The invasive strategy was also associated with less angina and fewer rehospitalizations. Patientsundergoingroutineinvasivetreatmentalsohadimproved quality of life. In an analysis of individual patient data340 that reported 5-year outcomes from the FRISC (Framingham and Fast Revascularization During Instability in Coronary Artery ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial,338 and RITA (Randomized Trial of a Conservative Treatment Strategy Versus an Interventional Treatment Strategy in Patients with Unstable to a routine invasive strategy experienced cardiovascular death or nonfatal MI versus 17.9% of patients (475 of 2746) in the selective invasive strategy (HR: 0.81; 95% CI: 0.71 to 0.93; P=0.002). The most marked treatment effect was on MI (10.0% routine invasive strategy versus 12.9% selective invasive strat- egy), and there were consistent trends for fewer cardiovascular mortality (HR: 0.90; 95% CI: 0.77 to 1.05). There were abso- lute reductions of 2.0% to 3.8% in cardiovascular death or MI in the low- and intermediate-risk groups and an 11.1% absolute risk reduction in the highest-risk patients. The invasive strategy demonstrated its greatest advantage in the highest-risk stratum of patients with no significant benefit on mortality over the noninvasive approach in moderate- and low-risk patients.342 An ischemia-guided strategy has been used with favorable results in initially stabilized patients with NSTE-ACS at elevated risk for clinical events, including those with positive troponin levels.338 One limitation of these studies is the absence of adherence to optimal medical therapy in non-invasively treated patients dur- ing long-term management. In addition, in FRISC-II, invasive management was delayed and patients with markedly positive stress tests (up to 2.9-mm exercise-induced ST depression) were randomized to noninvasive or invasive therapy.338 See Online Data Supplement 18 for additional information on comparison of early invasive strategy and ischemia-guided strategy. 4.4.4.1. 