance (P = .054). The recently reported 5-year follow-up of FRISC-II also demonstrated a significant reduction in the long-term incidence of death and MI by the invasive

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