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Routine vs. Selective Invasive Management for Acute Coronary Syndromes

In contrast to previous findings, results of a new randomized study indicate no advantage for a strategy of routine early angiography.

Current guidelines recommend early angiography and revascularization as necessary in high-risk patients who have acute coronary syndromes without ST-segment elevation. These investigators randomized 1200 such patients, all of whom had elevated troponin T levels, to one of two approaches: an early invasive strategy of routine angiography in all patients, or a more selective approach reserving angiography for refractory symptoms, hemodynamic or arrhythmic instability, or substantial ischemia identified by predischarge stress testing. Patients received aggressive medical management with aspirin and enoxaparin (plus abciximab for those undergoing percutaneous coronary intervention [PCI]); clopidogrel and intensive lipid-lowering therapy were recommended as well.

At 1 year, the primary endpoint (death, myocardial infarction, or rehospitalization for angina) had been reached by 22.7% of patients in the invasive arm and by 21.2% in the selective arm — a nonsignificant difference. Mortality rates were low (2.5% in both groups). MI was significantly more common in the invasive arm (15% vs. 10%), but rehospitalization occurred significantly less frequently (7.4% vs. 10.9%).

Comment: The results of this study, in contrast to several others (e.g., Journal Watch Jul 13 2001), did not demonstrate superior outcomes with an early invasive strategy. The higher rate of MI in the invasive arm appears related to a stringent definition for the periprocedural enzyme leaks that often accompany PCI. Although this one study probably won’t change current guidelines, it is sure to reopen the debate about the risks and benefits of a routine early invasive approach.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine September 30, 2005

Citation(s):

de Winter RJ et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005 Sep 15; 353:1095-104.

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

Boden WE. Acute coronary syndromes without ST-segment elevation — What is the role of early intervention? N Engl J Med 2005 Sep 15; 353:1159-61.

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