Comparison of Early Invasive and Conservative Strategies in Patients with Unstable Coronary Syndromes Treated with the Glycoprotein IIb/IIIa Inhibitor Tirofiban
Christopher P. Cannon, M.D., William S. Weintraub, M.D., Laura A. Demopoulos, M.D., Ralph Vicari, M.D., Martin J. Frey, M.D., Nasser Lakkis, M.D., Franz-Josef Neumann, M.D., Debbie H. Robertson, R.D., M.S., Paul T. DeLucca, Ph.D., Peter M. DiBattiste, M.D., C. Michael Gibson, M.D., Eugene Braunwald, M.D., for the TACTICS–Thrombolysis in Myocardial Infarction 18 Investigators
Background There is continued debate as to whether a routine,early invasive strategy is superior to a conservative strategyfor the management of unstable angina and myocardial infarctionwithout ST-segment elevation.
Methods We enrolled 2220 patients with unstable angina and myocardialinfarction without ST-segment elevation who had electrocardiographicevidence of changes in the ST segment or T wave, elevated levelsof cardiac markers, a history of coronary artery disease, orall three findings. All patients were treated with aspirin,heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban.They were randomly assigned to an early invasive strategy, whichincluded routine catheterization within 4 to 48 hours and revascularizationas appropriate, or to a more conservative (selectively invasive)strategy, in which catheterization was performed only if thepatient had objective evidence of recurrent ischemia or an abnormalstress test. The primary end point was a composite of death,nonfatal myocardial infarction, and rehospitalization for anacute coronary syndrome at six months.
Results At six months, the rate of the primary end point was15.9 percent with use of the early invasive strategy and 19.4percent with use of the conservative strategy (odds ratio, 0.78;95 percent confidence interval, 0.62 to 0.97; P=0.025). Therate of death or nonfatal myocardial infarction at six monthswas similarly reduced (7.3 percent vs. 9.5 percent; odds ratio,0.74; 95 percent confidence interval, 0.54 to 1.00; P<0.05).
Conclusions In patients with unstable angina and myocardialinfarction without ST-segment elevation who were treated withthe glycoprotein IIb/IIIa inhibitor tirofiban, the use of anearly invasive strategy significantly reduced the incidenceof major cardiac events. These data support a policy involvingbroader use of the early inhibition of glycoprotein IIb/IIIain combination with an early invasive strategy in such patients.
Source Information
From the Cardiovascular Division, Brigham and Women's Hospital, Boston (C.P.C., E.B.); Emory University, Atlanta (W.S.W.); Merck, West Point, Pa. (L.A.D., D.H.R., P.T.D., P.M.D.); Holmes Regional Medical Center, Melbourne, Fla. (R.V.); the Heart Center of Sarasota, Sarasota, Fla. (M.J.F.); Baylor College of Medicine, Houston (N.L.); Medizinische Klinik der Technischen Universität München, Munich, Germany (F.-J.N.); and Harvard Clinical Research Institute, Boston (C.M.G.).
Address reprint requests to Dr. Cannon at the TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, or at cpcannon{at}partners.org.
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