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EXPEDITED PUBLICATION

5-Year Clinical Outcomes in the ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) Trial

A Randomized Comparison of an Early Invasive Versus Selective Invasive Management in Patients With Non–ST-Elevation Acute Coronary Syndrome

From the Department of Cardiology, Academic Medical Center–University of Amsterdam, Amsterdam, the Netherlands

Manuscript received August 3, 2009; revised manuscript received November 5, 2009, accepted November 20, 2009.

^_* Reprint requests and correspondence: Dr. Robbert J. de Winter, Department of Cardiology, Cardiac Catheterization Laboratory B2-137, Academic Medical Center-University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (Email: r.j.dewinter{at}amc.uva.nl).

Objectives: We present the 5-year clinical outcomes according to treatment strategy with additional risk stratification of the ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) trial.

Background: Long-term outcomes may be relevant to decide treatment strategy for patients presenting with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) and elevated troponin T.

Methods: We randomly assigned 1,200 patients to an early invasive or selective invasive strategy. The outcomes were the composite of death or myocardial infarction (MI) and its individual components. Risk stratification was performed with the FRISC (Fast Revascularization in InStability in Coronary artery disease) risk score.

Results: At 5-year follow-up, revascularization rates were 81% in the early invasive and 60% in the selective invasive group. Cumulative death or MI rates were 22.3% and 18.1%, respectively (hazard ratio [HR]: 1.29, 95% confidence interval [CI]: 1.00 to 1.66, p = 0.053). No difference was observed in mortality (HR: 1.13, 95% CI: 0.80 to 1.60, p = 0.49) or MI (HR: 1.24, 95% CI: 0.90 to 1.70, p = 0.20). After risk stratification, no benefit of an early invasive strategy was observed in reducing death or spontaneous MI in any of the risk groups.

Conclusions: In patients presenting with NSTE-ACS and elevated troponin T, we could not demonstrate a long-term benefit of an early invasive strategy in reducing death or MI. (Invasive versus Conservative Treatment in Unstable coronary Syndromes [ICTUS]; ISRCTN82153174)

Key Words: NSTE-ACS • treatment strategy • long-term outcomes

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   HR = hazard ratio   MI = myocardial infarction   NSTE-ACS = non–ST-segment elevation acute coronary syndrome   PCI = percutaneous coronary intervention

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