Invasive treatment of ACS: early or later on?

In a recent online publication in the Journal of the American College of Cardiology, 30 December 2009, Damman from the group of de Winter (AMC, Amsterdam) published the five-year clinical outcome in the Invasive versus Conservative Treatment in Unstable coronary Syndromes (ICTUS)¹ trial. The ICTUS trial randomised 1200 patients to either an early invasive strategy or a selective invasive treatment strategy. Outcomes included a composite of death and myocardial infarction. The main findings of the recent study were that an early invasive strategy for managing patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was not better in the long run at preventing death or myocardial infarction than a more conservative approach. At five years, there was no significant benefit from coronary angiography with revascularisation within 48 hours when the groups were stratified by risk. These five-year data are consistent with earlier data reported from the ICTUS trial, which showed no benefits of early invasive management after one and three years of follow-up (de Winter et al, NEJM 2005; Hirsch et al, Lancet 2007). The present analysis therefore extends previous reports that, in patients presenting with NSTE-ACS and an elevated troponin T, an early invasive strategy is superior to a selective invasive strategy in reducing five-year death or myocardial infarction. Over five years, the revascularisation rates were 81% in the early invasive group and 60% in the selective invasive group. All-cause mortality was not significantly different between the early invasive and selective invasive groups (11.1 and 9.9%, respectively). Cumulative death or myocardial infarction rates were 22.3 and 18.1%, respectively, but the difference was again not significant. This (non-significant) increase in the early invasive group was primarily driven by an early increase in procedure-related myocardial infarctions and a trend toward higher late non-cardiovascular mortality. However, the early increase was not associated with increased cardiovascular mortality or myocardial infarctions during follow-up. …