Results of the Treat Angina With Aggrastat and Determine the Cost of Therapy With an Invasive or Conservative Strategy (TACTICS-TIMI 18) Trial: A Comparison of Invasive Versus Conservative Strategy in Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction

Background: In the treatment of patients with unstable angina and non-ST segment elevation myocardial infarction (UA/NSTEMI), debate exists as to whether an early invasive vs. a conservative strategy is optimal therapy. Methods: In the international TACTICS-TIMI 18 trial, 2220 patients with UA/NSTEMI who had either electrocardiographic changes, elevated cardiac markers or a history of prior coronary artery disease, were immediately treated with aspirin, heparin and the glycoprotein (GP) IIb/IIIa inhibitor tirofiban. They were randomized to an early invasive strategy with routine catheterization and revascularization as appropriate within 4–48 hours, or to a conservative, or “selective invasive” strategy, with catheterization performed only if the patient had objective evidence of recurrent ischemia or a positive stress test. The primary endpoint was a composite of death, myocardial infarction or rehospitalization for acute coronary syndromes at 6 months. Results: The rate of the primary endpoint was significantly reduced with the invasive strategy compared to the conservative strategy, 15.9% vs. 19.4%, odds ratio (OR) 0.78, p=0.025. The rate of death or MI at 6 months was also significantly reduced (9.5% vs. 7.3%, respectively, OR 0.74, p<0.05). Conclusion: In patients with UA/NSTEMI treated with the GP IIb/IIIa inhibitor tirofiban, an early invasive strategy resulted in a significant reduction in major cardiac events. These data suggest a need to update the ACC/AHA Unstable angina Guidelines, and to modify the clinical approach to managing unstable angina with broader use of an early invasive strategy with upstream GP IIb/IIIa inhibition.

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