Author + information
- Joshua Schulman-Marcus, MD∗ ( and )
- William E. Boden, MD
- ↵∗Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, New York 12208
We read with interest the findings of Hoedemaker et al. (1) regarding the 10-year follow-up from the ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial investigators, who did not observe a reduction in long-term mortality or spontaneous myocardial infarction in non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients undergoing an early invasive strategy. As the authors noted, these findings corroborate and extend similar findings from the RITA-3 (Randomized Intervention Trial of unstable Angina) long-term follow-up study (2). Such neutral findings of late benefit for the routine early invasive strategy in NSTE-ACS subjects have reasonably led to questions of whether current guidelines favoring this approach should be re-evaluated (3).
When interpreting trials such as ICTUS and RITA-3, it is essential to underscore that they compared initial diagnostic strategies, not early revascularization per se, versus optimal medical therapy. Individual site operators made revascularization decisions, and neither procedural details nor anatomic findings were consistently reported. Undoubtedly, some NSTE-ACS patients benefit from revascularization for high-risk anatomic coronary disease discovered by early coronary angiography. However, it also appears that not all early revascularization procedures for NSTE-ACS result in improved outcomes, as the ICTUS results demonstrate (1). In fact, a reasonable interpretation is that the additional 22% of patients who underwent revascularization in the early invasive arm of ICTUS gained little incremental benefit in outcomes but were exposed to the potential risks of revascularization (e.g., bleeding, periprocedural myocardial infarction, vascular complications). Thus, it is possible that this subset of patients would have fared just as well without revascularization, especially given the significant advances in contemporary optimal medical therapy over the past 2 decades.
In summary, the ICTUS findings suggest that much remains unknown about which patients benefit from early revascularization in NSTE-ACS. A reconsideration of this treatment premise with updated observational and trials data examining clinical outcomes is warranted. If ICTUS is a guide, the results may prove surprising.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Deepak L. Bhatt, MD, MPH, served as Guest Editor-in-Chief for this paper. Anthony Bavry, MD, served as Guest Editor for this paper.
- 2017 American College of Cardiology Foundation
- Hoedemaker N.P.,
- Damman P.,
- Woudstra P.,
- et al.
- Henderson R.A.,
- Jarvis C.,
- Clayton T.,
- Pocock S.J.,
- Fox K.A.
- Patel M.R.,
- Ohman E.M.