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May 14, 2019 e959 Laurent Bonello, MD, PhD Marc Laine, MD Gilles Lemesle, MD, PhD To the Editor: We read with interest the results of the VERDICT study (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) reported by Kofoed et al1 regarding the optimal timing of the invasive strategy in non–ST-segment elevation acute coronary syndromes. Despite several trials on the subject, this delay remains a matter of debate. In their randomized clinical trial, the authors compared an early (<12 hours; mean 4.7 hours) and a delayed (48–72 hours; mean 61.6 hours) invasive strategy. These 2 strategies resulted in similar rates of the primary end point, which included all-cause death, recurrent myocardial infarction, refractory ischemia, and heart failure. Although the authors should be congratulated for their excellent work, we underline some limitations of the present trial. First, the definition of both the very early and delayed groups was not consistent with previous trials, the guidelines, and current practice.2,3 In fact, an invasive strategy <12 hours is not what we could call very early, which is rather used for delays <2 hours. Furthermore, delaying the invasive strategy for up to 48 hours in the control group is likely to increase costs and length of stay and delay diagnosis confirmation; more importantly, this does not reflect contemporary practice, in which it is often performed the day after the admission. This is not in line with current guidelines and available evidence suggesting an improved outcome with an invasive strategy within 24 hours.2,3 In addition, despite the large difference in delays between the 2 groups, the rate of recurrent ischemia was surprisingly low (6%) compared with previous trials (15%).3 Moreover, it tended to be lower in the delayed group than with the very early strategy, which is puzzling and in contradiction to previous trials and meta-analyses.3 This may be related to the definition or the recording of these events, in particular in patients who stayed at a remote site before transfer. Second, regarding the primary end point in the trial, the choice of a 4-year follow-up is a limitation, because the timing of the invasive strategy is unlikely to affect such a long-term outcome, and the potential benefit observed for early outcomes is likely to disappear with recurrent events in the long run.3 An interim analysis at 30 days would have been of interest. Third, only 43.5% of the patients received percutaneous coronary intervention after initial coronary anatomy evaluation. Such a rate of percutaneous coronary intervention is lower than recent trials on the topic, in which it ranged between 60% and 100%.2 This may reduce the ability of the early group to deliver on its promise. Besides, it could also be related to frequent differential diagnosis, which could have skewed the results. Finally, pretreatment with P2Y12-ADP (P2Y12 Adenosine Di Phosphate) receptor antagonists was used in all patients despite recent evidences suggesting that it could be harmful, in particular with fewer than half of the patients undergoing percuta© 2019 American Heart Association, Inc. LETTER TO THE EDITOR