Early Invasive Versus Selective Strategy for Non–ST-Segment Elevation Acute Coronary Syndrome
Authors: Niels P.G. Hoedemaker, Peter Damman, Pier Woudstra, Alexander Hirsch, Fons Windhausen, Jan G.P. Tijssen, Robbert J. de Winter, R.J.G. Peters, P.H.J.M. Dunselman, F.W.A. Verheugt, C.L. Janus, V. Umans, P.E.F. Bendermacher, H.R. Michels, A. Sadée, D. Hertzberger, R.J. Peters, P.A.R.M. de Miliano, A.H. Liem, R. Tjon Joe Gin, M. van der Linde, D. Lok, G. Hoedemaker, M. Pieterse, L. van den Merkhof, M. Daniëls, M. van Hessen, W. Hermans, C.E. Schotborgh, C. de Zwaan, A. Bredero, P. de Jaegere, M. Janssen, J. Louwerenburg, M. Veerhoek, M. Schalij, A. de Porto, F. Zijlstra, J. Winter, P. de Feyter, R. Robles de Medina, P. Withagen, M. Sedney, H. Thijssen, C. van Rees, P. van den Bergh, C. de Cock, A. van ’t Hof, M.J. Suttorp, R.J. de Winter, F. Windhausen, J.H. Cornel, J.G.P. Tijssen, F.W.A. Verheugt, P.H.J.M. Dunselman, P.J. de Feyter, H.R. Michels, R.J. de Winter, F. Windhausen, J.G.P. Tijssen, D. Düren, K. Liem, G.T.B. Sanders, J. Fischer, J. van Straalen
Journal: Journal of the American College of Cardiology (2017)

The ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial compared early invasive strategy with a selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and an elevated cardiac troponin T. No long-term benefit of an early invasive strategy was found at 1 and 5 years.The aim of this study was to determine the 10-year clinical outcomes of an early invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and an elevated cardiac troponin T.The ICTUS trial was a multicenter, randomized controlled clinical trial that included 1,200 patients with NSTE-ACS and an elevated cardiac troponin T. Enrollment was from July 2001 to August 2003. We collected 10-year follow-up of death, myocardial infarction (MI), and revascularization through the Dutch population registry, patient phone calls, general practitioners, and hospital records. The primary outcome was the 10-year composite of death or spontaneous MI. Additional outcomes included the composite of death or MI, death, MI (spontaneous and procedure-related), and revascularization.Ten-year death or spontaneous MI was not statistically different between the 2 groups (33.8% vs. 29.0%, hazard ratio [HR]: 1.12; 95% confidence interval [CI]: 0.97 to 1.46; p = 0.11). Revascularization occurred in 82.6% of the early invasive group and 60.5% in the selective invasive group. There were no differences in additional outcomes, except for a higher rate of death or MI in the early invasive group compared with the rates for the selective invasive group (37.6% vs. 30.5%; HR: 1.30; 95% CI: 1.07 to 1.58; p = 0.009), driven by a higher rate of procedure-related MI in the early invasive group (6.5% vs. 2.4%; HR: 2.82; 95% CI: 1.53 to 5.20; p = 0.001).In patients with NSTE-ACS and elevated cardiac troponin T levels, an early invasive strategy has no benefit over a selective invasive strategy in reducing the 10-year composite outcome of death or spontaneous MI, and a selective invasive strategy may be a viable option in selected patients.