No benefit from early PCI/CABG in high risk unstable angina patients

Patients with chest pain are recognized as being at high risk of subsequent adverse cardiac events when their plasma levels of cardiac troponin are elevated as evidence of myocardial damage.

Based on earlier studies, ESC and ACC/AHA guidelines recommend early angiography and PCI or CABG (early invasive strategy) in all these high risk patients. Dutch clinical investigators presented data during the Hotline II session on Sunday afternoon, August 29th, showing that modern medical treatment, and angiography followed by PCI or CABG in selected patients (selective invasive strategy), may be equally effective.

Patients were eligible when presenting with chest pain within 24 hours, an elevated cardiac troponin T and either ischemic electrocardiographic changes or a documented history of coronary artery disease. From July 2001 to August 2003, 1200 patients were randomized between an early invasive treatment strategy that included coronary angiography within 24-48 hrs, PCI within 48 hrs or CABG as soon as possible; or a selective invasive strategy that included medical stabilization and angiography and revascularization only in case of refractory angina or ischemia on pre-discharge exercise testing.

Background therapy included aspirin, enoxaparin for at least 48 hours, beta-blockers, nitrates, clopidogrel, high dose statin therapy (80mg atorvastatin or equivalent), and abciximab at the time of all percutaneous coronary intervention. All revascularization procedures were done at one of the 12 participating high volume intervention centers. The primary endpoint was the combination of death, myocardial infarction or rehospitalization for acute coronary syndrome at one year.

Mortality was only 2% in ICTUS, considering these were high risk troponin-positive patients. There were significantly more myocardial infarctions in the early invasive strategy compared to the selective invasive strategy: 14.6% versus 9.4%. However, the number of rehospitalizations was higher in the selective invasive group. Thus, the outcome was comparable between the two treatment strategies, albeit with 25% less invasive procedures in the selective invasive treatment group.

The ICTUS investigators conclude that their study shows that early invasive and selective invasive strategies are equivalent treatment options in patients with nSTE-ACS and an elevated cardiac troponin. The findings in ICTUS challenge the current ESC and ACC/AHA guidelines on the management of nSTE-ACS patients.