Reviewed by Dr. Richard Mills
Hoedemaker, Niels PG, et al. Journal of the American College of Cardiology 69.15 (2017): 1883-1893

SUMMARY
While there is a clear, emergent indication for coronary angiography and PCI in patients presenting with STEMI, the need for and optimal timing of angiography in unstable angina (USA) and NSTEMI is more ambiguous. The ICTUS trial is one among several randomized control trials designed to answer whether patients presenting with USA or NSTEMI should routinely have coronary angiography +/- PCI within 24-72 hours of incident event. In this trial, 1200 patients admitted to 42 Dutch hospitals with USA or NSTEMI were randomly assigned to either receive early invasive angiography within 24-48 hours of admission or ‘selective angiography’ only in settings of continued chest pain or inducible ischemia on stress test prior to discharge. All patients received optimal medical therapy with aspirin, clopidogrel, enoxaparin, beta blockers, nitrates, and statin. This trial describes the 10 year follow up results. The primary outcome was a composite of all-cause death or incident myocardial infarction. The two arms of the trial were well-balanced. In the early invasive group, 97% of patients underwent coronary angiography +/- PCI during the hospitalization, compared to 53% in the selective invasive group. The primary outcome of all-cause death or MI occurred in 37.6% of patients in the early invasive group compared to 30.4% in the selective invasive group (HR 1.3 (1.07-1.58) p=0.009). The selective advantage for the selective invasive group may have been driven by a higher rate of procedure-related MI in the early invasive group (6.5% vs 2.4% p=0.0001). There was no difference in 10-year death or spontaneous MI between the early invasive and selective invasive arms.

COMMENTARY
This trial showed no benefit in the early invasive strategy of performing coronary angiography within 24-48 hours of presentation with USA or NSTEMI. There was no difference in 10 year death or spontaneous MI in the early invasive or selective invasive groups, although the early invasive group suffered from more procedure-related MIs. It should be noted, however, that over half the patients in the selective invasive group underwent coronary angiography during the incident hospitalization. Every patient in the selective invasive group underwent stress testing prior to discharge, which may not be feasible at a hospital like Parkland. Nevertheless, this study shows that in patients with NSTEMI or USA, it is reasonable to treat medically unless they exhibit high risk features such as peaking troponins, hemodynamic changes, inducible ischemia, or refractory angina.

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