NEW YORK (Reuters Health) – Patients with non-ST-segment elevation acute coronary syndrome and elevated troponin T get no long term benefits from early invasive treatment as opposed to initial conservative management, new research from the Netherlands shows.

Dr. Robbert J. de Winter and his team at the University of Amsterdam conducted a 5-year follow-up study of participants in the ICTUS trial. Complete follow-up was available for 583 subjects randomized to a conservative strategy and 592 randomized to early invasive management.

The results appear in the December 30th online issue of the Journal of the American College of Cardiology.

Patients in the early invasive group had coronary angiography within 24 to 48 hours of presentation, and revascularization when called for. In the conservative group, a “selective invasive strategy” was used: patients were medically stabilized, and angiography and revascularization were done in cases of hemodynamic or rhythmic instability, refractory angina, or significant ischemia upon exercise testing.

During the initial hospitalization, revascularization was done in 76% of the routine invasive treatment group and 40% of conservative treatment patients.

The early invasive strategy did not improve 1- or 3-year rates of the composite of death, myocardial infarction (MI), or rehospitalization for angina, the authors note.

Overall 5-year mortality was 9.9% with the conservative approach versus 11.1% with the early invasive approach (p = 0.49). Rates of MI at 5 years were 11.7% with early invasive treatment and 13.9% in controls (p = 0.20).

There was no significant benefit from an early invasive treatment among groups stratified by risk.

In fact, there was evidence that an early invasive approach may be harmful. Early invasive therapy was associated with a higher cumulative death or MI rate (22.3% vs 18.1% with conservative therapy, p = 0.053), primarily due to an early increase in procedure-related myocardial infarctions and a trend toward higher late non-cardiovascular mortality.

A selective invasive strategy may be an attractive alternative in medically stabilized patients, Dr. de Winter’s group concludes.

In an editorial, Dr. John A. Bittl, from the Ocala Heart Institute, Florida, and Dr. David J. Maron at Vanderbilt University Medical Center, Nashville, Tennessee, comment that advantages of an early conservative approach include the ability to safely postpone invasive procedures in bleeding patients and to perform semi-elective invasive evaluations.

On the other hand, physicians may prefer an immediate procedure to avoid long hospital stays or discharging potentially high-risk patients.

“In the new era of comparative effectiveness research,” the editorialists point out, “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 non-ST-segment elevation acute myocardial infarction.”

Reference:
J Am Coll Cardiol 2009.