ACS trials Flashcards
TACTICS TIMI 18
TACTICS-TIMI 18 (2001): RCT, early invasive strategy (< 48h, in combination w GB IIb IIIa inh tirofiban) vs selectively invasive strategy (conservative strategy), significantly reduced major CV events, among 2220 pts w NSTEMI. This benefit was largely limited to higher risk patient with TIMI score > 2. Criticism: nearly all pts received tirofiban (now used primary as bailout therapy in NSTEMI).
TIMACS
TIMACS (2009): in NSTEMI, early (< 24h) vs delayed (> 36h) revascularization was a/w similar primary outcome (death, MI, stroke at 6 months)
* NEUTRAL study
* Early revascularization reduced rate of secondary outcome (death, MI, refractory ischemia)
* There was greater benefit if pt had GRACE score > 140 and early invasive assessment
ATOLL
- ATOLL: in STEMI, enoxaparin was superior to UFH (death, recurrent ACS, urgent revascularization), without more bleeding
SYNERGY and ATOZ
- SYNERGY and ATOZ: in NSTEMI, enoxaparin was noninferior to UFH, without difference in major bleeding
MIAMI
- MIAMI (1985): IV metoprolol was not a/w improved survival
COMMIT CCS2
- COMMIT/CCS-2 trial (2005): in MI (45K pts) not undergoing PCI, IV metoprolol (titrated to HR 50 or SBP 90) followed by high-dose oral metoprolol succinate (50 mg q6h x48h) did NOT reduce death, reinfarction, or cardiac arrest, but INCREASED rate of cardiogenic shock.
PARADISE MI
PARADISE-MI: Entresto vs ramipril did not reduce CV death or HF hospitalization
EPHESUS
EPHESUS (2003): eplerenone 25-50 mg daily (vs placebo) reduced CV mortality, HF admission, SCD in > 6600 patients with acute MI (3-14 d) complicated by LV dysfunction (EF < 40%) and HF. There was an increase in hyperkalemia. A lot more patients (than in RALES) were on beta blockers.
ASSENT-4
- Fibrinolysis followed by immediate PCI (<3h) is a/w worse mortality (ASSENT-4)
STREAM
STREAM (2013): STEMI (within 3 hours) who cannot undergo primary PCI within 1 hours after first medical contact
* Prehospital fibrinolysis (TNK, half dose in > 75 yo, with clopidogrel and enoxaparin) with timely coronary angiography: effective reperfusion (same primary outcome: death, shock, CHF, reinfarction up to 30d)
* Emergency coronary angiography was performed if fibrinolysis failed: otherwise angiography was performed 6-24h after randomization
* Fibrinolysis was a/w higher rates of intracranial bleed
* Great example of pharmaco-invasive strategy at non-PCI centers
REDUCE AMI
REDUCE-AMI (2024): in AMI with preserved LVEF, BB (metoprolol or bisoprolol) was not a/w mortality or AMI benefit, compared to usual care
* RCT, to metoprolol target dose > 100 mg/d or bisoprolol > 5 mg/d
* BB started inpatient and continued after discharge
* Pts in usual care on beta blockers were tapered off over 2-4 weeks
* > 5000 pts, follow up 3.5 years, female 23%, median age 65 years
* Inclusion: type I MI or NSTEMI < 7 days prior, with catheterization stenosis > 50% or positive invasive physiologic testing, echo LVEF > 50%
* There was increased use of BB in usual care arm (Afib, PAD, HTN, subsequent reduced LVEF, stable angina)
* This was a registry collected data
* Criticism: majority of pts had single vessel disease treated with PCI (95%), lack of central adjudication of endpoints (registry collected data)
COLCOT
COLCOT trial (2019): in 4745 pts w/ MI in last 30 days, colchicine (0.5 mg/d), as compared to placebo, was a/w 1.6% absolute reduction in primary composite endpoint of death from CV cause, resuscitated cardiac arrest, recurrent MI, stroke or urgent hospitalization for angina leading to coronary revascularization, after 22.6 months.
IAMI
IAMI (2021): influenza vaccine vs placebo within 72 hours of angiography/PCI/hospitalization for recent MI or high-risk coronary heart disease was a/w lower risk of all-cause and CV mortality at 12 months
