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dLandmark RITA3 Trial Results on Acute Coronary Synromes Published
Sep 7, 2005, 23:57, Reviewed by: Dr.
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Landmark trial results published
today in 'The Lancet' reveal that changing the way we treat people suffering from Acute Coronary Syndromes (ACS), or 'threatened heart attack', could save more than 5,000 lives each year in the UK.
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By British Heart Foundation,
This BHF-funded research is the first large long-term study to show that early specialist assessment and procedures to repair or bypass damaged arteries can save lives of people with ACS - all the symptoms of threatened heart attack but without major damage - believed to be suffered by at least 155,000 people each year.
The results are today being presented to heart specialists at the European Society of Cardiology Congress 2005 in Stockholm.
Over 1800 patients with ACS at 45 hospitals in England and Scotland took part in the five-year trial and were randomly split into two groups.
One group, after thorough assessment, received traditional 'medicine-based' treatment including aspirin, statins and ACE inhibitors. They only proceeded to invasive therapy (angioplasty or bypass) if symptoms suggested a severely narrowed artery - the standard treatment in UK.
The second group, received the same assessment and medication but were referred rapidly (within 48 hours) for angiography regardless of symptoms.
Angiography involves injecting a dye into the patient�s circulation. This can then be seen with specialized X-rays, showing where blood vessels are narrowed or blocked. Guided by these results, patients went on to have either an angioplasty or coronary artery bypass procedure.
Five years after initial hospital admission the team saw...
* There had been 90 deaths (10.6%) caused by heart and circulatory disease in the medicine-based treatment group, as opposed to 62 (7.3%) in the procedure-based treatment group,
* There had been 74 (8.3%) non-fatal heart attacks in the medicine-based treatment group as opposed to 59 (6.8%) in the procedure-based treatment group.
Overall, the more aggressive, procedure-based treatment prevented between three and four people out of every 100 from suffering heart attack or dying in the five years after their initial admission. Only in low risk patients was medical therapy equivalent to intervention.
When scaled-up to relate to at least 155,000 ACS sufferers in the UK, this means over 5,000 lives saved by procedure-based treatment.
Professor Fox, who led the study at University of Edinburgh, said: "RITA 3 demonstrates, for the first time, that an interventional strategy is better than 'watchful waiting' for many patients with threatened heart attack because it saves lives and prevents heart attacks in the long term.
"The findings will provide robust evidence to support guidelines for the management of acute coronary syndrome."
Professor Peter Weissberg, Medical Director of the British Heart Foundation, said: "Chest pain is often a signal that a heart attack is just around the corner.
"This important trial clearly tells us that more aggressive treatment of Acute Coronary Syndromes in moderate and high risk patients doesn�t just improve symptoms; it can head off that heart attack and save lives, even five years down the road.
"Our view is that all patients with ACS should be assessed quickly by a cardiologist to ensure appropriate treatment. In many cases this should favour a more aggressive approach than is currently the norm." 
- The results are today being presented to heart specialists at the European Society of Cardiology Congress 2005 in Stockholm.
British Heart Foundation
- Acute Coronary Syndrome is a collective term for a set of heart symptoms that occur together, in this study these include unstable angina, chest pain due to partial blockage of the coronary arteries and evidence of damage to the heart muscle.
- 1810 patients with Acute Coronary Syndromes were split as: 915 patients on conservative, medicine-based, treatment arm and 895 patients on the more aggressive rapid angiography and procedure-based treatment arm.
- Patients were selected for the trial when the cardiologist was unsure of the best treatment for them after specific and thorough risk assessment. This assessment looked at medical history, lifestyle factors (e.g. smoking) and age. Patients at obvious high risk of heart attack did not take part in the trial, and received appropriate surgery as normal.
- Medicine-based treatment
This is the conservative, standard method of treatment in the UK
Assessment of patient�s level of heart health risk
Very high risk patients given rapid angiography
Moderate and low risk patients given medicines such as aspirin, statins and ACE inhibitors to improve symptoms.
Patient kept in hospital for a few days and symptoms reassessed.
If symptoms improved the patient is sent home and may return at a later date for further investigations to find underlying cause of chest pain. This might include an exercise test and a type of heart scan called an ECG.
If no improvement in symptoms, patients undergo angiography (see below).
- Procedure-based treatment
The BHF calls for this to be rolled out across NHS trusts
Angiogram undertaken within 48 hours after admission to hospital.
Subsequent treatment governed by the findings of the angiogram. Intervention likely if blockage or significant (more than 50%) narrowing of artery or arteries is seen.
Intervention might involve:
Angioplasty - insertion of probe into narrowed/blocked artery, and balloon inflated to reopen the blood vessel
Stenting � vessel reopened as above and held open by implanting an artificial tube in the artery
Coronary artery bypass � open heart surgery to reroute the blood flow around a blocked artery in the heart.
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