The VINO Study (2002) [15]

NSTEMI

137 patients were included from 10 centers based on inclusion (ECG change of ST depression) and exclusion criteria.

First day Angiography/ angioplasty group versus early conservative group (medical treatment followed by angiography if recurrent MI)

Composite end point of death or recurrent non-fatal MI at 6 months

Six month mortality (p < 0.03) or non-fatal reinfarction (p < 0.02) was significantly lower in the first day coronary angiography group

First day coronary angiography followed by angioplasty reduces mortality and reinfarction in NSTEMI patients

RITA-3 (2002) [16]

UA or NSTEMI

Multicenter trial of 1810 patients of mean age 62 and 38% women

Early intervention versus conservative strategy. The antithrombin agent in both groups was enoxaparin.

Co-primary endpoints of combined rate of death, non-fatal myocardial infarction, or refractory angina at 4 month. The other endpoint was a combined rate of death or non-fatal MI at year 1

At 4 months, 9.6% of patients in early intervention group versus 14.5% of patients in conservative group died or had MI or had refractory angina. Most of the difference was due to reduction in refractory angina. The rate was similar for both groups at 1 year.

Early intervention is better than conservative approach in NSTEMI patients mainly due to halved refractory angina cases and no increase in rate of death or MI

ISAR-COOL trial (2003) [17]

UA with NSTEMI or elevated cardiac troponin T

410 patients admitted to 2 tertiary care center with symptoms of unstable angina with NSTEMI or elevated cardiac troponin T

Anti thrombotic pretreatment for 3 to 5 days preceding coronary angiography versus early intervention following 6 hours of pretreatment. Antithrombotic included Iv unfractionated heparin, aspirin, clopidogrel and IV tirofiban

Composite 30-day incidence of non-fatal MI or death from any cause

11.6% of Group receiving prolong anti thrombotic pretreatment had primary endpoint compared to 5.9% of group receiving early intervention.

Early intervention with intense anti thrombotic pretreatment has a better outcome compared to the group receiving prolong pretreatment with anti thrombotic

ICTUS trial (2007) [18]

NSTEMI and elevated cardiac troponin T

1200 patients from 42 aged 18 to 80 years with inclusion criteria of symptomatic patient with raised cardiac biomarker and either ischemic change in EKG or documented history of CAD and other exclusion criteria’s

Early invasive strategy, including early routine PCI and revascularization when appropriate, versus selective invasive strategy, where PCI was done if the patient had refractory angina or recurrent ischemia

Frequency of death, MI or re-hospitalization after 1 year. Follow up was done at 4 year

At the end of 1 year no difference between the groups with respect to primary endpoint. Similar results were seen at the end of 4 year.

Early invasive strategy not better than selective invasive strategy.