Sabatine Marc S, Morrow David A, Giugliano Robert P, Murphy Sabina A, Demopoulos Laura A, DiBattiste Peter M, Weintraub William S, McCabe Carolyn H, Antman Elliott M, Cannon Christopher P, Braunwald Eugene
TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
Circulation. 2004 Feb 24;109(7):874-80. doi: 10.1161/01.CIR.0000112604.74713.35. Epub 2004 Feb 2.
TIMI IIIB and TACTICS-TIMI 18 were 2 trials of an early invasive strategy in unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI) that were conducted nearly a decade apart but with virtually identical enrollment criteria and designs, except that upstream glycoprotein IIb/IIIa inhibition was mandated and coronary artery stenting was routinely used in TACTICS-TIMI 18. We sought to examine the effect of these advances on clinical outcomes and the benefits of an early invasive strategy in UA/NSTEMI.
Patients were stratified on the basis of their TIMI risk score into low-, intermediate-, and high-risk categories. Within each risk category, the rates of clinical outcomes and the benefit of an early invasive strategy were compared. Compared with patients in TIMI IIIB and adjusting for baseline risk, patients in TACTICS-TIMI 18 had lower rates of death, MI, or rehospitalization for acute coronary syndromes (OR, 0.62; P<0.0001). Across both trials, the benefit of an early invasive strategy was significantly greater with increasing baseline risk: OR, 1.39 in low-risk, 0.80 in intermediate-risk, and 0.57 in high-risk patients (P< or =0.004 for interactions). After adjustment for baseline risk, an early invasive strategy tended toward a more favorable result in TACTICS-TIMI 18 than in TIMI IIIB (OR, 0.79; 95% CI, 0.56 to 1.11).
Advances in the care of patients with UA/NSTEMI, including glycoprotein IIb/IIIa inhibition and stenting, were associated with lower rates of death, MI, and rehospitalization for acute coronary syndromes and a trend toward a greater benefit of an early invasive strategy.
TIMI IIIB试验和TACTICS - TIMI 18试验是针对不稳定型心绞痛（UA）/非ST段抬高型心肌梗死（NSTEMI）的早期侵入性策略进行的两项试验，这两项试验相隔近十年，但除了TACTICS - TIMI 18试验中强制使用上游糖蛋白IIb/IIIa抑制剂并常规应用冠状动脉支架置入术外，入选标准和设计几乎相同。我们试图研究这些进展对临床结局的影响以及早期侵入性策略在UA/NSTEMI中的益处。
根据TIMI风险评分将患者分为低、中、高风险类别。在每个风险类别中，比较临床结局发生率和早期侵入性策略的益处。与TIMI IIIB试验中的患者相比，并校正基线风险后，TACTICS - TIMI 18试验中的患者发生死亡、心肌梗死或因急性冠状动脉综合征再次住院的发生率较低（OR，0.62；P<0.0001）。在两项试验中，随着基线风险增加，早期侵入性策略的益处显著增大：低风险患者中OR为1.39，中风险患者中为0.80，高风险患者中为0.57（交互作用P≤0.004）。校正基线风险后，TACTICS - TIMI 18试验中早期侵入性策略的结果比TIMI IIIB试验更倾向于有利（OR，0.79；95%CI，0.56至1.11）。
UA/NSTEMI患者治疗方面的进展，包括糖蛋白IIb/IIIa抑制和支架置入术，与急性冠状动脉综合征的死亡、心肌梗死和再次住院发生率降低以及早期侵入性策略有更大益处的趋势相关。
