ESC 2014

1. PROCEEDINGS From
ESC CONGRESS 2014

2. RITA 3
10-year mortality outcome of a routine invasive
strategy in
Non-ST segment Elevation Acute Coronary
Syndrome: The British Heart Foundation RITA 3
randomised trial. (ISRCTN 07752711)
Robert A Henderson

3. Introduction
• Randomised trial of routine invasive versus selective invasive
strategies
1810 pts with NSTE ACS
• At 5 years a routine invasive strategy was associated with:
– 26% reduction in the odds of CV death and MI
– 24% reduction in the odds of all cause mortality
• The benefits of routine invasive treatment appeared greatest in
patients at highest baseline ischaemic risk
• The objective of this analysis is to determine the impact of a
routine invasive strategy on longer-term (10 year) mortality

5. Methods
 RITA-3 was designed to document clinical events to 5 years by
patient contact (vital status known at 5 years for 99.6%)
 Thereafter, all patients were prospectively registered with ONS
(England) & GRO (Scotland) to ascertain deaths from national
mortality data.
 All-cause mortality at 10 years was a pre-specified secondary
outcome
 Modified post-discharge GRACE score* was used to calculate
a risk score for each patient and form low, medium & high risk
groups with approximately one-third of deaths in each group
Baseline renal function and in-hospital PCI
were excluded from the risk model
Eagle JAMA 2004;291:2727
ONS - Office of National
Statistics
GRO - General Register Office

15. Conclusion
 The mortality advantage of a routine invasive strategy seen in RITA-3
at 5 years attenuated during later follow-up
 At 10 years there was no evidence of a difference in all-cause or
cardiovascular mortality .
 An updated IPD meta-analysis of FRISC, ICTUS and RITA-3 is
planned.
 Further trials of contemporary intervention strategies in patients with
NSTE-ACS are warranted particularly in high risk patients.

16. Lars Wallentin, Ralph A. H. Stewart et al.

20. Objectives
This predefined part of the STABILITY study of patients with stable
CHD with optimal medical treatment raised the following questions:
 Is Lp-PLA2 activity prognostic for outcomes?
 Which factors contribute to high Lp-PLA2 activity?
 Does darapladib provide persistent long-term reduction of
Lp-PLA2 activity?
 Does high Lp-PLA2 activity identify patients with a larger
benefit of darapladib treatment?

32. Conclusions
In patients with stable CHD (3.7 years on a background of OMT):
 Lp-PLA2 activity is an independent risk marker for CV events.
 Dyslipidemia, Male gender, white race & NA region contribute to
higher Lp-PLA2 activity while statin treatment is associated with
lower Lp-PLA2 activity levels.
 Darapladib provides a persistent ,a 65% reduction of the Lp-PLA2
activity during treatment.
 Lp-PLA2 activity at baseline do not predict the effects of darapladib
treatment on coronary events.

33. Implications
In patients with stable CHD:
 Lp-PLA2 activity level does not identify patients with a specific
effect of darapladib treatment.
 Lp-PLA2 activity might be an indicator or part of an atherosclerotic
process although lowering of the activity does not have a clinically
significant effect in subjects treated with optimal standard of care.
 Measuring Lp-PLA2 activity for identification of the risk of
cardiovascular events, without indication for a specific treatment,
needs further evaluation.

54. Background
 Diabetes mellitus (DM) is involved in AS development and is
associated with qualitative changes in valvular tissue (inflammation,
metalloproteinase)
 DM has a negative impact on immediate and long term outcome after
surgical aortic replacement.
 While DM is not part of the Euroscore, it has been integrated to the
STS score.
 The impact of DM on post-transcatheter aortic valve replacement
(TAVR) outcome is unknown.