The 5-year clinical results of ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) confirm and extend the one-year results of the trial, which found no evidence of an advantage for an early invasive strategy in the treatment of ACS. The 5-year paper is published online in the Journal of the American College of Cardiology.
ICTUS randomized 1,200 patients with ACS to an early invasive or selective invasive strategy. Here are the major results at 5 years:
Revascularization:
- early invasive: 81%
- selective invasive: 60%
Death or MI (p=0.053):
- early invasive: 22.3%
- selective invasive: 18.1%
The ICTUS investigators said the marginal increase in death or MI was largely driven by procedural MIs.
Commenting on the discrepancy between ICTUS and the 5 year results of RITA-3 and FRISC II, which did lend some support to the early invasive approach, the ICTUS investigators noted a higher rate of revascularization among their patients in the selective invasive group. In addition, ICTUS found no benefit for an early invasive approach for higher risk patients, who have been thought to be more likely to derive benefit from an early invasive strategy.
One drawback to the delayed approach is that the length of stay for ACS these days is considerably shorter than the 6-7 days observed in ICTUS, write John Bittl and David Maron in an accompanying editorial. On the other hand, the editorialists write that the findings of ICTUS “suggest that the timing of invasive evaluation can be flexible for most patients with NSTEMI.” A key to success, no matter which strategy is employed, is optimal medical therapy including aspirin, a thienopyridine, an antithrombin, beta blockade, statin therapy, intravenous nitroglycerin, and probably an ACE inhibitor, write the editorialists.
ICTUS is unlikely to dramatically change practice, write Bittl and Maron:
Until further research is completed, a dualistic approach will dominate the management of ACS. All patients with NSTEMI will require intensive medical therapy, and almost all patients will undergo invasive procedures. Angiographic approaches will prevail because the “plumbing model” of coronary artery disease comes up in bedside discussions of ACS more often than the new paradigm of endothelial dysfunction, arterial inflammation, and plaque rupture. In the new era of comparative effectiveness research, however, cost and quality metrics will be measured alongside hard clinical outcomes to ultimately define how various strategies reduce resource utilization and achieve optimal benefits for patients with NSTEMI.
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