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Towards a reappraisal of the TACTICS TIMI 18 trial in the era of modern pharmacological and interventional therapies
  1. Wail Nammas
  1. Cardiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
  1. Correspondence to Dr Wail Nammas, Cardiology Department, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt; wnammas{at}

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Making science appealing is quite a challenging task; and the scientific research industry is among the most sophisticated and promising. One important fact to keep in mind about science is that it never stands still, but is constantly changing. This may explain why we can never get too close to it, because it is like the mirage that recedes each time we approach it. Making good sense of this notion is never more relevant than in the realm of randomised controlled trials when comparing two alternative therapeutic strategies. A randomised controlled trial should be interpreted exclusively within the background of the population actually enrolled, and the therapeutic regimens received. Overextending the conclusions of a clinical trial beyond the specific population ultimately enrolled, and the context of pharmacological interventions eventually rendered, would be a grave prejudice. To underscore this viewpoint, let us review evidence from one of the landmark randomised controlled trials published a little more than a decade ago, that rigorously contributed to the standard-of-care approach in the management of patients presenting with non-ST-elevation acute coronary syndrome (ACS). The TACTICS TIMI 18 trial randomly assigned a little over 2200 patients with unstable angina, or non-ST-elevation acute myocardial infarction (MI), to either an early invasive strategy based on routine catheterisation within 48 h, and revascularisation as appropriate, or a conservative strategy in which catheterisation was performed only if the patient had objective evidence of recurrent ischaemia or an abnormal stress test.1 At 6-month follow-up, the primary endpoint (a composite of death, non-fatal MI and rehospitalisation for ACS) occurred less frequently with the invasive, as compared with the conservative strategy (p=0.025), and so was the composite of death or non-fatal MI (p<0.05). The conclusion, accordingly, was that ‘in patients with unstable angina and MI without ST-segment elevation who were treated with the …

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