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TIMACS: Early intervention did not prevent death, MI, stroke
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An early invasive strategy in patients with acute coronary syndromes did not differ from a delayed invasive strategy, study results suggested.
Researchers for the Timing of Intervention in Patients with Acute Coronary Syndromes (TIMACS) study enrolled 3,031 patients with non-ST elevation ACS into the international, randomized study. Patients were randomly assigned after having either unstable angina or non-ST elevation MI to either an early intervention group that received coronary angiography followed by either CABG or percutaneous coronary intervention as soon as possible (n=1,593) or a delayed intervention group receiving coronary angiography at any time beyond 36 hours followed by either CABG or PCI (n=1,438). The primary outcome was death, MI or stroke at 180 days.
According to the study results, there was no difference between the groups for the primary outcome (HR=0.85; 95% CI, 0.68-1.06). For the secondary endpoint of death, MI or refractory ischemia at 180 days, a benefit from early intervention was observed vs. delayed intervention (HR=0.72; 95% CI, 0.58-0.79). A 16% RR reduction was also observed for the secondary endpoint of death, MI, stroke, refractory ischemia or repeat intervention (HR=0.84; 95% CI, 0.71-0.99). The researchers also reported a difference between the study groups according to baseline risk. Using the GRACE risk score, patients receiving early intervention who were classified as high risk (GRACE score >140, n=961) had lower rates of death, MI or stroke at six months than those treated with delayed intervention (14.1% vs. 21.6%; HR=0.65; 95% CI, 0.48-0.88).
For more information:
- Mehta S. LBCT II, #1313. Presented at: American Heart Association Scientific Sessions; Nov. 8-12, 2008; New Orleans.
We know from TIMACS that there definitely was no evidence of harm with early intervention strategy and therefore no need to cool off patients, so the cooling-off hypothesis has finally been refuted. Hard endpoints were each numerically lower, and bleeding rates were numerically lower as well with an early strategy. There was no statistically significant difference in the primary endpoint, and so hospitals that cath within the first few days of an index hospitalization can continue to do so. If there is recurrent ischemia, they can cath right away, and this is still consistent with evidence-based medicine. There is a strong suggestion that earlier is better, especially if patients are at high risk. From the patient’s perspective, it is better to cath earlier. There is nothing to lose with potential to gain. So if it were me, take me early.
– Deepak L. Bhatt, MD
Cardiology Today Editorial Board member