The conservative arm had no recurrent rest symptoms on therapy, and negative stress tests prior to discharge. In terms of “subtraction anxiety”, to me that is quite different from “you have a 90% prox LAD that we are leaving alone….but you go and have yourself a great day”.
It is interesting that this trial was really looking at UA patients….since many/most patients with actual NSTEMI (by virtue of biomarker rise) would have been excluded. I would take this info in conjunction with ICTUS, where biomarker rise alone was also NOT a good discriminator for benefit with early invasive strategy.
So for me, this really underscores that an early invasive strategy for NSTE-ACS should be used for NSTEMI pts who have enrichment factors a la TIMI risk score, as was demonstrated by TACTICS (although I also note that one can attain intermediate to high risk TIMI scores without biomarker elevation).
Great points, Steve! We are going to review ICTUS next.
We agree that we should be selective in early invasive strategy for NSTEMI. Patient's risk factors, age and size of the infarct, all affect the treatment effect. An invasive strategy for all comers is not the right thing to do.
Thank you... very interested in your last point about hsTriponin... how do you think this new sensitivity will impact treatment in the US? Can you elaborate on that last point? Thanks again
Great question. The new troponin assays now detect smaller myocardial infarctions compared to older troponin assays. The degree of troponin elevation predicts worse outcomes. Invasive strategy for small myocardial infarctions may not be beneficial.
The conservative arm had no recurrent rest symptoms on therapy, and negative stress tests prior to discharge. In terms of “subtraction anxiety”, to me that is quite different from “you have a 90% prox LAD that we are leaving alone….but you go and have yourself a great day”.
It is interesting that this trial was really looking at UA patients….since many/most patients with actual NSTEMI (by virtue of biomarker rise) would have been excluded. I would take this info in conjunction with ICTUS, where biomarker rise alone was also NOT a good discriminator for benefit with early invasive strategy.
So for me, this really underscores that an early invasive strategy for NSTE-ACS should be used for NSTEMI pts who have enrichment factors a la TIMI risk score, as was demonstrated by TACTICS (although I also note that one can attain intermediate to high risk TIMI scores without biomarker elevation).
Great points, Steve! We are going to review ICTUS next.
We agree that we should be selective in early invasive strategy for NSTEMI. Patient's risk factors, age and size of the infarct, all affect the treatment effect. An invasive strategy for all comers is not the right thing to do.
Thank you... very interested in your last point about hsTriponin... how do you think this new sensitivity will impact treatment in the US? Can you elaborate on that last point? Thanks again
Great question. The new troponin assays now detect smaller myocardial infarctions compared to older troponin assays. The degree of troponin elevation predicts worse outcomes. Invasive strategy for small myocardial infarctions may not be beneficial.