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ICTUS: No long-term benefits with early invasive treatment
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Early invasive treatment did not reduce death or MI among patients with non-ST segment elevation acute coronary syndromes and elevated troponin T levels, according to a five-year follow-up of the ICTUS trial.
Data indicated no significant differences in death or spontaneous MI among patients randomly assigned to an early invasive treatment group compared with those assigned to selective invasive treatment (17.5% vs. 16.1%).
The researchers performed angiography within 24 to 48 hours for patients in the early invasive treatment group (n=604) and revascularization when appropriate. Patients in the selective treatment group (n=596) who were medically stabilized were assigned to angiography and revascularization in case of refractory angina, hemodynamic or rhythmic instability or clinically significant ischemia on the predischarge exercise test.
After stratifying patients by FRISC score, the researchers found that death and spontaneous MI rates increased with risk (9.9% in low-risk patients, 16.8% in intermediate-risk patients and 32.1% in high-risk patients). However, they found that no significant benefits were attributable to early invasive treatment regardless of risk status.
These findings contrast with previous results from the RITA-3 and FRISC II trials and run contrary to current recommendations from the American College of Cardiology, the American Heart Association and the European Society of Cardiology, which favor early invasive intervention for patients with non-ST segment elevation ACS who have high-risk features.
“The explanation for diverging results [among] the three trials is likely multifactorial,” the researchers wrote. They suggested that differences in clinical practice, heterogeneity in the intensity of revascularization over time and the “relatively high intensity” of revascularization in the ICTUS participants assigned to selective invasive treatment may have played important roles in outcome differences.
Kaplan-Meier estimates indicated that cumulative revascularization was at 81% among the early invasive patients and 60% in the selective invasive patients, with CABG among the first procedure performed in 23% of early invasive patients and 25% of selective invasive patients.
“Although many may prefer an early invasive strategy in patients with non-ST segment elevation ACS and high-risk features, a selective invasive strategy may be an attractive alternative in medically stabilized patients,” the researchers wrote.
Damman P. J Am Coll Cardiol. 2009;doi:10.1016/j.jacc.2009.11.026.