Meeting highlights. Highlights of the 48th scientific sessions of the American College of Cardiology.

Unstable Angina The Trial: FRISC II Presenters: Lars Wallentin and Bo Lagerqvist, Cardiothoracic Centre, University Hospital, Uppsala, Sweden. The study: A randomized, placebo-controlled trial of lowmolecular-weight heparin (dalteparin) in conjunction with either early revascularization or conservative medical therapy in 2457 patients with unstable angina or non–Q-wave myocardial infarction (MI). On admission, all patients received dalteparin (120 IU/kg every 12 hours) for the acute treatment phase (5 to 7 days) and were randomized to receive either invasive (n51222; routine angiography and intervention, if indicated, within 2 to 7 days) or conservative (n51235; angiography and intervention only if driven by refractory clinical symptoms) treatment. After the acute treatment phase, patients were further randomized to treatment with dalteparin (5000 or 7500 IU BID) or placebo in a prolonged (90 day), double-blind treatment phase. The primary endpoint of the study was a clinical outcome of death or MI (defined both conservatively [2/3 of pain, ECG changes, and enzyme elevation] or using enzymatic markers); initial 3-month follow-up data were presented. The results: A total of 98% (95% within 6 days) of the invasive treatment group underwent angiography, compared with 48% (14% within 6 days) of the conservative treatment group. Revascularization was performed in 78% of patients in the invasive treatment group (44% had percutaneous coronary intervention [PCI] and 34% had coronary artery bypass grafting [CABG]) and 38% of patients in the conservative treatment group (18% had PCI and 19% had CABG); abciximab was used in '10% of coronary interventions. The composite primary endpoint was significantly reduced in the invasive treatment group (8.6% versus 11.8% using a conservative definition of MI; 9.5% versus 12.0% using enzymatic markers). Despite slightly higher initial in-hospital mortality (1.2% versus 0.4%), by 3 months, mortality tended to be lower in the invasive treatment group (1.9% versus 3.0%). The clinical benefits of the invasive strategy were largely confined to male patients; endpoint events at 3 months (using enzymatic markers) were significantly reduced in men (9.1% versus 13.9%), whereas they tended to be slightly, but not significantly, higher in women (10.5% versus 8.2%). Invasive treatment significantly reduced mortality in men (1.5% versus 3.2%) but not women (2.9% versus 2.6%). The invasive treatment group had fewer symptoms of angina and fewer readmissions than the conservative treatment group. During the prolonged treatment phase in the noninvasively treated patients, composite endpoint events in the lowmolecular-weight heparin group were significantly reduced at 45 days (3.7% versus 6.5% with placebo); however, continuing therapy to 3 months provided no additional benefit. At 3 months, the incremental benefit in the low-molecular-weight heparin group had eroded somewhat (6.7% versus 8.0%) and was not statistically significant. Summary: In patients with unstable angina, an invasive strategy results in significantly better clinical outcomes than a conservative strategy. However, the survival benefits seem to be confined to men; an invasive strategy resulted in no mortality benefit in women. Invasive therapy was associated with fewer symptoms and fewer readmissions than conservative therapy. Three months of low-molecular-weight heparin therapy after hospitalization provided little or modest benefit. There did seem to be some incremental benefit with lowmolecular-weight heparin in the first 4 to 6 weeks after admission; however, this benefit mainly occurred when combined with a noninvasive strategy; longer term therapy provided no advantage over placebo in the invasive strategy group.