timing of intervention in patients with acute coronary syndromes (timacs) aha, 2008
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Timing of Intervention in Patients with Acute Coronary
Syndromes (TIMACS)
AHA, 2008
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Background
For UA/NSTEMI pts that are treated with an invasive strategy, the timing of catheterization has not been rigorously investigated.
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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
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• 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.
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End point HR (95% CI) p
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
Mehta SR et al. American Heart Association 2008 Scientific Sessions; November 10, 2008; New Orleans, LA.
Primary and secondary outcomes in TIMACS hazard ratio (95% CI), early vs delayed strategies
*Primary end point
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*Low/intermediate risk=GRACE score <140 High risk=GRACE score >140
Rates of death, MI, or stroke within six months according to GRACE risk level and HR (95% CI), early vs delayed
Mehta SR et al. American Heart Association 2008 Scientific Sessions; November 10, 2008; New Orleans, LA.
Risk level by GRACE score*
Early (%)
Delayed (%)
HR (95% CI) p
Low/intermediate (n=2070)
7.7 6.7 1.14 (0.82–1.58) 0.43
High (n=961) 14.1 21.6 0.65 (0.48–0.88) 0.005
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Arch Intern Med 2003;163:2345-2353
GRACE score – predicts the risk of in-hospital mortality
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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”.