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Invasive vs. Conservative Management of NSTEACS

Recent studies generally have supported an early invasive approach (routine angiography and, when indicated, revascularization) in patients with non–ST-segment-elevation acute coronary syndromes (NSTEACS; Journal Watch Cardiology Jul 29 2005). The partially industry-supported ICTUS trial from the Netherlands further tested this strategy.

Twelve hundred NSTEACS patients with recent symptoms and elevated troponin T levels were initially treated with aspirin and enoxaparin before random assignment to one of two strategies: an early invasive strategy within 48 hours that included abciximab for PCI or a conservative, selectively invasive strategy (revascularization only for refractory angina despite medical treatment, hemodynamic or rhythmic instability, or clinically significant ischemia on predischarge exercise testing). By 1 year, 79% of the early invasive group and 54% of the selective invasive group had been revascularized. The groups had similar incidences of the primary endpoint (death, recurrent MI, or rehospitalization for angina; 22.7% and 21.2%, respectively) and an identical mortality rate (2.5%). MIs were significantly more common in the early invasive group (15% vs. 10%), but most were small (creatine-kinase MB 1–3x the upper limit of normal) and/or related to PCI.

Comment: The ICTUS data must be placed in the context of longer-term findings from the British RITA-3 trial (Journal Watch Cardiology Oct 7 2005). Five-year results from RITA-3 show a marked, steadily increasing benefit of an early invasive strategy over a conservative strategy in high-risk NSTEACS patients, despite a small hazard in the first year. In ICTUS, the early invasive strategy’s lack of benefit at 1 year may reflect the early MI hazard found in RITA-3 and other studies, the sensitive definition for small MIs in ICTUS, or the higher rate of revascularization in the ICTUS selectively invasive group (compared with the RITA-3 conservative group). Although, as an editorialist notes, the ICTUS data challenge the assumed fundamental superiority of an early invasive strategy in high-risk ACS patients, I (and most interventionists) will continue to use it based on RITA-3 and previous studies that support it.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology December 30, 2005

Citation(s):

de Winter RJ et al. for the Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005 Sep 15; 353:1095-104.

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• Medline abstract (Free)

Boden WE. Acute coronary syndromes without ST-segment elevation — What is the role of early intervention? N Engl J Med 2005 Sep 15; 353:1159-61.

• Original article (Subscription may be required)
• Medline abstract (Free)