Early Invasive Versus Selective Strategy for Non-ST-Segment Elevation Acute Coronary Syndrome: The ICTUS Trial

J Am Coll Cardiol. 2017 Apr 18;69(15):1883-1893. doi: 10.1016/j.jacc.2017.02.023.


Background: The ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial compared early invasive strategy with a selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and an elevated cardiac troponin T. No long-term benefit of an early invasive strategy was found at 1 and 5 years.

Objectives: The aim of this study was to determine the 10-year clinical outcomes of an early invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and an elevated cardiac troponin T.

Methods: The ICTUS trial was a multicenter, randomized controlled clinical trial that included 1,200 patients with NSTE-ACS and an elevated cardiac troponin T. Enrollment was from July 2001 to August 2003. We collected 10-year follow-up of death, myocardial infarction (MI), and revascularization through the Dutch population registry, patient phone calls, general practitioners, and hospital records. The primary outcome was the 10-year composite of death or spontaneous MI. Additional outcomes included the composite of death or MI, death, MI (spontaneous and procedure-related), and revascularization.

Results: Ten-year death or spontaneous MI was not statistically different between the 2 groups (33.8% vs. 29.0%, hazard ratio [HR]: 1.12; 95% confidence interval [CI]: 0.97 to 1.46; p = 0.11). Revascularization occurred in 82.6% of the early invasive group and 60.5% in the selective invasive group. There were no differences in additional outcomes, except for a higher rate of death or MI in the early invasive group compared with the rates for the selective invasive group (37.6% vs. 30.5%; HR: 1.30; 95% CI: 1.07 to 1.58; p = 0.009), driven by a higher rate of procedure-related MI in the early invasive group (6.5% vs. 2.4%; HR: 2.82; 95% CI: 1.53 to 5.20; p = 0.001).

Conclusions: In patients with NSTE-ACS and elevated cardiac troponin T levels, an early invasive strategy has no benefit over a selective invasive strategy in reducing the 10-year composite outcome of death or spontaneous MI, and a selective invasive strategy may be a viable option in selected patients.

Keywords: invasive treatment; long-term outcome; non–ST-segment elevation myocardial infarction.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Acute Coronary Syndrome* / diagnosis
  • Acute Coronary Syndrome* / mortality
  • Acute Coronary Syndrome* / therapy
  • Aged
  • Comparative Effectiveness Research
  • Conservative Treatment* / adverse effects
  • Conservative Treatment* / methods
  • Coronary Angiography / methods
  • Electrocardiography / methods*
  • Female
  • Follow-Up Studies
  • Humans
  • Long Term Adverse Effects* / diagnosis
  • Long Term Adverse Effects* / epidemiology
  • Long Term Adverse Effects* / etiology
  • Male
  • Myocardial Infarction* / diagnosis
  • Myocardial Infarction* / epidemiology
  • Myocardial Infarction* / etiology
  • Myocardial Revascularization* / adverse effects
  • Myocardial Revascularization* / methods
  • Netherlands
  • Outcome and Process Assessment, Health Care
  • Patient Selection
  • Survival Analysis
  • Time-to-Treatment
  • Troponin T / analysis


  • Troponin T