"Early Versus Delayed Intervention in Acute Coronary Syndromes". The New England Journal of Medicine. 2009. 360(21):2165-2175. PubMed
Links to original sources: Wiki Journal Post Full Journal Article
Does early intervention improve outcomes compared to delayed intervention in patients with acute coronary syndromes without ST-segment elevation?
In patients with acute coronary syndromes without ST-segment elevation, early intervention did not significantly improve the primary outcome of death, myocardial infarction, or stroke compared to a delayed intervention, but it did reduce the rate of secondary outcomes such as refractory ischemia and was superior in high-risk patients.
Earlier trials demonstrated that routine invasive strategies improve outcomes in patients with acute coronary syndromes without ST-segment elevation. The optimal timing of such interventions was uncertain. The Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial showed no significant difference in the primary outcome between early and delayed intervention strategies over six months. However, early intervention reduced refractory ischemia occurrences and provided significant benefits for high-risk patients.
Current guidelines recommend risk stratification for patients with acute coronary syndromes, suggesting that an invasive strategy is generally safe, and the decision between early or delayed intervention may be based on patient risk levels and facility availability.
- Multicenter, randomized, parallel-group trial - N=3,031 patients with acute coronary syndromes - Early intervention (coronary angiography within 24 hours) vs. delayed intervention (coronary angiography after at least 36 hours) - Mean follow-up: 6 months
- Adults with unstable angina or myocardial infarction without ST-segment elevation and at least two of the following risk factors: age ≥60, elevated cardiac biomarkers, or ECG changes indicative of ischemia
- Early intervention group underwent coronary angiography within 24 hours of randomization - Delayed intervention group underwent coronary angiography after a minimum of 36 hours post-randomization
- Primary: Composite of death, myocardial infarction, or stroke at 6 months - Secondary: Composite of death, myocardial infarction, or refractory ischemia at 6 months - Other outcomes included the individual components of the primary and secondary outcomes
- The trial might have been underpowered to detect small differences in the primary outcome. - The trial did not include a conservative-therapy group for comparison.
- Supported by the Canadian Institutes of Health Research, OASIS-5 study sponsors (including GlaxoSmithKline, Sanofi-Aventis, Organon NV), a New Investigator Award from the Canadian Institutes of Health Research, and the Heart and Stroke Foundation of Ontario.
- Additional details about the TIMACS trial can be found in the New England Journal of Medicine, supplementary material, and registered protocols on ClinicalTrials.gov (NCT00552513).