Invasive Strategy Favored for ACS

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Invasive Strategy Favored for ACS

Optimal treatment for patients with unstable angina and MI without ST-segment elevation still is elusive. Glycoprotein (GP) IIb/IIIa inhibitors and stents have improved outcomes in such patients who undergo percutaneous revascularization and may have tipped the balance in favor of an invasive strategy for acute coronary syndrome (ACS).

This industry-sponsored trial enrolled 2220 patients; each had experienced an angina episode within 24 hours of presentation and had at least 1 of these characteristics: (1) new ST-segment depression, transient ST-segment elevation, or T-wave inversion; (2) elevated levels of cardiac markers; or (3) history of coronary disease. Patients were treated with aspirin, heparin, and the GPIIb/IIIa inhibitor tirofiban; randomization was either to an early invasive strategy (catheterization within 4 to 48 hours and revascularization, if indicated) or to a conservative strategy (catheterization performed only in response to recurrent ischemia or an abnormal stress test).

Incidence of the 6-month composite endpoint of death, nonfatal MI, or rehospitalization for ACS was significantly lower in the invasive group (15.9 percent vs. 19.4 percent). The invasive strategy was beneficial in high-risk patients -- those with troponin T levels >0.01 ng/mL or those with high or intermediate TIMI risk scores -- but not in low-risk patients.

Comment: This study, which reflects contemporary practice, shows that an invasive strategy may be preferable for patients with unstable angina and MI without ST-segment elevation, particularly for those at intermediate and high risk as indicated by troponin T level or TIMI risk score. Note that, compared with previous studies, in this study the invasive strategy may have had an edge because most subjects received stents and GPIIb/IIIa inhibition.

— HM Krumholz

Published in Journal Watch Cardiology August 3, 2001

Citation(s):

Cannon CP et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001 Jun 21 344 1879-1887.

Medline abstract (Free)

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