FRISC 2: Early Invasive vs Early Non-invasive Management 
in Unstable Coronary Artery Disease

	Doctors treating patients with unstable angina have 2 
approaches to lowering risk: either conservative, non-invasive 
testing that decides what further tests and treatment will be, 
or an invasive cardiac cath that immediately decides the need 
for angioplasty or bypass. Many trials found no benefit to 
early cath. However, these trials have been criticized for 
various reasons.
	Dr. Lars Wallentin from Akademiska University Hospital 
in Sweden studied these 2 strategies in managing unstable angina. 
This is the FRISC II study (Fast Revascularization During 
Instability in Coronary Artery Disease) and involved 58 
centers in Norway, Sweden, and Denmark from 1996 to 1998.
	Men were over 40 years old, and all women were 
postmenopausal. All patients had angina less than 48 hours 
since admission, and had signs of ischemia or heart attack. None
had angioplasty within the past 6 months.
	Patients who required it were given aspirin, 
beta-blockers, nitro, and the low molecular weight heparin - 
dalteparin - on the first and second hospital days.
	Patients were randomized to a non-invasive or invasive
group. The invasive strategy consisted of cath any time from day 
2 to day 7. The non-invasive strategy was exercise testing with 
referral to cath if the test was positive, or if the patient had 
ischemia not responding to meds or another event leading to a
heart attack.
	Primary outcome was death or heart attack by 6 months.
Secondary outcome was angina, readmission, later 
revascularization or bleeding.
	1219 patients were in the invasive group and 1214 
patients in the non-invasive group. Their average age was 65.
Only 30% of patients had high blood pressure and 13% had diabetes.
Cath was done in only 14% of the non-invasive group in the first 
6 days. However, 48% of the non-invasive group wound up getting a 
cath by 6 months. At 6 months, revascularization had more often
been done in the invasive group (78%) than the non-invasive 
group (38%). 44% of the invasive group had angioplasty vs 18%
of the non-invasive group. 34% of the invasive group had bypass 
vs 19% of the non-invasive.
	RESULTS: Primary outcome of death or heart attack at 6 
months was 10% in the invasive group compared to 12% in the 
non-invasive group. Men in the invasive group had reduction 
for death (1.5% vs 3.2%) and combined death and heart attack 
(9.1% vs 13.9%). However, women in the invasive group had no 
such trends. Angina was reduced 50% in the invasive group, as 
was readmission.
	In contrast to other studies - TIMI IIIb and VANQWISH -
FRISC II found that an early invasive strategy reduced death and 
heart attack in men. It is unclear whether women should be 
treated differently or if there were simply too few women in the 
study to get reliable results.
	It is unclear why this study's results differ from 
earlier studies. Further study of methods used, procedure 
success and complication rates when the study is published
may show why there are improved outcomes in this trial
and not in other trials, like VANQWISH and TIMI IIIb.