Author + information
- Robert A. Henderson, DM∗ (, )
- Chris Jarvis, MSc,
- Tim Clayton, MSc,
- Stuart J. Pocock, PhD and
- Keith A.A. Fox, MB, ChB
- ↵∗Trent Cardiac Centre, Nottingham University Hospitals, City Hospital Campus, Hucknall Road, Nottingham, Nottinghamshire, NG96BG, United Kingdom
We thank Dr. Kostis and colleagues for their comments on our recent paper (1) reporting the 10-year mortality outcomes of the RITA-3 trial.
We agree that relative differences in mortality between randomized groups may attenuate over time as more deaths occur in each group, and estimation of average survival may provide an alternative approach to evaluating the effects of treatment. Restricted mean survival analysis (to estimate the area between the survival curves out to 10 years) gave a mean survival difference of 0.18 years in favor of a routine invasive strategy with a 95% confidence interval of −0.44 to 0.08 years, p = 0.170. These results are compatible with the survival differences reported in our paper and support our conclusion that the reduced mortality associated with the routine invasive strategy at 5 years attenuates during later follow-up.
Moreover, RITA-3 recruited patients with non–ST-segment elevation acute coronary syndrome before the widespread use of drug-eluting stents and other novel therapies. The impact of contemporary invasive strategies on longer term mortality is therefore unknown, supporting our call for further randomized trials. In the interim, guideline committees will need to consider our results, and any long-term results of the FRISC-2 (Fragmin and Fast Revascularisation during Instability in Coronary artery disease 2) and ICTUS (Invasive versus Conservative Treatment in Unstable Coronary Syndromes) trials, when determining whether their recommendations need to be revised.
Please note: RITA-3 was funded by a competitive grant from the British Heart Foundation, and the British Heart Foundation received a donation from Aventis Pharma. Additional governmental support (Culyer) was obtained to reimburse interventional centers for part of the costs of percutaneous coronary intervention procedures on trial patients. Mr. Clayton has received grant support from The Medicines Company. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Henderson R.A.,
- Jarvis C.,
- Clayton T.,
- Pocock S.J.,
- Fox K.A.A.