Letters to the editor

In a recent editorial, Dr Christopher P. Cannon reviewed the published studies comparing invasive with conservative treatment strategies in patients with non-STelevation acute coronary syndrome (NSTE-ACS). He concluded that it has been very clearly shown that an early invasive approach to all patients with NSTE-ACS is beneficial. Dr Cannon didn’t mention the Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) trial. This study was presented at a Hot Line session at the European Society of Cardiology Congress 2004 in Munich, Germany. This study set out to determine whether an early invasive strategy was superior to a more selective strategy in 1200 patients presenting with NSTE-ACS. Patientswere randomly assigned toeither an early invasive treatment strategy or a selective strategy. The early invasive strategy included angiography within 24–48 h, percutaneous coronary intervention within 48 h, or coronary bypass surgery as soon as possible; the selective strategy included medical stabilization and angiography, and revascularization only with refractory angina or ischaemia on pre-discharge exercise testing. Lead ICTUS investigator Robbert de Winter (University of Amsterdam, The Netherlands) reported that the primary composite endpoint of death, myocardial infarction, or ACS re-hospitalization at 1 year occurred similarly in both groups. This important study implies that all patients with NSTE-ACS should undergo risk stratification assessment and only the high risk patients should promptly be treated invasively, since not all patients with NSTE-ACS would benefit from an early invasive approach.