The ICTUS trial: Early invasive or selectively invasive management for ACS [Classics Series]

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1. There was no significant difference in the composite rate of death, nonfatal myocardial infarction, or rehospitalization for angina in patients with acute coronary syndromes treated with early invasive versus selectively invasive strategies

2. Myocardial infarction was significantly more frequent in the early invasive management group but rehospitalization was significantly less frequent in this group

Original Date of Publication: September 15, 2005

Study Rundown: Guidelines of the American College of Cardiology-American Heart Association and European Society of Cardiology recommend an early invasive strategy for the treatment of acute coronary syndromes (ACS) without ST-segment elevation based on evidence from multiple previously conducted randomized trials. The ICTUS trial suggests that selectively invasive management may be an acceptable alternative approach to treatment. With advances in medical therapy and higher rates of revascularization, patients treated with the selectively invasive strategy showed no difference in the cumulative rate of death, nonfatal myocardial infarction, or rehospitalization for angina at one-year after randomization.

These results suggest that an early invasive strategy may not be superior to a selectively invasive strategy for the treatment of ACS without ST-segment elevation and with elevated cardiac troponin T levels.

Please click to read study in NEJM

In-Depth [randomized, controlled study]: In this study, published in 2005 in NEJM, 1,200 patients with ACS without ST-segment elevation and with elevated cardiac troponin T levels were randomly assigned to management with early invasive strategy or selectively invasive strategy. Both treatment groups received optimized medical therapy. The early invasive strategy involved angiography within 24 to 48 hours of randomization and percutaneous coronary intervention where appropriate. Patients assigned to selectively invasive management were scheduled for angiography and revascularization only if symptoms persisted despite medical therapy or if patients showed hemodynamic or rhythmic instability. A composite of death, recurrent myocardial infarction or rehospitalization for angina within one year was measured as the primary endpoint. There was no significant difference in the cumulative event rate at one-year between the two groups. Mortality at one-year after randomization was 2.5% in both groups. The risk of myocardial infarction was significantly higher in the early invasive strategy group, while rehospitalization was significantly less frequent in this group.

By Adrienne Cheung, Andrew Cheung, M.D.

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