What's new in the other general journals

Trial challenges guidelines for patients with acute coronary syndrome

The management of patients with an acute coronary syndrome has been edging towards a more invasive package, including drugs and early coronary angiography followed by revascularisation if appropriate. European and American guidelines recommend this approach, and many cardiologists accept it. But the evidence against routine aggressive treatment is mounting.

The latest randomised trial, which is large and well done, reports that patients treated early and invasively do no better, and may do worse, than similar patients who are managed with drugs then carefully selected for more invasive treatment later if they need it.

All 1200 Dutch patients had an acute coronary syndrome and a raised serum concentration of troponin T. They had the best available medical treatment, including aspirin, clopidogrel, enoxaparin, and statins. A total of 604 patients had early invasive treatment, starting with coronary angiography within 24 to 48 hours after admission. The rest were managed conservatively unless they remained unstable or failed an exercise test before discharge. A year later, 23% (137) of the patients treated aggressively, and 21% (126/596) of the patients treated more conservatively had died, had a heart attack, or come back in to hospital with angina. Overall mortality was low (2.5%) and was the same in both groups. In this trial, as in others, early revascularisation was associated with a higher risk of heart attack, especially after the treatment (15% v 10%, P = 0.005).

New England Journal of Medicine 2005;353: 1095-104

Patients with most to gain are least likely to get drug treatments for heart failure

We already know that patients with heart failure don't always get the drug treatments they need. But a new study shows that the sickest patients are the most likely to miss out. In a cohort of 1418 hospital patients with heart failure, researchers found a paradoxical relation between risk of death and treatment with β blockers, …