MORTALITY OF ACUTE MYOCARDIAL INFARCTION IN RELATION WITH TIMI RISK SCORE

Abstract

Background: The Thrombolysis in Myocardial Infarction (TIMI) risk score is said to be an important factor in predicting mortality risk in fibrinolysis-eligible STEMI patients. An attempt was made to assess the situation by comparing risk stratification based on the TIMI score with the hospital outcome of such individuals. Methods: 145 STEMI patients were included in this srudy , TIMI risk scores were calculated and analysed vis-Ã -vis various relevant parameters.. Based on their TIMI scores, the patients were placed into three risk groups: low-risk,moderate-risk, and high-risk. All patients received standard anti-ischemic medication, were thrombolyzed, monitored in the ICCU, and monitored throughout their hospital stay for post-MI sequelae. Results: According to the TIMI risk score, 79 patients (54.5%) had low-risk , 48 (33.1%) to the moderate-risk , and 18 (12.4%) to the high-risk . The highest mortality rate (total 17 deaths) was found in the high-risk group (55.6%), followed by moderate-risk (12.2%) and low-risk (1.28%) groups, respectively. Killips categorization grade 2-4 had the highest relative risk (RR-15.85) of the seven potentially dubious variables evaluated, followed by systolic BP 100mmHg (RR-10.48), diabetes mellitus (RR-2.79), and age >65 years (RR- 2.59). Conclusions: In patients with STEMI, the TIMI risk scoring system appears to be a straightforward, valid, and practical bedside tool for quantitative risk classification and short-term prognosis prediction.

Full text

ISSN: 2320-5407 Int. J. Adv. Res. 9(12), 403-407
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Journal Homepage: - www.journalijar.com
Article DOI: 10.21474/IJAR01/13923
DOI URL: http://dx.doi.org/10.21474/IJAR01/13923
RESEARCH ARTICLE
MORTALITY OF ACUTE MYOCARDIAL INFARCTION IN RELATION WITH TIMI RISK SCORE
Owais Ahmed Wani1, Nasir Ali2, Ouber Qayoom1 and Rajveer Beniwal1
1. Dr NB Cardiology, SSH, GMC Jammu.
2. Consultant Cardiology, SSH, GMC Jammu.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History
Received: 10 October 2021
Final Accepted: 14 November 2021
Published: December 2021
Key words:-
AMI, In-Hospital Outcome, Myocardial
Infarction, TIMI Score, STEMI
Background: The Thrombolysis in Myocardial Infarction (TIMI) risk
score is said to be an important factor in predicting mortality risk in
fibrinolysis-eligible STEMI patients. An attempt was made to assess
the situation by comparing risk stratification based on the TIMI score
with the hospital outcome of such individuals.
Methods: 145 STEMI patients were included in this srudy , TIMI risk
scores were calculated and analysed vis-à-vis various relevant
parameters.. Based on their TIMI scores, the patients were placed into
three risk groups: 'low-risk,"moderate-risk,' and 'high-risk.' All patients
received standard anti-ischemic medication, were thrombolyzed,
monitored in the ICCU, and monitored throughout their hospital stay
for post-MI sequelae.
Results: According to the TIMI risk score, 79 patients (54.5%) had
low-risk , 48 (33.1%) to the moderate-risk , and 18 (12.4%) to the high-
risk . The highest mortality rate (total 17 deaths) was found in the high-
risk group (55.6%), followed by moderate-risk (12.2%) and low-risk
(1.28%) groups, respectively. Killips categorization grade 2-4 had the
highest relative risk (RR-15.85) of the seven potentially dubious
variables evaluated, followed by systolic BP 100mmHg (RR-10.48),
diabetes mellitus (RR-2.79), and age >65 years (RR- 2.59).
Conclusions: In patients with STEMI, the TIMI risk scoring system
appears to be a straightforward, valid, and practical bedside tool for
quantitative risk classification and short-term prognosis prediction.
Copy Right, IJAR, 2021,. All rights reserved.
……………………………………………………………………………………………………....
Introduction:-
Ischemic Heart Disease (IHD) is still the biggest cause of death worldwide, and the epidemic is on the rise. IHD and
stroke combined killed 12.5 million people in 2010, accounting for 1 in every 4 deaths worldwide, compared to 1 in
every 5 deaths in 1990; IHD ranked first in terms of Years of Life Lost (YLL) in 2010, compared to fourth in 1990.1
Worse, Indians are affected by cardiovascular diseases (CVD) a decade earlier than their western counterparts, with
IHD accounting for the majority of CVD death in India (83 percent ). 2-4
Inspite of therapeutic advances in MI management, large scale randomised clinical trials reported 6-9% early
mortality rates (30-35 days), even for patients receiving thrombolytic therapy within 6 hours of symptom onset.5,6
Careful attention to pivotal factors that increase the risk of early mortality may further elaborate the role of early
invasive therapeutics that would lower the fatality rate of ST Elevation Myocardial Infarction (STEMI). Effective
Corresponding Author:- Owais Ahmed Wani
Address:- Dr NB Cardiology, SSH , GMC Jammu.

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risk stratification is integral to management of acute coronary syndromes. The Thrombolysis in Myocardial
Infarction (TIMI) risk score for STEMI is one such simple integral score purported to be a robust clinical tool for
mortality risk prediction in fibrinolysis-eligiblepatients with STEMI.7 It’s validation in local population is, however,
largely untested.
The purpose of this study was to determine the predictive importance of the TIMI risk score in a local community of
acute STEMI patients who were eligible for thrombolytic therapy, by connecting risk stratification by TIMI score
with hospital outcomes of these patients.
Methods:-
The current study was a prospective observational study that lasted two years, from september 2019 to
september 2021. It was conducted at a tertiary care government hospital in north India. All adult patients over the
age of 18 who presented to the Cardiology OPD or emergency department and with cardiac condition compelling
admission to ICCU; while satisfying the following inclusion criteria were enrolled.
Inclusion criteria
1. Patients with ST Elevation Myocardial Infarction (STEMI) presenting for the first time.
2. Patients with ST Elevation Myocardial Infarction (STEMI) eligible for thrombolysis. (As per the ACC/AHA
STEMI Management Guideline).8
Exclusion criteria
1. Patients with Non- ST Elevation Myocardial Infarction.
2. Patients with ST Elevation Myocardial Infarction (STEMI) in which thrombolysis is contraindicated due to any
reason.
3. Unwilling for consent.
An informed written consent was elicited from each participant before enrollment. All patients were thoroughly
evaluated; with detailed history, clinical examination, clinically indicated laboratory investigations and ECG. The
diagnosis of STEMI was considered if the patient fulfilled following 2 criteria-
1. Presence of chest pain or other symptoms suggestive of acute MI.
2. ST elevation on admission or during hospital evaluation in two or more contiguous leads (greater than 0.2mv in
lead V1, V2 and V3 or greater than 0.1mv in other leads).
The patients were divided into three risk groups, namely ‘low-risk’, ‘moderate-risk’ and ‘high-risk’ based on their
TIMI scores (0-4 low risk, 5-8 moderate risk, 9-14 high risk). All patients received routine anti-ischemic therapy and
were thrombolysed subsequently with 1.5 million IU of Streptokinase in 100 ml of normal saline over 60 minutes
followed by routine post MI management. The patients were closely monitored in ICCU and followed during their
hospital stay for occurrence of post-MI complications including death. Ethical approval was obtained from
Institutional Ethics Committee before proceeding with the study.
Statistical analysis was performed using chi-square test for comparing variables between three TIMI score groups.
Relative risks (RR) were calculated wherever suitable. P-value <0.05 was considered statistically significant.
STATA version 10.0 was used to perform statistical analysis.
Results:-
In total, 145 ST-Elevation Myocardial Infarction (STEMI) cases met the inclusion criteria, and TIMI scores were
generated for further categorization and analysis..
The participants' average age was 57.9+11.2 years, with females (63.3+7.5 years, n=34) having a higher age than
males (56.0+11.8 years, n=111). The most prevalent symptom reported by all patients was chest discomfort (136,
93.8 percent), which was followed by perspiration (63, 43.4 percent), vomiting (34, 23.4 percent), dyspnea (32, 22.1
percent), and palpitation (32, 22.1 percent) (17, 11.7 percent ). The median elapsed time before a patient could reach
a medical facility was 10.4+11.3 hours, with 106 (73.1%) individuals having an elapsed time of more than 4 hours
and 39 (26.7%) being seen within 4 hours. Out of 145 patients, 79 (54.5%) belonged to low-risk group, 48 (33.1%)
to moderate-risk group and 18 (12.4%) to high-risk group according to TIMI risk score. The mortality (total 17

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deaths) was observed to be highest in the high-risk group (55.6%), followed by moderate-risk (12.2%) and low-risk
group (1.28%) respectively (Table 1).
Table 1:- Distribution of patients according to TIMI risk Scores.
TIMI RISK GROUP
PATIENTS
MORTALITY AMOUNG GROUP
NUMBER
%
NUMBER
%
LOW RISK
79
54.50%
1
1.30%
MODERATE RISK
48
33.1
6
12.20%
HIGH RISK
18
12.4
10
55.60%
The most prevalent risk factor was hypertension (79, 54.5 percent), followed by smoking (61, 42.1%), dyslipidemia
(39, 26.9%), diabetes mellitus (36, 24.8%), and having a family history of AMI (36, 24.8%). (34, 23.4 percent ). The
subsequent mortality and TIMI risk score grouping revealed significant associations for all the mentioned risk
factors (Table 2).
Anterior wall MI was shown to be more prevalent than other types of MI (92, 63.4 percent) (inferior wall MI- 26.2
percent , mixed MI- 10.4 percent ). Anterior wall MI was also more deadly, with 13 (14.1%) patients dying as a
result of the incident. P-value was significant for trend of TIMI risk scores across thevarious types of MIs. Forty-
four cases (30.3%) belonged to Killips classification grade 2-4, with significant association with TIMI risk score. As
many as 16 out of 44 (36.4%) belonging to Killips classification grade 2-4 expired.
Table 2:- TIMI Risk score groups and association of various risk factors.
Risk Factor
TIMI Risk score
Mortality
Low
Moderate
High
P Value
Hypertension (n=79)
12 (11.4%)
36 (45.6%)
28 (35.4%)
15 (19.0%)
0.015
Smoking (n=61)
10 (16.4%)
33 (54.1%)
16 (26.2%)
12 (19.7%)
0.026
Dyslipidemia (n=39)
10 (25.6%)
16 (41.0%)
14 (35.9%)
9 (23.1%)
0.015
Diabetes Mellitus (n=36)
8 (22.2%)
24 (66.6%)
6 (16.7%)
6 (16.7%)
0.011
AMI family history (n=34)
9 (26.5%)
13 (38.2%)
12 (35.3%)
9 (26.5%)
0.037
Potentially suspect variables were checked for association with mortality amongst study participants. Out of the 7
variables studied, Killips classification grade 2-4 had the highest relative risk (RR-15.85) which was significant.
Other variables with significant relative risks signifying association with morality were systolic BP <100mmHg
(RR- 10.48), diabetes mellitus (RR- 2.79) and age >65 years (RR- 2.59) (Table 3).
Table 3:- Variables associated with in-hospital mortality amongst participants.
Variable
RR
95% CI
P- Value
Killips Grade 2-4
15.85
1.86-26.31
<0.001
Systolic BP <100 mmHg
10.48
4.03-27.27
<0.001
Diabetes mellitus
2.79
1.16-6.68
0.019
Age >65 years
2.59
1.08-6.23
0.030
Heart rate >110/min
2.14
0.86-5.30
0.092
Elapsed time >4 hours
1.71
0.52-5.65
0.36
Hypertension
1.34
0.95-1.91
0.16
Table 4:- Association of variables with TIMI risk scores.
Variable
Low risk (%)
Moderate risk (%)
High risk (%)
Systolic BP <100mmHg
4 (5.12)
11 (22.44)
12 (66.67%)
HR >100/min
34 (43.58)
26 (53.06)
8 (44.44)
Elapsed time > 4 hours
51 (65.38)
40 (81.63)
15 (85.33)
Weight <67 kg
73 (93.58)
48 (97.95)
18 (100)
Extensive ant. wall MI
44 (56.41)
35 (71.42)
15 (88.23)
Hospitalisation time <24
72 (92.8)
41 (83.67)
12 (70.58)

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hrs
Elevated blood pressure
36 (46.15)
28 (57.14)
15 (88.23)
Angina
12 (15.38)
12 (24.48)
02 (11.76)
Diabetes mellitus
24 (30.76)
05 (10.2)
05 (29.41)
Selected variables were further studied to check for association with TIMI risk scores. Frequency of all the studied
variables was observed to be more in high risk group as compared to moderate and low risk groups; except in angina
and diabetes mellitus, where the frequency didn’t vary much (Table 4).
Discussion:-
In every acute coronary episode, early recognition is critical. Over the years, a variety of risk scores have been
offered. The Thrombolysis in Myocardial Infarction (TIMI) risk score, obtained from clinical trial populations, and
the Global Registry of Acute Coronary Events Risk Score (GRACE RS), derived from an international registry, are
two of the most renowned.7.9 However, their effectiveness has not been sufficiently verified in representative patient
populations, necessitating this research.
A total of 145 confirmed STEMI cases were investigated, with TIMI risk scores calculated and analysed in relation
to several relevant parameters. The age and gender distribution of the participants in this study was mainly similar to
that of past similar studies, allowing for fair comparisons. 10-12
Chest pain was the ubiquitous presentation amongst participants in the current study, which is similar to the 95%
positivity reported by Berg J et al and to the findings of Zucker D et al.13,14 The average time elapsed before the
patient could reach medical facility was 10.4+11.31 hours; much higher than that reported by Jacqueline L et al
(6.7+8.6 hours), but comparable to the mean 10.6 hours reported by Zornoff et al in their Canadian study in
1996.10,15 The reason of discordance here could be due to relatively lesser penetration of specialized health services
in our country, apparently similar to the Canadian health services in the 1990s.
According to the TIMI risk score, 54.5 percent of the 145 patients were in the low-risk group, 33.1 percent in the
moderate-risk group, and 12.4% in the high-risk group, with the high-risk group having the highest mortality (55.6
percent ).
Previous studies have found a similar distribution of TIMI risk scores among MI patients, as well as similar high
mortality rates, adding to the evidence that TIMI risk score is a predictor of mortality in the studied scenario.10-12,16
Hypertension and smoking were the most common risk factors in the present study and the subsequent mortality and
TIMI risk score grouping revealed significant associations for all the mentioned risk factors, much in line with the
available literature.14-16 A total of 44 (30.3%) participants belonged to Killips classification grade 2-4, and with the
relative risk being significant at more than 15, it was the single biggest determinant of in-hospital mortality in the
present study. Previous researchers seemed to have under-grouped the Killips classified cases.10,11 Nonetheless,
there is agreement over their important predictive role, with Jacqueline L et al, among others, reporting the mortality
among Killips class 2-4 to be as high as 54.8%.10,17 Systolic BP <100 mmHg was the other significant determinant
of death (RR-10.5). This is also much in-line with the available literature, reported more prominently in the elderly
population.10,11,18
Systolic BP <100 mmHg, HR >100/min, elapsed time >4 hours, weight <67kg, extensive ant. wall MI,
hospitalisation time <24hrs, elevated blood pressure was some of the variables which confirmed the discriminatory
role of TIMI risk score, as their frequency was observed to be more in high risk group as compared to moderate and
low risk groups. This important sits perfectly well with the findings of previous similar studies.10,12,15-17 The
discriminatory capacity of the TIMI risk score was further confirmed by the significant area under ROC curve
(0.86).
Conclusion:-
The study concludes that in STEMI cases, the greater the TIMI risk score upon admission, the worse the prognosis.
The TIMI risk score system appears to be a straightforward, valid, and useful bedside tool for quantitative risk
classification and short-term prognosis prediction in STEMI patients, and it is recommended for this purpose.

ISSN: 2320-5407 Int. J. Adv. Res. 9(12), 403-407
407
Funding:
No funding sources
Conflict of interest:
None declared
Ethical approval:
The study was approved by the Institutional Ethics Committee
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