title: Early invasive versus selectively invasive management for acute coronary syndromes.
abstract: BACKGROUND
  Current guidelines recommend an early invasive strategy for patients who have acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level. However, randomized trials have not shown an overall reduction in mortality, and the reduction in the rate of myocardial infarction in previous trials has varied depending on the definition of myocardial infarction.
  
  
  METHODS
  We randomly assigned 1200 patients with acute coronary syndrome without ST-segment elevation who had chest pain, an elevated cardiac troponin T level (> or =0.03 mug per liter), and either electrocardiographic evidence of ischemia at admission or a documented history of coronary disease to an early invasive strategy or to a more conservative (selectively invasive) strategy. Patients received aspirin daily, enoxaparin for 48 hours, and abciximab at the time of percutaneous coronary intervention. The use of clopidogrel and intensive lipid-lowering therapy was recommended. The primary end point was a composite of death, nonfatal myocardial infarction, or rehospitalization for anginal symptoms within one year after randomization.
  
  
  RESULTS
  The estimated cumulative rate of the primary end point was 22.7 percent in the group assigned to early invasive management and 21.2 percent in the group assigned to selectively invasive management (relative risk, 1.07; 95 percent confidence interval, 0.87 to 1.33; P=0.33). The mortality rate was the same in the two groups (2.5 percent). Myocardial infarction was significantly more frequent in the group assigned to early invasive management (15.0 percent vs. 10.0 percent, P=0.005), but rehospitalization was less frequent in that group (7.4 percent vs. 10.9 percent, P=0.04).
  
  
  CONCLUSIONS
  We could not demonstrate that, given optimized medical therapy, an early invasive strategy was superior to a selectively invasive strategy in patients with acute coronary syndromes without ST-segment elevation and with an elevated cardiac troponin T level.
authors.affiliation: Academisch Medisch Centrum, Amsterdam, Netherlands. r.j.dewinter@amc.uva.nl
authors.forename: Robbert J
authors.initials: RJ
authors.lastname: de Winter
authors.forename: Fons
authors.initials: F
authors.lastname: Windhausen
authors.forename: Jan Hein
authors.initials: JH
authors.lastname: Cornel
authors.forename: Peter H J M
authors.initials: PH
authors.lastname: Dunselman
authors.forename: Charles L
authors.initials: CL
authors.lastname: Janus
authors.forename: Peter E F
authors.initials: PE
authors.lastname: Bendermacher
authors.forename: H Rolf
authors.initials: HR
authors.lastname: Michels
authors.forename: Gerard T
authors.initials: GT
authors.lastname: Sanders
authors.forename: Jan G P
authors.initials: JG
authors.lastname: Tijssen
authors.forename: Freek W A
authors.initials: FW
authors.lastname: Verheugt
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000789:Angina, Unstable / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality / Q000517:prevention & control / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012306:Risk; D055502:Secondary Prevention; D020107:Troponin T / Q000097:blood
chemical_list: D010975:Platelet Aggregation Inhibitors; D020107:Troponin T