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December 14, 2005

Routine vs Selective Invasive Strategies in Acute Coronary Syndromes—Reply

Author Affiliations

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2005;294(22):2844-2846. doi:10.1001/jama.294.22.2845-b

In Reply: The meta-analysis by Drs Bavry and Kumbhani1 using selective inclusion of trials of invasive vs conservative therapy performed after 1999 is consistent with the overall results of our meta-analysis, which includes the totality of data from all of the randomized trials addressing this question. Figure 5 of our article reports a subgroup analysis of trials performed after 1999 and shows consistent benefit of the invasive strategy in these latter trials. However, the analysis by Bavry and Kumbhani did not show a mortality benefit at 12 months and included a trial that allocated patients to management strategy according to day of the week, potentially producing a biased result in favor of invasive therapy.2 Second, randomized trials evaluating the use of stents have not found stent use to reduce mortality or MI.3 Third, the overwhelming majority of patients in the recent trials did not actually use Gp IIb/IIIIa inhibitors: only 10% in FRISC II,4 less than 5.2% in RITA 3,5 and 0% in VINO.6

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