From the Guidelines
The TIMING trial is not directly addressed in the provided evidence, but based on the most recent and highest quality study, primary PCI is the preferred treatment for STEMI patients, especially when presentation occurs between 3 and 12 hours after onset of symptoms 1. The provided evidence focuses on guidelines for percutaneous coronary interventions, emphasizing the importance of primary PCI in specific scenarios. Key points from the study include:
- Primary PCI is the treatment of choice for STEMI patients in hospitals with PCI facilities and experienced teams.
- Patients with contraindications to thrombolysis should be transferred for primary PCI immediately.
- Emergency PCI may be life-saving in cardiogenic shock and should be considered early.
- Primary PCI has a superior preservation of myocardium compared to thrombolysis, especially in the 3-12 hour time frame after symptom onset.
- Within the first 3 hours after symptom onset, both reperfusion strategies seem equally effective in reducing infarct size and mortality.
Some important considerations when evaluating the effectiveness of primary PCI include:
- The time interval between symptom onset and treatment
- The presence of contraindications to thrombolysis
- The availability of PCI facilities and experienced teams
- The potential for stroke and other complications associated with thrombolysis
- The importance of routine coronary angiography and PCI after successful thrombolysis to improve outcomes 1.
From the Research
Overview of TIMING TRIAL
- The TIMING trial is a registry-based, randomized, noninferiority, open-label, blinded end-point study that investigated the efficacy and safety of early versus delayed initiation of non-vitamin K antagonist oral anticoagulants (NOACs) after acute ischemic stroke in patients with atrial fibrillation 2.
- The study aimed to determine the optimal time point to initiate NOACs after acute ischemic stroke in patients with atrial fibrillation.
Study Design and Outcomes
- The study randomized 888 patients to either early (≤4 days) or delayed (5-10 days) NOAC initiation, with the choice of NOAC at the investigators' discretion 2.
- The primary outcome was the composite of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or all-cause mortality at 90 days.
- The study found that early initiation of NOAC was noninferior to delayed start of NOAC after acute ischemic stroke in patients with atrial fibrillation, with numerically lower rates of ischemic stroke and death and the absence of symptomatic intracerebral hemorrhages 2.
Implications of the Study
- The TIMING trial suggests that early initiation of NOAC after acute ischemic stroke in patients with atrial fibrillation is safe and effective, and should be considered for acute secondary stroke prevention in patients eligible for NOAC treatment 2.
- The study's findings have implications for clinical practice, as they provide evidence-based guidance on the optimal timing of NOAC initiation after acute ischemic stroke in patients with atrial fibrillation.
Comparison with Other Studies
- The TIMING trial's findings are consistent with other studies that have investigated the use of anticoagulation therapy in patients with atrial fibrillation, such as the CHA2DS2-VASc score studies 3, 4, 5, 6.
- However, the TIMING trial is unique in its focus on the timing of NOAC initiation after acute ischemic stroke in patients with atrial fibrillation.