Vroeg invasieve behandelstrategie niet beter dan selectief invasieve bij patiënten met een acuut coronair syndroom zonder ST-elevatie en met een verhoogde troponinewaarde: langetermijnresultaten van de ICTUS-studie

To determine whether routine coronary angiography followed by revascularisation where appropriate is better than initial drug treatment in patients with non-ST-segment elevation acute coronary syndromes (nSTE-ACS) and elevated troponin T concentrations.

Design

Multicentre randomised clinical trial (www.controlled-trials.com, number: SRCTN82153174).

Method

Patients with nSTE-ACS and elevated cardiac troponin were randomly assigned to an early invasive strategy or a selective invasive strategy. The early invasive strategy consisted of coronary angiography and revascularisation as indicated within 48 hours. The selective invasive strategy consisted of initial drug therapy; catheterisation was performed if the patient developed refractory angina or recurrent ischaemia. The main endpoints were a composite of death, recurrent myocardial infarction and rehospitalisation for anginal symptoms within 3 years, and all-cause mortality within 4 years.

Results

A total of 1200 patients were enrolled from 42 hospitals in the Netherlands. The in-hospital revascularisation rate was 76 in the early invasive group and 40 in the selective invasive group. After 3 years, the cumulative rate for the composite endpoint was 30.0 in the early invasive group and 26.0 in the selective invasive group (hazard ratio 1.21; 95 CI: 0.97-1.50; p = 0.09). The 4-year all-cause mortality rate was similar in both treatment groups (7.9 vs 7.7; p = 0.62).

Conclusion

Long-term follow-up of this trial suggests that an early invasive strategy is not better than a selective invasive strategy in patients with nSTE-ACS and elevated cardiac troponin. Therefore, implementation of either strategy is acceptable in these patients.

Ned Tijdschr Geneeskd. 2008;152:437-44