The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making

Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 08/2000; 284(7):835-42.
Source: PubMed


Patients with unstable angina/non-ST-segment elevation myocardial infarction (MI) (UA/NSTEMI) present with a wide spectrum of risk for death and cardiac ischemic events.
To develop a simple risk score that has broad applicability, is easily calculated at patient presentation, does not require a computer, and identifies patients with different responses to treatments for UA/NSTEMI.
Two phase 3, international, randomized, double-blind trials (the Thrombolysis in Myocardial Infarction [TIMI] 11B trial [August 1996-March 1998] and the Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q-Wave MI trial [ESSENCE; October 1994-May 1996]). A total of 1957 patients with UA/NSTEMI were assigned to receive unfractionated heparin (test cohort) and 1953 to receive enoxaparin in TIMI 11B; 1564 and 1607 were assigned respectively in ESSENCE. The 3 validation cohorts were the unfractionated heparin group from ESSENCE and both enoxaparin groups.
The TIMI risk score was derived in the test cohort by selection of independent prognostic variables using multivariate logistic regression, assignment of value of 1 when a factor was present and 0 when it was absent, and summing the number of factors present to categorize patients into risk strata. Relative differences in response to therapeutic interventions were determined by comparing the slopes of the rates of events with increasing score in treatment groups and by testing for an interaction between risk score and treatment. Outcomes were TIMI risk score for developing at least 1 component of the primary end point (all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization) through 14 days after randomization.
The 7 TIMI risk score predictor variables were age 65 years or older, at least 3 risk factors for coronary artery disease, prior coronary stenosis of 50% or more, ST-segment deviation on electrocardiogram at presentation, at least 2 anginal events in prior 24 hours, use of aspirin in prior 7 days, and elevated serum cardiac markers. Event rates increased significantly as the TIMI risk score increased in the test cohort in TIMI 11B: 4.7% for a score of 0/1; 8.3% for 2; 13. 2% for 3; 19.9% for 4; 26.2% for 5; and 40.9% for 6/7 (P<.001 by chi(2) for trend). The pattern of increasing event rates with increasing TIMI risk score was confirmed in all 3 validation groups (P<.001). The slope of the increase in event rates with increasing numbers of risk factors was significantly lower in the enoxaparin groups in both TIMI 11B (P =.01) and ESSENCE (P =.03) and there was a significant interaction between TIMI risk score and treatment (P =. 02).
In patients with UA/NSTEMI, the TIMI risk score is a simple prognostication scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapeutic decision making. JAMA. 2000;284:835-842

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Available from: Branco Mautner, Nov 27, 2014
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    • "Similarly, the treatment of men is striking; independent of factors such as age or TIMI scores (Antman et al. 2000, p. 836), men show a clear trend towards being admitted more frequently to intensive care units or to intermediate units compared with women (Carbajosa et al. 2011, p. 88). We observed that variables such as age, gender, cardiovascular risk factors, coronary background, evolutionary complications and treatments received during the acute phase of the disease or after discharge and the type of hospital or area of admission can influence early or late mortality of a patient with coronary involvement (Aros et al. 1994, p. 1167). "
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    DESCRIPTION: Aims and objectives. The objectives of this study were to analyse the differences in the treatment and the evolution of acute coronary syndromes according to the gender of the patient and to determine the likely causes of these differences. Background. Epidemiological studies confirm the differences in the course and treatment of acute coronary syndromes according to factors such as gender and age. The factors associated with the observed gender-based differences are not known. Design and methods. This prospective study was conducted on 596 patients treated in the Hospital Emergency Service of the Hospital Complex of Navarra, Spain, from 1 January 2012 to April 2013 with acute coronary syndromes. A bivariate and logistic analysis has been made by adjusting the age and severity of process to know the differences by gender. Results. A total of 71�8% (n = 428) were men, and the remaining 28�2% (168) were women. The mean age of the men was 66�4 � 12�7 years, and the mean age of the women was 72�5 � 13�9 years. We found that antiplatelet drugs (68�4 vs. 22�7%), blockers (70 vs. 25�4%), ACE inhibitors (56�2 vs. 15�6%), fibrinolysis (17�2 vs. 4�5%, p = 0�025) and primary angioplasty (AP) (38�7 vs. 16�3%, p = 0�008) were less frequently administered to women compared with men. We observed an additional delay in the demand for health care in women with acute coronary syndromes compared with men. Conclusions. There is an association between treatment differences and gender. The delay in the request of health care in women is observed to be the largest correlating factor, in addition to voluntary discharge in women affected by acute coronary syndromes. Relevance to clinical practice. Delays in seeking medical care or voluntary discharge are likely factors related to worse outcomes in women. These factors should be explored, and the results should be made available to the public, particularly to women.
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    • "Rapid and accurate risk stratification of chest pain patients in the emergency department (ED) plays an important role in guiding appropriate disposition and early intervention so as to rapidly identify those with high risk of adverse coronary events. A conventional risk score for potential acute coronary syndromes (ACS) is the thrombolysis in myocardial infarction (TIMI) score [1]. The TIMI score was suggested to be a useful tool in the ED setting [2] [3]. "

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    • "In this observational cohort study of ED patients with chest pain, the 12-lead ECG combined with HRV and vital signs were found to strongly associate with acute cardiac complications within 72 h. A novel scoring method ESS has been proposed to integrate multiple sources of predictors for risk stratification, which showed superior performance compared with several existing methods such as TIMI [5], MEWS [6], and an intelligent scoring method DIST [14]. As illustrated in Fig. 5, ESS was the best performer in accurately identifying both high risk patients and low risk patients. "
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    ABSTRACT: Fast and accurate risk stratification is essential in the emergency department (ED) as it allows clinicians to identify chest pain patients who are at high risk of cardiac complications and require intensive monitoring and early intervention. In this paper, we present a novel intelligent scoring system using heart rate variability, 12-lead electrocardiogram (ECG), and vital signs where a hybrid sampling-based ensemble learning strategy is proposed to handle data imbalance. The experiments were conducted on a dataset consisting of 564 chest pain patients recruited at the ED of a tertiary hospital. The proposed ensemble-based scoring system was compared with established scoring methods such as the modified early warning score and the thrombolysis in myocardial infarction score, and showed its effectiveness in predicting acute cardiac complications within 72 h in terms of the receiver operation characteristic analysis.
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