Transcript Document

Timing of Intervention in
Patients with Acute Coronary
Syndromes (TIMACS)
AHA, 2008
Background
For UA/NSTEMI pts that are treated with
an invasive strategy, the timing of
catheterization has not been rigorously
investigated.
TIMACS: Methods
• Pts with UA/NSTEMI randomized to early
invasive strategy (angiography within 24 hrs)
or delayed invasive strategy (angiography any
time after 36 hrs).
• Primary endpoint:
- composite of death, new MI, or CVA at 6
months.
• Secondary endpoints:
- death, new MI, or refractory ischemia
- death, new MI, CVA, refractory ischemia,
repeat revascularization
- CVA
• 3,031 pts enrolled (1,593 pts in early invasive
strategy – median time to cath 14 hrs; 1,438 pts in
delayed invasive strategy – median time to cath 50
hrs).
• Mean age 65.4 yrs; 35% females.
• 77% pts with NSTEMI
• 27% pts with DM; 20% pts with h/o MI
• ASA (98%), Thienopyridine (87%), BBlockers
(86.9%), Statins (85%), LMWH (64.3%), UFH
(24.6%), Fondaparinux (41.5%, part of the pts were
enrolled in OASIS), gp2b/3a (23%), bivalirudin
(0.5%).
• 25% pts crossed from delayed to early strategy
(refractory ischemia, new MI or instability). 12%
crossed from early to delayed strategy.
Primary and secondary outcomes in TIMACS
hazard ratio (95% CI), early vs delayed
strategies
End point
HR (95% CI)
Death, MI, stroke*
0.85 (0.68–1.06) 0.15
Death, MI, refractory
ischemia
0.72 (0.58–0.89) 0.002
Death, MI, stroke,
refractory ischemia,
repeat intervention
0.84 (0.71–0.99) 0.039
Refractory ischemia
0.30 (0.17–0.53) <0.00001
*Primary end point
Mehta SR et al. American Heart Association 2008 Scientific
Sessions; November 10, 2008; New Orleans, LA.
p
Rates of death, MI, or stroke within six
months according to GRACE risk level and
HR (95% CI), early vs delayed
Risk level by Early Delayed HR (95% CI)
GRACE score* (%) (%)
Low/
intermediate
(n=2070)
7.7
6.7
High (n=961) 14.1 21.6
p
1.14 (0.82–1.58) 0.43
0.65 (0.48–0.88) 0.005
*Low/intermediate risk=GRACE score <140
High risk=GRACE score >140
Mehta SR et al. American Heart Association 2008 Scientific
Sessions; November 10, 2008; New Orleans, LA.
GRACE score – predicts the risk of in-hospital mortality
Arch Intern Med 2003;163:2345-2353
TIMACS: Conclusions
• Early invasive strategy in pts with UA/NSTEMI is
not superior to delayed invasive strategy with
regard to the composite of death, new MI and
CVA at 6 months, unless pt is high risk (as
assessed by the GRACE risk model).
• Early invasive strategy is superior in reducing
the incidence of refractory angina without
increasing the risk of bleeding.
• Early invasive strategy can be implemented very
early after pt’s admission – no benefit in
“cooling pt off”.