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Early Invasive Strategy Benefits Patients with Acute Coronary Syndrome and Elevated Troponins

In the recent TACTICS-TIMI 18 study, patients with unstable angina or non–ST-segment-elevation myocardial infarction were randomized to early invasive treatment (angiography within 48 hours) or conservative treatment (angiography and revascularization if patients had recurrent ischemia at rest or with provocative testing, despite medical therapy); those who underwent early invasive treatment had significantly reduced rates of a combined endpoint of death, nonfatal MI, and rehospitalization for acute coronary syndrome (JW Aug 1 2001, p. 119, accession number 010713001, and N Engl J Med 2001; 344:1879). Now, in this prespecified secondary analysis, the investigators evaluated the effect of baseline troponin levels on the benefit derived from early invasive treatment.

Among patients with elevated troponin I (0.1 mg/dL), the combined endpoint occurred significantly less often among those who underwent early invasive treatment than among those who received conservative treatment (15.3 percent vs. 25 percent); even patients with modest elevations (0.1-0.4 mg/dL) derived significant benefit from the invasive approach. Patients with troponin levels lower than 0.1 mg/dL showed no discernible benefit from early invasive treatment (16 percent vs. 12.4 percent with conservative treatment).

Comment: These data provide additional support for an early invasive strategy in patients with acute coronary syndrome who have elevated troponin levels. Editorialists warn that problems with standardization and precision of some assays may complicate widespread clinical application of these data and that clinical context remains crucial. It's also important to remember that biochemical markers of necrosis are only 1 component in identifying high-risk patients.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine December 21, 2001

Citation(s):

Morrow DA et al. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: Results from a randomized trial. JAMA 2001 Nov 21 286 2405-2412.

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• Medline abstract (Free)

Quinn MJ and Moliterno DJ. Troponins in acute coronary syndromes: More TACTICS for an early invasive strategy. JAMA 2001 Nov 21 286 2461-2462.

• Original article (Subscription may be required)
• Medline abstract (Free)