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ICTUS: Early vs. selective invasive strategy yields similar outcomes in non-ST-segment elevation ACS
An early invasive treatment strategy was not more beneficial than a selective invasive strategy in patients with non-ST-segment elevation ACS and elevated cardiac troponin T, according to 10-year data from the ICTUS trial.
Of 1,200 patients (median age, 62 years; 75% men) enrolled at 42 Dutch centers in the ICTUS trial, 604 were assigned to an early invasive strategy and 596 to a selective invasive strategy. The 10-year composite of death or spontaneous MI served as the primary outcome.
Outcomes similar
The 10-year revascularization rate was 82.6% in the early invasive strategy group and 60.5% in the selective invasive strategy group, with no difference in revascularization from 1 to 10 years of follow-up (P = .61).
Results revealed no difference in the composite outcome of death or spontaneous MI between the early invasive strategy vs. the selective invasive strategy groups (33.8% vs. 29%; HR = 1.12; 95% CI, 0.97-1.46).
Additional outcomes, including all-cause death (26.6% vs. 23.7%; HR = 1.14; 95% CI, 0.91-1.44) and CV death (17.6% vs. 15.2%; HR = 1.15; 95% CI, 0.86-1.54), also did not differ significantly between treatment groups.
The 10-year outcome of death or MI, however, was higher in the early invasive strategy group, compared with the selective invasive strategy group (37.6% vs. 30.4%; HR = 1.3; 95% CI, 1.07-1.58). This difference was largely driven by a higher rate of procedure-related MI in the early invasive strategy group vs. the selective invasive strategy group (6.5% vs. 2.4%; HR = 2.82; 95% CI, 1.53-5.2), the researchers noted.
Data demonstrated no benefit with early vs. selective invasive strategy based on patients’ baseline characteristics or whether they were considered low-, intermediate- or high-risk at baseline.
All patients had non-ST-segment elevation ACS and elevated cardiac troponin T. In the early invasive strategy group, revascularization by PCI or CABG was guided by angiography, which was performed within 24 to 48 hours after randomization. In the selective invasive strategy group, patients received optimal medical treatment, and angiography was performed in cases of refractory angina or inducible signs of ischemia during a mandatory predischarge ischemia detection test.
Appropriate strategies
In an accompanying editorial, Anthony A. Bavry, MD, MPH, of the department of medicine at the University of Florida and the North Florida/South Georgia Veterans Health System, both in Gainesville, noted that the optimal management of patients with non-ST-segment elevation ACS remains debatable.
“Invasive therapy remains an appropriate treatment strategy for patients with [non-ST-segment elevation] ACS,” wrote Bavry, a member of the Cardiology Today’s Intervention Editorial Board.
“The last decade taught us that invasive therapy reduces adverse ischemic events, including early and intermediate death, [MI] or urgent revascularization for unstable angina. The benefit from invasive therapy applies to both men and women. Future research will need to refine the lowest-risk patients who are appropriate for conservative therapy.” – by Melissa Foster
Disclosure: The study was supported by Interuniversity Cardiology Institute of the Netherlands, the Working Group on Cardiovascular Research of the Netherlands and educational grants from Eli Lilly, Medtronic, Pfizer, Sanofi, and Sanofi-Synthelabo. Roche Diagnostics provided the reagents for core laboratory cardiac troponin T measurements. One researcher reports receiving a research grant from AstraZeneca. Bavry reports receiving an honorarium from the American College of Cardiology.