1. MICHELANGELO: OASIS 5 Women’s Substudy Dr. Eva Swahn Department of Cardiology, Heart Centre, University Hospital, Linköping Sweden Disclosure Funded by Sanofi-Synthelabo, Organon NV and GSK Dr. Swahn has no conflicts of interest

2. Background Women with NSTE ACS have less severe CAD and better prognosis than men. Some treatments (eg LMWH or CABG surgery) are associated with a higher risk in women. Others (GPIIB/ IIIa inhib) appear ineffective. Randomized trials of routine invasive strategy in NSTE ACS show benefits in men but the results in women are contradictory.

3. Routine invasive Selective invasive FRISCII (2001) (12 m f-u) 43 (12.4%)34 (8.5%) RITA3 (2002) (12 m f-u) 30 (8.6%)17 (5.1%) TACTICS (2002) (6 m f-u) 26 (6.6%)35 (9.7%) Death/MI

4. Female Patients Randomized to OASIS 5 Routine Invasive Selective Invasive Primary Outcomes over duration of 2 yr follow-up 1. Death/MI/Stroke/Refractory ischemia 2. Death/MI/Stroke Primary Outcomes over duration of 2 yr follow-up 1. Death/MI/Stroke/Refractory ischemia 2. Death/MI/Stroke MICHELANGELO: OASIS 5 Women’s Substudy Women’s Substudy (NSTE ACS) Fondparinux vs Enoxaparin (NSTE ACS) Fondparinux vs Enoxaparin Randomized to WSS Cath followed by PCI/CABG within 7 days Only in presence of symptoms or severe ischemia 184 patients randomized

5. Study Design A randomized, international, multi-center open trial Sub-study of MICHELANGELO: OASIS-5 trial. Eligible female patients in participating OASIS 5 centers were randomized to receive either: routine early coronary angiography and, if appropriate, intervention within 7 days of randomization or selective invasive strategy (coronary angiography only in case of symptoms i.e. severe ischemia during index hospital admission or on a stress test).

6. Study Objectives To evaluate whether, among women with NSTACS, an early invasive strategy, is superior to a selective invasive strategy in terms of Death/MI/Stroke over a duration of 2 year follow-up All patients were concurrently managed with intense anti-ischemic and antithrombotic medication during index hospitalization.

7. Indications for revascularization in the selective invasive group Refractory ischemia. New ST elevation. Development of hemodynamic instability or CHF. Intractable life-threatening arrhythmia. Incapacitating angina or severe ischemia at a stress test. Incapacitating angina despite optimal medical therapy during follow-up. Reinfarction during follow-up.

8. Follow-up Schedule As per the main study at 30, 90 and 180 days Out-patient visit or telephone contact with survivors at 1 and 2 years. Appropriate CRF and event forms filled in according to the protocol.

9. Statistical Considerations Based on the over all results of the FRISC II trial we assumed a reduction in the rate of death, MI from 17.5% to 12.5% at 3 years with a routine invasive strategy. To detect a relative risk reduction of 28.5 %, with 80% power, a sample size of 1,600 was planned. The curtailment in the sample size as well as follow-up time reduced the effective power to about 12% to detect the hypothesized reduction in outcome(2 sided  =0.05). The effect of Invasive strategy on outcomes was assessed using Cox’s Proportional Hazard Model.

10. Baseline Characteristics Table 1 Baseline characteristics Data are given as percentages unless otherwise indicated. MI= myocardial infarction. PCI= percutaneous coronary intervention. CABG= coronary artery bypass grafting. ACE= angiotensin converting enzyme. AF=atrial fibrillation. CCU=coronary care unit. * Defined as pulmonary rales or given iv diuretics. **Significance was calculated by χ²- test except for age for which the p value was calculated with the t test. Selective Invasive (n = 92) Routine Invasive (n = 92) Age (SD)67.8 (8.8)68.2 (9.2) n%n% Previous MI 1819.62223.9 Previous PCI 1112.077.6 CABG Surgery 33.355.4 Stroke 44.34 PAD 22.244.3 Hypertension 6267.45762.0 Diabetes 2729.31920.7 Current Smoker 2426.199.8 Onset to Rand (hrs) 9213.3 +/- 6.39212.5 +/- 6.6

11. Ischemic Symptoms/ECG/ Enzymes, Biomarkers Selective Invasive (n = 92) Routine Invasive (n = 92) n%n% Troponin or CK-MB > ULN 7278.37379.3 ECG compatible with ischemia 6570.77076.1 ST depression ≥ 0.5 mm4549.04751.8 Any ECG abnormality7986.07986.0

12. Concomitant Medications during Initial Hospitalization Selective Invasive (n = 92) Routine Invasive (n = 92) n%n% ASA9198.992100 Clopidogrel/Ticlopidine7076.17985.9 Dual Anti-platelet Rx6975.07985.9 GP IIb/IIIa77.61112.0 IV UFH66.51112.0 LMWH2021.72223.9 Only LMWH1415.21920.7 Beta Blocker8693.58794.6 ACE/ARB7480.46570.7 Statins7783.78188.0

13. Interventions during Initial Hospitalization Selective Invasive (n = 92) Routine Invasive (n = 92) n%n% Coronary Angiography3740.28895.7 PCI2223.94245.7 CABG Surgery66.51112.0

14. Interventions during Long term Follow-up Selective Invasive (n = 92) Routine Invasive (n = 92) n%n% Coronary Angiography6065.28996.7 PCI3639.04448.0 CABG Surgery1112.01516.0

15. Cox PH Ratios: 2 yr outcome Selective Invasive (n = 92) Routine Invasive (n = 92) Hazard Ratio (95% CI) n%n% Death/MI/Stroke1615.41921.01.46 (0.73 – 2.94) Death/MI/RI1920.81921.00.99 (0.52 – 1.90) Death/MI1314.31718.81.39 (0.67 – 2.88) Death22.288.84.65 (0.97 – 22.2) MI1213.31112.90.95 (0.42 – 2.19) Stroke44.422.30.67 (0.12 – 3.70) Major Bleeding22.2910.06.90 (1.48 – 32.1) Death/MI/Stroke/ Major Bldg 1415.42527.42.16 (1.11 – 4.20)

16. Days 0.0 0.05 0.10 0.15 0.20 050100200300400500600700 Death/MI/Stroke Selective invasive Routine invasive Cumulative Hazard

17. Days Cumulative Hazard 0.0 0.02 0.04 0.06 0.08 050100200300400500600700 Death Selective invasive Routine invasive

18. Female Patients Randomized to OASIS 5 Routine Invasive Selective Invasive Primary Outcomes over duration of 2 yr follow-up 1. Death/MI/Stroke/Refractory ischemia 2. Death/MI/Stroke Primary Outcomes over duration of 2 yr follow-up 1. Death/MI/Stroke/Refractory ischemia 2. Death/MI/Stroke MICHELANGELO: OASIS 5 Women’s Substudy Women’s Substudy (NSTE ACS) Fondparinux vs Enoxaparin (NSTE ACS) Fondparinux vs Enoxaparin Randomized to WSS Cath followed by PCI/CABG within 7 days Only in presence of symptoms or severe ischemia 184 patients randomized

19. Meta analysis - Death/MI Study name Death or MI / Total Statistics for each studyOdds ratio and 95% CI RoutineSelectiveOddsLowerUpper Invasive ratiolimit p-Value FRISC II43 / 34842 / 4011.210.771.890.42 RITA 330 / 35017 / 3321.740.943.210.08 TACTICS26 / 39535 / 3620.660.391.120.12 OASIS 513 / 9210 / 921.350.563.250.50 112 /1185104/11871.110.831.470.48 0.10.20.512510 Favours Early Invasive Favours Selective Invasive

20. Meta analysis - Death Study nameDead / TotalStatistics for each studyOdds ratio and 95% CI RoutineSelectiveOddsLowerUpper Invasive ratiolimit p-Value FRISC II14 / 34813 / 4011.250.582.700.57 RITA 318 / 3508 / 3322.200.945.120.07 TACTICS15 / 39513 / 3621.060.502.260.88 OASIS 58 / 921 / 928.671.0670.770.04 55 /118535 /11871.500.962.350.07 0.010.1110100 Favours Early Invasive Favours Selective Invasive

21. FINAL Enrollment by Country CountryNo. of SitesNo. of Patients Argentina22 Sweden14108 Poland673 South Africa11 TOTAL23184

22. Conclusions In this study, women with NSTE ACS did not benefit from a routine invasive strategy. On the contrary, patients randomised to a routine invasive strategy had a higher mortality rate. The results taken together with the results of previous larger trials suggest that the results from men do not necessarily apply to women and that large scale randomised trials in women are needed to determine the optimal strategy in NSTE ACS.