Author + information
- Niels P.G. Hoedemaker, MD,
- Peter Damman, MD, PhD and
- Robbert J. de Winter, MD, PhD∗ ()
- ↵∗Department of Cardiology, Heart Centre, Academic Medical Center, University of Amsterdam, B2-137, PO Box 22660, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
We thank Drs. Schulman-Marcus and Boden for their interest regarding our recent publication showing long-term comparable outcomes after a routine invasive versus selective invasive treatment strategy in non–ST-segment elevation acute coronary syndrome (NSTE-ACS) (1).
In their letter, they underscore the fact that trials such as ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) compare initial diagnostic strategies, not early revascularization, versus optimal medical therapy. This comment is of paramount importance in a comparison of the ICTUS results with those of other randomized trials that did show a mortality benefit with routine intervention. If the ICTUS data are analyzed retrospectively and actual revascularization is compared with optimal medical therapy, actual revascularization was associated with lower mortality and fewer myocardial infarctions (2). However, in a comparison of routine invasive versus selective invasive diagnostic (or treatment) strategies, comparable outcomes are observed. Although trials showing a benefit of a routine invasive strategy have a comparator strategy arm more closely resembling optical medical therapy, in the ICTUS trial, the comparator selective invasive strategy leads to in-hospital revascularization in 40% of patients.
Although we agree that revascularization is associated with procedure-related adverse outcomes, no differences in bleeding were observed between a routine invasive and selective invasive strategy. Procedure-related myocardial infarction was significantly more common with routine intervention but not related with long-term mortality (3).
Therefore, we believe that neither harm nor benefit is associated with routine intervention in NSTE-ACS. However, most of these trials were performed more than a decade ago. It is time for an adequately powered trial comparing a routine invasive with a selective invasive strategy in the current era of radial access, drug-eluting stents, high-sensitivity troponin assays, and novel pharmacological therapies. Novel imaging methods may support identification of NSTE-ACS patients with a high-risk anatomic coronary disease who might benefit from routine revascularization.
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
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