Article

Validation of the Thrombolysis In Myocardial Infarction (TIMI) risk index for predicting early mortality in a population-based cohort of STEMI and non-STEMI patients

February 2007
Canadian Journal of Cardiology 23(1):51-6

February 2007
23(1):51-6

DOI:10.1016/S0828-282X(07)70213-1

Source
PubMed

Authors:

Pamela J Bradshaw

University of Western Australia

Alice Newman

Institute for Clinical Evaluative Sciences

Show all 5 authorsHide

The Thrombolysis In Myocardial Infarction (TIMI) risk index for the prediction of 30-day mortality was developed and validated in patients with ST-segment elevation myocardial infarction (STEMI) who were being treated with thrombolytics in randomized clinical trials. When tested in clinical registries of patients with STEMI, the index performed poorly in an older (65 years and older) Medicare population, but it was a good predictor of early death among the more representative population on the National Registry of Myocardial Infarction-3 and -4 databases. It has not been tested in a population outside the United States or among non-STEMI patients. The TIMI risk index was applied to the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study cohort of 11,510 acute MI patients from Ontario. The model's discriminatory capacity and calibration were tested in all patients and in subgroups determined by age, sex, diagnosis and reperfusion status. The TIMI risk index was strongly associated with 30-day mortality for both STEMI and non-STEMI patients. The C statistic was 0.82 for STEMI and 0.80 for non-STEMI patients, with overlapping 95% CI. The discriminatory capacity was somewhat lower for patients older than 65 years of age (0.74). The model was well calibrated. The TIMI risk index is a simple, valid and moderately accurate tool for the stratification of risk for early death in STEMI and non-STEMI patients in the community setting. Its routine clinical use is warranted.

Application of thrombolysis in myocardial infarction risk index in the prediction of long‑term outcomes for patients with ST‑elevation myocardial infarction and multiple vessel disease: A single‑center prospective observational cohort study

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Oct 2021

The thrombolysis in myocardial infarction (TIMI) risk index has been indicated to be a simple and useful tool for risk stratification of patients with ST-elevation myocardial infarction (STEMI). However, the predictive value of the TIMI risk index regarding the long-term outcome for patients with STEMI with multiple vessel disease has remained to be determined. In the present study, a total of 369 patients diagnosed with STEMI who received emergency percutaneous coronary intervention treatment were analyzed. A five-year follow-up was performed to record the primary endpoint of all-cause mortality, as well as the secondary endpoints of myocardial infarction, stroke, emergent revascularization and admission due to heart failure. A receiver operating characteristic (ROC) curve was used to determine the cut-off value of the TIMI risk index for predicting all-cause death, based on which the patients were divided into a high TIMI group and a low TIMI group. Kaplan-Meier survival curves were used to compare the long-term survival of the two groups and multivariate Cox regression analysis was used to evaluate the predictive value of the risk factors regarding primary and secondary endpoints. The ROC curve indicated that the TIMI risk index was associated with three-year all-cause death with a cut-off value of 30.35 (area under curve, 0.705; P=0.001). The high TIMI group (>30.35) and low TIMI group (<30.35) exhibited a significant difference in all-cause death (P=0.009) but not in any of the secondary endpoints (P=0.527). Multivariate Cox regression analysis demonstrated that a high TIMI risk index was an independent risk factor for all-cause death in patients with STEMI and multiple-vessel disease (hazard ratio=3.709, 95% CI: 1.521-9.046, P=0.004). In conclusion, the TIMI risk index was associated with long-term outcomes for patients with STEMI and multiple-vessel disease and may be of value for risk prediction.

Comparison of In-Hospital Complications among Patients with Right Ventricular Infarction

Article

Full-text available

Jan 2023

Background: Patients with right ventricular infarction is a critical condition and may cause adverse cardiac events. Objective: The purpose of the present study was to compare the in-hospital complications among patients with right ventricular infarction based on TIMI risk score. Methodology: This prospective observational study was conducted in the Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh from May 2007 to April 2008 for a period of one year. All the patients who were admitted into the coronary care unit of NICVD with acute inferior myocardial infarction with or without anterior myocardial infarction were selected as study population. Inclusion Criteria were patients admitted in CCU (NICVD) with acute inferior myocardial infarction with right ventricular infarction. Patients were categorized into two groups according to the extent of TIMI risk score. Patients with low TIMI risk score (0 to 3) were included in Group I and patients with high TIMI risk-score (4 to 14) were include in group II. Patients were followed up in their hospital stay to see the incidence of major cardiac events. Results: A total number of 60 patients with right ventricular infarction of which 30 consecutive patients with low TIMI risk score (0 to 3) were in Group I and 30 consecutive patients with high TIMI risk score (4 to 14) were in Group II. In-hospital mortality was 18.3% in the study populations and it was significantly higher in group II (33.3%) than group (3.3%). The next most common complication is cardiogenic shock followed by complete heart block, Cardiac arrest, VT and 2nd degree heart block. Conclusion: In conclusion the in-hospital mortality in the study populations is significantly higher in group II than group I Journal of National Institute of Neurosciences Bangladesh, July 2022;8(2):143-146

Use of TIMI Risk Index as a Simple and Valuable Prognostic Tool in Patients with ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention

Article

Full-text available

Apr 2022

Shock index and TIMI risk index as valuable prognostic tools in patients with acute coronary syndrome complicated by cardiogenic shock

Article

Full-text available

Jan 2020
PLOS ONE

Background The aim of the study was to evaluate the usefulness of the shock index (SI) and the TIMI risk index (TRI Thrombolysis in Myocardial Infarction Risk Index) one hour after successful primary percutaneous coronary intervention (pPCI) for predicting in-hospital mortality in patients with acute coronary syndrome complicated by cardiogenic shock (CS). Methods Forty-seven consecutive patients with acute myocardial infarction (AMI) complicated by CS were included in this prospective observational study. All patients underwent pPCI and obtained TIMI Grade Flow 3. SI and TRI were calculated one hour after pPCI. Results The primary endpoint—death from cardiovascular causes—occurred in 17 patients (36%). All calculated parameters were significantly higher in fatal CS than in the non-fatal CS group. A multivariate logistic regression model found only TRI to be an independent, significant predictor of death in the study group, with a proposed cut-off point of 66, with sensitivity 76.5% and specificity 83.3% (AUC 0.811, p = 0.00001). Conclusions The simple parameters of clinical assessment—SI and TRI—calculated one hour after a successful pPCI of infarct related artery are important predictors of death in AMI complicated by cardiogenic shock.

Comparative analysis of MCDM methods for the assessment of mortality in patients with acute coronary syndrome

Article

Full-text available

Dec 2017
ARTIF INTELL REV

Multi-criteria decision-making (MCDM) methods are commonly used in many fields of research, e.g., engineering and manufacturing systems, water resources studies , medicine, and etc. However, there is no effective approach of selecting a MCDM method to problem, which is solved. The formal requirements of each MCDM method are not sufficient because most methods would seem to be appropriate for most problems. Therefore, the main purpose of the paper is a comparison of accuracy selected MCDM methods. Proposed approach is presented on the example of mortality in patients with acute coronary syndrome. Additionally, the paper presents characteristic objects method (COMET) as a potential decision making method for use in medical problems, which accuracy is compared with TOPSIS and AHP. In the experimental study, the average and standard deviation of the root mean square error of evaluations are examined for groups of randomly selected patients, each described by age, blood pressure, and heart rate. Then, the correctness of choosing the patient in the best and worst condition is also examined among randomly selected pairs. As a result of the experimental study, rankings obtained by the COMET method are distinctly more accurate than those obtained by TOPSIS or AHP techniques. The COMET method, in the opposite of others method, is completely free of the rank reversal phenomenon, which is identified as a main source of problems with evaluations accuracy.

The utility of the TIMI risk index on admission for predicting angiographic no-reflow after primary percutaneous coronary intervention in patients with STEMI

Article

Full-text available

Apr 2016
TURK J MED SCI

Background/aim: The thrombolysis in myocardial infarction (TIMI) risk score (TRS), and the TIMI risk index (TRI) have been reported in coronary artery disease patients. We investigated whether admission TRI is associated with no-reflow (NRF) in patients undergoing primary percutaneous coronary intervention (p-PCI). Materials and methods: ST-segment elevation myocardial infarction (STEMI) patients treated with p-PCI were included in the study. TRI was calculated on admission using specified variables. We defined the angiographic NRF phenomenon as a coronary TIMI flow grade of ≤2 after the vessel was recanalized or a TIMI flow grade of 3 together with a final myocardial blush grade (MBG) of <2 in a manner as described in previous studies. Results: A total of 371 patients (aged 62 ± 14 years; 73/27 men to women ratio) who underwent p-PCI were enrolled in the study. In terms of age, NRF patients were older than reflow patients (P < 0.017 for MBG). Killip class III-IV designations were more common in NRF patients (P = 0.029 for MBG). TRI (P = 0.014 for MBG) values were significantly greater in the NRF group. TRI was an independent predictor of NRF according to MBG flow (P = 0.003, B = -0.035, Exp B = 0966, 95% CI, 0.944-0.988). Conclusion: Admission TRI may predict the development of NRF phenomenon after p-PCI in patients with acute STEMI.

Comparison of the GRACE risk score and the TIMI risk index in predicting the extent and severity of coronary artery disease in patients with acute coronary syndrome

Article

Full-text available

Oct 2014

The prognostic value of the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) and the Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) has been reported in coronary artery disease (CAD) patients. We aimed to evaluate the relationship between the GRS, TRI, and severity of CAD evaluated by SYNTAX score (SS) in patients with acute coronary syndrome (ACS). Patients with ACS who were admitted to the coronary care unit of our institution were retrospectively evaluated in this study. A total of 287 patients with ACS [154 non-ST elevated ACS (NSTE-ACS), 133 ST elevated myocardial infarction (STEMI)] were included in the study. The GRS and TRI were calculated on admission using specified variables. The severity of CAD was evaluated using the SS. The patients were divided into low (GRS<109)-, intermediate (GRS 109-140)-, and high (GRS>140)-risk groups and group 1 (TRI<17), group 2 (TRI 17-26), and group 3 (TRI>26) according to GRS and TRI scores. A Pearson correlation analysis was used for the relation between GRS, TRI, and SS. Patients with a history of coronary artery bypass surgery, those who had missing data for calculating the GRS and TRI, and those whose systolic blood pressure (SBP) was more than 180 mm Hg or whose diastolic blood pressure (DBP) was more than 110 mm Hg were excluded from the study. Were excluded from the study. There were significant differences in mean age (p<0.001), heart rate (p<0.001), SS (p<0.001), TRI (p<0.001), rate of NSTE-ACS (p<0.001), and STEMI (p<0.001) in all patients between the risk groups. There was a positive significant correlation between the GRS and the SS (r=0.427, p<0.001), but there were no significant correlation between the TRI and SS (r=0.121, p=0.135). The area under the ROC curve value for GRS was 0.65 (95% CI: 0.56-0.74, p=0.001) in the prediction of severity of CAD. The GRS is more associated with SS than TRI in predicting the severity of CAD in patients with ACS.

The effect of streptokinase therapy in STEMI and conventional therapy in NSTEMI patients on TIMI risk index, B-type natriuretic peptide and high-sensitive C-reactive protein

Article

Full-text available

Sep 2011
ANADOLU KARDIYOL DER

In this study, it was aimed to investigate the effect of streptokinase therapy in ST elevation myocardial infarction (STEMI) and conventional therapy in non-ST elevation myocardial infarction (NSTEMI) patients on the thrombolysis in myocardial infarction (TIMI) risk index (TRI), B-type natriuretic peptide (BNP), and high-sensitive C-reactive protein (hs-CRP) levels. Eighty-six STEMI (male/female ratio: 65/21, mean age 57.52±9.87 years) and eighty NSTEMI patients (male/female ratio: 50/30, mean age 57.6±1.7 years) were included in this prospective observational study. Hs-CRP and BNP were measured and TIMI risk index was calculated in all patients. Coronary angiography was performed in all patients for principally determining TIMI flow rate. Chi-square test, paired t-test or Wilcoxon signed rank test, ANOVA and Spearman correlation analysis were used for statistical analysis where appropriate. STEMI patients had higher systolic blood pressure, heart rate, BNP and hs-CRP values than NSTEMI patients at admission (p=0.04, p=0.01, p=0.001 and p=0.01, respectively). Thrombolytic therapy in STEMI patients resulted in statistically significant higher levels of BNP, hs-CRP and TRI values compared to baseline levels (p=0.001, p=0.001 and p=0.042, respectively). For NSTEMI patients conventional therapy yielded statistically significant decrease in systolic blood pressure levels and increase in TRI (p=0.001 and p=0.047, respectively). We found significantly lower BNP, hs-CRP in patients with higher TIMI flow rate (p=0.001 and p=0.001 respectively). Thrombolytic therapy with streptokinase failed to decrease BNP, hs-CRP and TRI values in STEMI patients. Conventional therapy in NSTEMI patients also resulted in higher TRI values than baseline values. We reached TIMI 3 flow in only 10.5% of the study patients, which may be responsible for our findings.

In-hospital outcome of acute myocardial infarction in correlation with 'thrombolysis in myocardial infarction' risk score

Article

Full-text available

Oct 2009

Effective risk stratification is integral to management of acute coronary syndromes (ACS). The Thrombolysis in Myocardial Infarction (TIMI) risk score for ST-segment elevation myocardial infarction (STEMI) is a simple integer score based on 8 high-risk parameters that can be used at the bedside for risk stratification of patients at presentation with STEMI. To evaluate the prognostic significance of TIMI risk score in a local population group of acute STEMI. The study included 160 cases of STEMI eligible for thrombolysis. TIMI risk score was calculated for each case at the time of presentation and were then followed during their hospital stay for the occurrence of electrical and mechanical complications as well as mortality. 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). The frequencies of complications and deaths were compared among the three risk groups. Post MI arrhythmias were noted in 2.2%, 16% and 50%; cardiogenic shock in 6.7%, 16% and 60%; pulmonary edema in 6.7%, 20% and 80%; mechanical complications of MI in 0%, 8% and 30%; death in 4.4%, 8%, and 60% of patients belonging to low-risk, moderate-risk and high-risk groups respectively. Frequency of complications and death correlated well with TIMI risk score (p = 0.001). TIMI risk score correlates well with the frequency of electrical or mechanical complications and death after STEMI.

Data analytics approach for short- and long-term mortality prediction following acute non-ST-elevation myocardial infarction (NSTEMI) and Unstable Angina (UA) in Asians

Article

Full-text available

Feb 2024
PLOS ONE

Background Traditional risk assessment tools often lack accuracy when predicting the short- and long-term mortality following a non-ST-segment elevation myocardial infarction (NSTEMI) or Unstable Angina (UA) in specific population. Objective To employ machine learning (ML) and stacked ensemble learning (EL) methods in predicting short- and long-term mortality in Asian patients diagnosed with NSTEMI/UA and to identify the associated features, subsequently evaluating these findings against established risk scores. Methods We analyzed data from the National Cardiovascular Disease Database for Malaysia (2006–2019), representing a diverse NSTEMI/UA Asian cohort. Algorithm development utilized in-hospital records of 9,518 patients, 30-day data from 7,133 patients, and 1-year data from 7,031 patients. This study utilized 39 features, including demographic, cardiovascular risk, medication, and clinical features. In the development of the stacked EL model, four base learner algorithms were employed: eXtreme Gradient Boosting (XGB), Support Vector Machine (SVM), Naive Bayes (NB), and Random Forest (RF), with the Generalized Linear Model (GLM) serving as the meta learner. Significant features were chosen and ranked using ML feature importance with backward elimination. The predictive performance of the algorithms was assessed using the area under the curve (AUC) as a metric. Validation of the algorithms was conducted against the TIMI for NSTEMI/UA using a separate validation dataset, and the net reclassification index (NRI) was subsequently determined. Results Using both complete and reduced features, the algorithm performance achieved an AUC ranging from 0.73 to 0.89. The top-performing ML algorithm consistently surpassed the TIMI risk score for in-hospital, 30-day, and 1-year predictions (with AUC values of 0.88, 0.88, and 0.81, respectively, all p < 0.001), while the TIMI scores registered significantly lower at 0.55, 0.54, and 0.61. This suggests the TIMI score tends to underestimate patient mortality risk. The net reclassification index (NRI) of the best ML algorithm for NSTEMI/UA patients across these periods yielded an NRI between 40–60% (p < 0.001) relative to the TIMI NSTEMI/UA risk score. Key features identified for both short- and long-term mortality included age, Killip class, heart rate, and Low-Molecular-Weight Heparin (LMWH) administration. Conclusions In a broad multi-ethnic population, ML approaches outperformed conventional TIMI scoring in classifying patients with NSTEMI and UA. ML allows for the precise identification of unique characteristics within individual Asian populations, improving the accuracy of mortality predictions. Continuous development, testing, and validation of these ML algorithms holds the promise of enhanced risk stratification, thereby revolutionizing future management strategies and patient outcomes.

Comparative analysis of four established risk scores for prediction of in-hospital mortality in patients undergoing primary percutaneous coronary intervention

Article

Full-text available

Dec 2022

Objective: This study was conducted to compare the predictive power of Shock Index (SI), TIMI Risk Index (TRI), LASH Score, and ACEF Score for the prediction of in-hospital mortality in a contemporary cohort of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) at a tertiary care cardiac center of a developing country. Methods: Consecutive patients diagnosed with STEMI and undergoing primary PCI were included in this study. SI, TRI, LASH, and ACEF were computed and their predictive power was assessed as the area under the curve (AUC) on the receiver operating characteristics (ROC) curve analysis for in-hospital mortality. Results: We included 977 patients, 780 (79.8%) of which were male, and the mean age was 55.6 ± 11.5 years. The in-hospital mortality rate was 4.3% (42). AUC for TRI was 0.669 (optimal cutoff: ≥17.5, sensitivity: 76.2%, specificity: 45.6%). AUC for SI was 0.595 (optimal cutoff: ≥0.9, sensitivity: 21.4%, specificity: 89.8%). AUC for LASH score was 0.745 (optimal cutoff: ≥0, sensitivity: 76.2%, specificity: 66.9%). AUC for the ACEF score was 0.786 (optimal cutoff: ≥1.66, sensitivity: 71.4%, specificity: 73.5%). Conclusion: In conclusion, ACEF showed sufficiently high predictive power with good sensitivity and specificity compared to other three scores. These simplified indices based on readily available hemodynamic parameters can be reliable alternatives to the computational complex scoring systems for the risk stratification of STEMI patients.

THE INTERNATIONAL JOURNAL OF CURRENT MEDICAL AND BIOLOGICAL SCIENCES e-ISSN: 2791-8815 Original Article The Relationship between SYNTAX Score and Resting/Post-exercise Ankle-Brachial index in Patients with Acute Coronary Syndrome Akut Koroner Sendromlu Hastalarda SYNTAX Skoru ile Dinlenme/Egzersiz Sonrası Ayak Bileği-Kol İndeksi Arasındaki İlişki

Article

Full-text available

Jul 2022

Background: The aim of this study is to determine the relationship between the complexity of coronary artery disease (CAD), determined by the SYNTAX score, and the resting and post-exercise Ankle-Brachial Index (ABI). Materials and Methods: Patients who were treated for Acute Coronary Syndrome (ACS) were evaluated in our study. The patients were divided into two groups according to their SYNTAX Score ≤22 or >22. In addition, patients were evaluated in two groups as <30 and ≥30 in the SYNTAX II (PCI) scoring. The measurements of the resting ABI and the post-exercise ABI were done in these patients.Results: The mean age of 118 patients was 57.50±11.19 years and 26 (22%) patients were female. In the group with SYNTAX Score>22, lower resting ABI (p <0.001) and postexercise ABI (p <0.001) were observed, whereas the higher SYNTAX II PCI (p= 0.005) score was found. While lower resting ABI (p<0.001) and post-exercise ABI (p<0.001) were observed in the group with SYNTAX II PCI Score ≥30, TIMI (0.015), GRACE score (0.004) and SYNTAX score (p= 0.001) were higher. As a result of the ROC analysis: resting ABI cut-off value was detected as 0.935 with a sensitivity of 75% and a specificity of 75% [p<0.001; AUC(95% CI)= 0.786 (0.697- 0.875)] and post-exercise ABI cut-off value was detected as 0.945 with a sensitivity of 80% and a specificity of 81% to predict SYNTAX score >22 [p <0.001; AUC (95% CI)= 0.836 (0.761-0.912)]. Diabetes mellitus, history of CAD, resting and postexercise ABI variables were found to be independent predictors of the extent of CAD, expressed as SYNTAX score >22 and SYNTAX II PCI score ≥30.Conclusion: In ACS patients, post-exercise ABI measurements have a stronger diagnostic power than resting ABI measurements in predicting CAD complexity. ABI measures at resting and post-exercise are independent predictors of CAD complexity in ACS patients. Keywords: Acute Coronary Syndrome, Ankle-Brachial Index, Coronary Artery Disease, SYNTAX Score

Noninvasive Assessment of Prognosis After Acute Myocardial Infarction in Diabetic and Non-diabetic Patients Noninvasive Assessment of Prognosis After Acute MyocardialInfarction in Diabetic and Non-diabetic Patients

Article

Full-text available

Jan 2007

Abstract Background: Diabetes mellitus constitutes an additional risk for patients with acute myocardial infarction (AMI). The present study aimed to evaluate the impact of diabetes on the prognosis after AMI through noninvasive assessment of the major determinants of adverse outcomes post-infarction in diabetic and non-diabetic patients. Patients and Methods:The study was conducted on 32 patients presenting with their first STEMI, all of whom received thrombolytic therapy using streptokinase within 6 hours from symptom onset. Patients were chosen to form 2 groups; group A: included 16 diabetic patients and group B: included 16 non-diabetic patients. Using some of the prognostic parameters derived from clinical, laboratory, electrocardiographic and echocardiographic examinations and, when performed, post-discharge exercise ECG stress testing, the baseline characteristics, the course and the clinical outcome were compared in both groups. Results: Compared to non-diabetics, diabetic patients had significantly larger infarct size, in terms of larger number of leads showing ST�segment elevation in the admission ECG (p= 0.013) and a higher enzymatic infarct size, as measured by peak creatine kinase (CK) and CK-MB (p=0.022 and p=0.020; respectively). In addition, they were less likely to have complete ST-segment resolution (STR) at 180 minutes after the initiation of thrombolytic therapy (p=0.004). Moreover, they had significantly lower left ventricular (LV) ejection fraction (p=0.013), higher resting wall motion score index (p=0.009) and higher prevalence of restrictive LV filling pattern (p=0.028). During a follow up period of at least six months, diabetic patients were less likely to have event-free survival (p=0.012). Using univariate analysis, predictors of outcome after AMI were the presence of diabetes, levels of fasting and 2-hour postprandial blood glucose, time to treatment, peak CK-MB level, anterior infarction, ejection fraction, the presence of restrictive LV filling pattern and the achievement of complete STR. However, after adjustment for other confounding factors, the only variable which retained its significance was the achievement of complete STR (adjusted OR= 0.032, 95% CI= 0.002- 0.619, p= 0.023). Conclusions: From this study, it can be concluded that a greater proportion of diabetic patients fail to achieve normal myocardial perfusion after thrombolytic therapy, a finding associated with higher morbidity and mortality in this patient cohort. In addition, achievement of complete STR is an independent factor for event free survival after AMI

Use of the Thrombolysis in Myocardial Infarction Risk Index for Elderly Patients With ST-Segment Elevation Myocardial Infarction

Article

Full-text available

Nov 2021

Background: Thrombolysis in Myocardial Infarction (TIMI) Risk Index (TRI) is a simple risk assessment tool for patients with ST-segment elevation myocardial infarction (STEMI). However, its applicability to elderly patients with STEMI undergoing percutaneous coronary intervention (PCI) is uncertain. Methods: This was a retrospective analysis of elderly (≥60 years) patients who underwent PCI for STEMI from January 2010 to April 2016. TRI was calculated on admission using the following formula: heart rate × (age/10) ² /systolic blood pressure. Discrimination and calibration of TRI for in-hospital events and 1 year mortality were analyzed. Results: Totally 1,054 patients were divided into three groups according to the tertiles of the TRI: <27 ( n = 348), 27–36 ( n = 360) and >36 ( n = 346). The incidence of acute kidney injury (AKI; 7.8 vs. 8.6 vs. 24.0%, p < 0.001), AHF (3.5 vs. 6.6 vs. 16.2%, p < 0.001), in-hospital death (0.6 vs. 3.3 vs. 11.6%, p < 0.001) and MACEs (5.2 vs. 5.8 vs. 15.9%, p < 0.001) was significantly higher in the third tertile. TRI showed good discrimination for in-hospital death [area under the curve (AUC) = 0.804, p < 0.001; Hosmer-Lemeshow p = 0.302], which was superior to its prediction for AKI (AUC = 0.678, p < 0.001; Hosmer-Lemeshow p = 0.121), and in-hospital MACEs (AUC = 0.669, p < 0.001; Hosmer-Lemeshow p = 0.077). Receiver-operation characteristics curve showed that TRI > 42.0 had a sensitivity of 64.8% and specificity of 82.2% for predicting in-hospital death. Kaplan-Meier analysis showed that patients with TRI > 42.0 had higher 1 year mortality (Log-rank = 79.2, p < 0.001). Conclusion: TRI is suitable for risk stratification in elderly patients with STEMI undergoing PCI, and is thus of continuing value for an aging population.

Glucose-insulin-potassium therapy in acute myocardial infarction: Ten years follow-up

Article

Jan 2015

The importance of TIMI risk score in patients with acute myocardial infarction with ST segment elevation

Article

Jan 2012

Uji Validasi Simple Risk Index dan Evaluation of Methods and Management of Acute Coronary Events dalam Memprediksi Mortalitas Pasien Sindrom Koroner Akut di Intensive Coronary Care Unit Rumah Sakit Cipto Mangunkusumo

Article

Full-text available

Dec 2017

Pendahuluan. Stratifikasi risiko merupakan komponen penting dalam tata laksana menyeluruh pasien sindrom koroner akut (SKA) untuk menghindari tindakan yang berlebihan pada pasien dengan risiko rendah, dan sebaliknya. Simple Risk Index (SRI) dan Evaluation of Methods and Management of Acute Coronary Events (EMMACE) telah divalidasi sebelumnya, namun uji validasi yang mengevaluasi performa skor SRI dan EMMACE di Indonesia dengan karakteristik pasien yang dapat berbeda dari negara lain belum dilakukan. Penelitian ini dilakukan untuk mengevaluasi performa skor SRI dan EMMACE memprediksi mortalitas 30 hari pasien SKA. Metode. Studi kohort retrospektif dilakukan dengan menggunakan data rekam medis pasien SKA yang dirawat di Intensive Coronary Care Unit Rumah Sakit Cipto Mangunkusumo (ICCU RSCM) tahun 2003-2010. Pengambilan sampel dilakukan dengan metode konsekutif. Analisis data dilakukan dengan menggunakan program SPSS for Windows versi 17. Performa diskriminasi dinyatakan dengan nilai area under the receiver-operator curve (AUC) dan performa kalibrasi dinyatakan dengan plot kalibrasi dan uji Hosmer Lemeshow. Hasil. Didapatkan total subjek sebanyak 922 pasien yang terdiri dari 453 pasien STEMI, 234 pasien NSTEMI, dan 235 pasien UAP yang dirawat di ICCU RSCM pada tahun 2003-2010. Skor SRI untuk STEMI memberikan performa diskriminasi dan performa kalibrasi yang baik dengan nilai AUC sebesar 0,92 dan plot kalibrasi (R2)= 0,98 dengan hasil uji Hosmer Lemeshow mendapatkan nilai p=0,01. Skor SRI pada pasien SKA secara keseluruhan juga memberikan performa diskriminasi dan kalibrasi yang baik. Performa diskriminasi skor SRI pada pasien SKA mencapai nilai AUC sebsar 0,87 dan performa kalibrasi menunjukkan nilai R2= 0,99 dengan nilai p pada uji Hosmer lemeshow sebesar 0,52. Sementara itu, skor EMMACE pada pasien SKA memberikan perfoma diskriminasi yang baik (AUC= 0,87), namun performa kalibrasi tidak sebaik skor SRI (R2= 0,54; nilai p= 0,52). Simpulan. Skor SRI memiliki performa diskriminasi dan kalibrasi yang baik pada STEMI maupun SKA secara keseluruhan dalam memprediksi mortalitas pasien yang dirawat di ICCU RSCM. Skor EMMACE memiliki performa diskriminasi yang baik, namun performa kalibrasinya kurang baik. Kata Kunci: EMMACE, mortalitas, SKA, skor, SRI, validasi Validity of Simple Risk Index and Evaluation of Methods and Management of Acute Coronary Events to Predict Mortality in Acute Coronary Syndrome Patients in Intensive Coronary Care Unit Cipto Mangunkusumo Hospital Introduction. Risk stratification is an important part in the management of patients with an Acute Coronary Syndrome (ACS) to avoid overtreatment or undertreatment. Although Simple Risk Index (SRI) and Evaluation of Methods and Management of Acute Coronary Events (EMMACE) have been validated in other countries, no study of its applicability has been performed in Indonesia with different patients’ characteristics. This study aims to obtain the calibration and discrimination performance of SRI and EMMACE to predict 30 days mortality in ACS patients in ICCU of Cipto Mangunkusumo Hospital. Methods. A retrospective cohort study with consecutive sampling was conducted in ACS patients hospitalized in the ICCU Cipto Mangunkusumo hospital between the period of 2003 up to 2010. Data analyzed performed by SPPS program for Windows Version 17. The discrimination performance was explained using a value of area under the receiver-operator curve (AUC) while calibration performance was evaluated using hosmer lemeshow and plot calibration. Results. A total of 922 patients were included in this study consisted of 453 STEMI patients, 234 NSTEMI patients and 235 UAP patients. Simple Risk Index (SRI) score for STEMI had presentable discrimination and calibration performance (AUC= 0,92; R2= 0,98; and p value= 0,01). Simple Risk Index (SRI) score for overall ACS also showed sufficient performance and calibration discrimination (AUC= 0,87; R2= 0,99; and p value= 0,52). Meanwhile, EMMACE score in ACS patients showed satisfactory performance discrimination (AUC= 0,87), but the calibration perfomance was not as satisfactory as the SRI score with the calibration plot (R2)= 0,54 (p value= 0,52). Conclusions. Simple Risk Index (SRI) score shows a satisfactory discrimination and calibration performance both in STEMI and overall ACS patients in predicting mortality of ACS patients in ICCU Cipto Mangunkusumo Hospital. Evaluation of Methods and Management of Acute Coronary Events (EMMACE) score, nonetheless, displays sufficient discrimination performance, but poor performance of calibration.

Validación del puntaje de riesgo TIMI como predictor de mortalidad en pacientes chilenos con infarto agudo al miocardio con supradesnivel de ST

Article

Full-text available

May 2017
REV MED CHILE

Background: Thrombolysis in myocardial infarction risk score (TIMI-RS) was designed to predict early mortality in patients with a ST elevation acute myocardial infarction (STEAMI). Aim: To evaluate the predictive capacity for hospital mortality of TIMI-RS. Material and methods: Patients with ≤ 12-hour evolution STEAMI were selected from a prospective registry of all patients hospitalized in our coronary unity within January 1988 and December 2005. Observed mortality was analyzed according to TIMI-RS and its predictive capacity was estimated. Results: We analyzed 1125 consecutive patients aged 61 ± 13 years (76% men). Fifty one percent were smokers, 47% hypertensive and 40% had a history of angina. Fifty eight percent of patients underwent reperfusion therapy. Most patients had TIMI-RS scores ≤ 5 points and only 3.6% had scores ≥ 10 points. Overall mortality was 14.8% and there was an 80% concordance between observed mortality and that predicted with the TIMI-RS score. The area under the curve for the receiver operating characteristic (ROC) curve was 0.7. Conclusions: TIMI-RS was acceptably useful to predict in-hospital mortality in this group of patients with STEAMI. Differences between the observed and originally predicted mortality are explained by the clinical profile and therapeutic protocols applied to patients in different studies. Thus, caution needs to be taken when interpreting the risk associated to a specific score, particularly within non-reperfused patients whose risk might be underestimated.

Mechanisms for and consequences of cellular lipid accumulation – The role of the Very Low Density Lipoprotein (VLDL) receptor

Article

Jeanna Perman Sundelin

Validation of Grace Risk Score in predicting in-hospital mortality in patients with non ST-elevation myocardial infarction and unstable angina

Article

Full-text available

Jul 2014
J Pakistan Med Assoc

Objective: To validate the global registry of acute coronary event (grace) risk score in a Pakistani population at Tabba Heart Institute Karachi in patients with non ST-Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA). Methods: In this prospective Observational registry study, 530 adults hospitalized patients with a diagnosis of Non-ST-Elevation Myocardial Infarction and unstable angina were enrolled between March 2012 and August 2012 at the Tabba Heart Institute, Karachi, Pakistan. For each patient, the grace risk score was calculated and its discrimination evaluated and correlated with in-hospital mortality using the Kendall's tau-b bivariate correlation test. Each patient was grouped either into high, intermediate or low risk groups according to their GRS. Results: A total of 530 patients with NSTEMI and UA were included; the overall mean grace risk score in our population was 131.87 +/- 41.56. The GRACE Risk Score showed good discrimination, with Area under the ROC curve of 0.803 (95% CI 0.705-0.902, P < 0.001). During the in-hospital stay, total of 19 (3.6%) patients died, and out of those 15 (8.4%) patients belonged to high risk group. Conclusion: GRACE RS strongly validates the in-hospital mortality among our patient population presenting with a wide spectrum of complications. However, more multicentre registries on a larger population with long-term follow up are required to study detailed trends in our population.

Timely treatment for acute myocardial infarction and health outcomes: An integrative review of the literature

Article

Full-text available

Jan 2014
Aust Crit Care

Coronary heart disease is the most common condition affecting Australians. The time sensitive nature of treating ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive research for several years. Despite important advances in strategies to reduce time to treatment, time continues to represent a major determinant of mortality and morbidity. Door to balloon time (DTBT) is a key indicator of quality of care for STEMI. Nurses play a pivotal role in streamlining the care processes to influence timely management of STEMI. The aim of this paper is to review the evidence on the time to treat STEMI, the associated factors impacting upon health outcomes and explore systems of care that reduce time to treatment, using an integrative review approach. Established databases were searched from 2000 to 2012. The search terms 'myocardial infarction', 'emergency medicine', 'angioplasty balloon', 'time factors', 'treatment outcome', 'mortality', 'prognosis', 'female', 'age factors', and 'readmission', were used in various combinations. Research studies that addressed the aims of this paper were examined. Twenty-nine papers were included in this integrative review. The literature demonstrates a strong relationship between shorter DTBT and reduced in-hospital mortality. Factors such as age, gender, time of presentation and co-morbid condition were associated with increased in-hospital mortality. There is sparse literature examining the effect timely reperfusion has on longer-term mortality and other longer-term outcomes such as readmission rates and occurrence of heart failure. Additionally, strategies that effectively reduced DTBT were identified, yet little has been reported on the impact reduced DTBT has had upon health outcomes and whether these improvements were sustained. Whilst the importance of timely reperfusion is now well recognised, additional efforts to streamline the process of care and demonstrate sustained improvement for STEMI patients is required. Nurses in the areas of emergency medicine and cardiac care, play an essential role in facilitating this.

Access to primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in Canada: A geographic analysis

Article

Full-text available

Feb 2010

Primary percutaneous coronary intervention (PCI) is preferred over fibrinolysis for the treatment of ST-segment elevation myocardial infarction (STEMI). In the United States, nearly 80% of people aged 18 years and older have access to a PCI facility within 60 minutes. We conducted this study to evaluate the areas in Canada and the proportion of the population aged 40 years and older with access to a PCI facility within 60, 90 and 120 minutes. We used geographic information systems to estimate travel times by ground transport to PCI facilities across Canada. Time to dispatch, time to patient and time at the scene were considered in the overall access times. Using 2006 Canadian census data, we extracted the number of adults aged 40 years and older who lived in areas with access to a PCI facility within 60, 90 and 120 minutes. We also examined the effect on these estimates of the hypothetical addition of new PCI facilities in underserved areas. Only a small proportion of the country's geographic area was within 60 minutes of a PCI facility. Despite this, 63.9% of Canadians aged 40 and older had such access. This proportion varied widely across provinces, from a low of 15.8% in New Brunswick to a high of 72.6% in Ontario. The hypothetical addition of a single facility to each of 4 selected provinces could increase the proportion by 3.2% to 4.3%, depending on the province. About 470 000 adults would gain access in such a scenario of new facilities. We found that nearly two-thirds of Canada's population aged 40 years and older had timely access to PCI facilities. The proportion varied widely across the country. Such information can inform the development of regionalized STEMI care models.

GRACE Score and TIMI Score Combined with NT-proBNP on Predicting the Prognosis of Patients with Acute Myocardial Infarction

Article

Full-text available

Jan 2021

睿杰金

Sudden Cardiac Arrest During the Immediate Revascularization Period in Patients With Non-ST Elevation Myocardial Infarction: A Case Series

Article

Nov 2021

Introduction The timing of sudden cardiac arrest (SCA) after myocardial infarction (MI) has been a subject of research because of the impact on preventive strategies. Currently, there is limited data on the risk of SCA in the immediate post revascularization period (≤48 h) in non-ST segment elevation myocardial infarction (NSTEMI). Methods We retrospectively reviewed the electronic medical record system and identified patients who underwent revascularization for NSTEMI at Grady Memorial Hospital, Atlanta, Georgia between January 1st, 2014–December 31st, 2019. We selected patients who had SCA within 48 h of revascularization and evaluated their socio-demographic and inpatient characteristics and outcomes. Results Sixteen (16) cases of SCA in the immediate post revascularization period (within 48 h) were identified and analyzed which corresponds to an incidence rate of 1.8% (n = 16/869). The mean age (SD) was 69 years (14.6) and 75% were males. On angiography, more than 80% of the patients had hemodynamically significant lesions in the left anterior descending arteries and its territories and 50% had multivessel disease. All 16 patients had at least one coronary artery with hemodynamically significant lesion and successfully underwent revascularization. Three-quarter of the patients had a shockable rhythm. The etiology of SCA was in-stent thrombosis in 25% of the patients, cardiogenic shock in 19%, acute respiratory failure in 13% and unknown in 44% of the cases. The 30-day mortality rate was 38%. Conclusion The rate of SCA is high in the first 48 h after MI even with revascularization. Risk stratification for SCA during this critical period may improve outcomes.

The investigation of TIMI risk index for prediction of contrast-induced acute kidney injury in patients with ST elevation myocardial infarction

Article

Jan 2019
ACTA CARDIOL

Objective: Contrast-induced acute kidney injury (CI-AKI) is a well-known and life-threating complication in patients with ST-elevation myocardial infraction (STEMI) after primary percutaneous coronary intervention (PCI). Several studies demonstrated that the Thrombolysis in Myocardial Infarction (TIMI) Risk Index (TRI) is a useful risk model in predicting early mortality in patients with acute coronary syndrome. The objective of the present study is to evaluate the predictive value of admission TRI for the occurrence of CI-AKI in patients with STEMI treated with primary PCI. Methods: This retrospective study was consisted of a total of 660 consecutive STEMI patients who had undergone primary PCI from December 2015 to March 2017.The primary end-point was CI-AKI incidence after primary PCI during the in-hospital course. Results: The TRI of CI-AKI group was higher than the non-CI-AKI group (24.2 (19.3–32.2) vs. 17.5 (12.9–24.3), p < .001, respectively). In multivariable logistic regression analysis, TRI was found to be an independent predictors of CI-AKI (OR: 1.055, 95% CI: 1.027–1.083, p < .001). The discriminative power of TRI with regards to occurrence of CI-AKI was superior compared to its components. Conclusion: This study is the first to demonstrate that TRI can be used to predict the development of CI-AKI in patients with STEMI who undergo primary PCI. Health professionals might be able to use the TRI risk score to predict CI-AKI due to the simplicity and accessibility of this risk index.

The predictive role of modified TIMI risk index in patients with ST-segment elevation myocardial infarction

Article

Feb 2018
ACTA CARDIOL

Background: The prognostic value of thrombolysis in myocardial infarction (TIMI) risk index (TRI) has been reported in patients with coronary artery disease. In this study, we evaluated the additional prognostic value of blood urea nitrogen (BUN) level to the TRI in patients with ST-segment elevation myocardial infarction (STEMI). Methods: We evaluated the in-hospital and long-term (3-year) prognostic value of modified TRI (mTRI) in patients with STEMI. The mTRI is calculated using the following equation; mTRI = (TRI × BUN)/10. Patients were stratified into 5 groups according to 20-point increments of mTRI. Results: The patients with higher mTRI had significantly higher in-hospital and long-term mortality. The risk for in-hospital and long-term mortality was highest for those within the Q5 (36.8 and 42.3%, respectively) and it was significantly higher than all the other groups (p < .001 for both). Conclusions: In this study, the prognostic value of TRI has been augmented by multiplication of TRI with BUN/10. Therefore, we present a pilot study of association of mTRI with overall STEMI patients.

Accuracy of the TIMI and GRACE scores in predicting coronary disease in patients with non-ST-elevation acute coronary syndrome

Article

Full-text available

Jan 2018

Introduction The GRACE and TIMI scores have been well validated for assessment of prognosis in non-ST-elevation acute coronary syndrome (NSTE-ACS). However, their value in predicting coronary artery disease (CAD) has been little studied. We aimed to assess the relationship between these scores and the extent of coronary disease. Methods We analyzed 238 consecutive patients admitted for NSTE-ACS and undergoing a coronary angiogram during hospitalization. The severity of CAD was assessed using the SYNTAX score. Obstructive CAD was defined as ≥50% stenosis in the left main or ≥70% stenosis in other vessels. Severe CAD was defined as a SYNTAX score >32. The Pearson test was used to assess the correlation between scores. Results The SYNTAX score was higher in patients at high risk (GRACE score: p<0.001 and TIMI score: p=0.001). Moreover, there was a significant positive correlation between the GRACE and SYNTAX scores (r=0.23, p<0.001) as well as between TIMI and SYNTAX (r=0.2, p=0.002). Both clinical scores can predict obstructive CAD moderately well (area under the curve [AUC] for GRACE score: 0.599, p=0.015; TIMI score: AUC 0.639, p=0.001) but not severe disease. A GRACE score of 120 and a TIMI score of 2 were predictive of obstructive CAD with, respectively, a sensitivity of 57% and 75.7% and a specificity of 61.8% and 47.9%. Conclusion The GRACE and TIMI scores correlate moderately with the extent of coronary disease assessed by the SYNTAX score. They can predict obstructive CAD but not severe disease.

Accuracy of the TIMI and GRACE scores in predicting coronary disease in patients with non-ST-elevation acute coronary syndrome

Article

Full-text available

Jan 2018

Introduction: The GRACE and TIMI scores have been well validated for assessment of prognosis in non-ST-elevation acute coronary syndrome (NSTE-ACS). However, their value in predicting coronary artery disease (CAD) has been little studied. We aimed to assess the relationship between these scores and the extent of coronary disease. Methods: We analyzed 238 consecutive patients admitted for NSTE-ACS and undergoing a coronary angiogram during hospitalization. The severity of CAD was assessed using the SYNTAX score. Obstructive CAD was defined as ≥50% stenosis in the left main or ≥70% stenosis in other vessels. Severe CAD was defined as a SYNTAX score >32. The Pearson test was used to assess the correlation between scores. Results: The SYNTAX score was higher in patients at high risk (GRACE score: p<0.001 and TIMI score: p=0.001). Moreover, there was a significant positive correlation between the GRACE and SYNTAX scores (r=0.23, p<0.001) as well as between TIMI and SYNTAX (r=0.2, p=0.002). Both clinical scores can predict obstructive CAD moderately well (area under the curve [AUC] for GRACE score: 0.599, p=0.015; TIMI score: AUC 0.639, p=0.001) but not severe disease. A GRACE score of 120 and a TIMI score of 2 were predictive of obstructive CAD with, respectively, a sensitivity of 57% and 75.7% and a specificity of 61.8% and 47.9%. Conclusion: The GRACE and TIMI scores correlate moderately with the extent of coronary disease assessed by the SYNTAX score. They can predict obstructive CAD but not severe disease.

Risk stratification after ST-segment elevation myocardial infarction

Article

Nov 2016

Introduction: Risk stratification according to the timing of assessment, treatment modality and outcome of interest is highly advisable in patients with ST-elevation myocardial infarction (STEMI) to identify optimal treatment strategies, proper length of hospital stay and correct timing of follow-up. Areas Covered: This review is an overview summarizing the characteristics and performance of available risk-scoring systems for STEMI. In particular, we sought to highlight the characteristics of STEMI cohorts used for derivation and validation of the available algorithms and appraise their discrimination ability, calibration and global accuracy. Expert commentary: Applying the appropriate score, customized on patients’ profile and clinical characteristics at presentation or during the hospitalization, might prove useful to improve the overall quality of care provided to STEMI patients.

Usefulness of the Thrombolysis In Myocardial Infarction Risk Index in Acute Heart Failure: A Pilot Study

Article

Aug 2016

Background: Risk stratification in acute heart failure (AHF) is vital for both physicians and paramedical personals. Thrombolysis in myocardial infarction (TIMI) risk index (TRI) and modified TRI (mTRI) are novel and simple predictive risk indices that have been examined in patients with acute coronary syndrome. Objective: In the current study, we evaluated the relationship among TRI, mTRI, and mortality in patients with AHF. Methods: A total of 293 patients with AHF were retrospectively analyzed. The patients were divided into 2 groups: group 1 consisted of patients who survived and group 2 consisted of patients who died during a follow-up period of 120 days. Multivariate hierarchical logistic regression analysis was performed to evaluate the relationship among TRI, mTRI, and mortality. Results: All causes of death occurred in 84 patients (28.6%). Thrombolysis in myocardial infarction risk index was significantly higher in patients who died during follow-up (20.2 ± 12.4 vs 14.8 ± 8.9). The new risk score showed good predictive value for 120-day mortality. Before laboratory analysis, in-multivariate hierarchical logistic regression analysis TRI remained as an independent risk factor for mortality (odds ratio, 2.56; P < .001). After the laboratory analysis, despite the fact that TRI has lost its predictive value, mTRI remained an independent risk factor for mortality (odds ratio, 2.08; P = .01). Conclusion: The TRI is a simple and strong predictor of all-cause mortality in patients who were admitted with AHF. The current study reveals for the first time the strong predictive value of TRI in patients with AHF.

Long-Term Prognostic Implications of the Admission Shock Index in Patients With Acute Myocardial Infarction Who Received Percutaneous Coronary Intervention

Article

Jun 2016

The admission shock index (SI) enables prediction of short-term prognosis. This study investigated the prognostic implications of admission SI for predicting long-term prognoses for acute myocardial infarction (AMI). The participants were 680 patients with AMI who received percutaneous coronary intervention. Shock index is the ratio of heart rate and systolic blood pressure. Patients were classified as admission SI <0.66 (normal) and ≥0.66 (elevated; 75th percentile). The end point was 5-year major adverse cardiac events (MACEs). Elevated admission SI was seen in 176 patients. Peak creatine kinase levels were significantly higher and left ventricular ejection fraction was lower in the elevated SI group, which had a worse MACEs. In multivariate Cox regression analysis, SI ≥0.66 was a risk factor for MACE. Elevated admission SI was associated with poorer long-term prognosis.

The relationship of TIMI risk index with SYNTAX and Gensini risk scores in predicting the extent and severity of coronary artery disease in patients with STEMI undergoing primary percutaneous coronary intervention

Article

Full-text available

Oct 2015

The prognostic value of the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) and the Thrombolysis in Myocardial Infarction (TIMI) risk index (TRI) have been reported in patients with coronary artery disease (CAD). In this study, we sought to evaluate the association between TRI and the extent and severity of CAD evaluated by SYNTAX score (SS) and Gensini score in patients with ST elevation myocardial infarction (STEMI). A total of 290 patients with STEMI were included in the study. GRS and TRI were calculated on admission using specified variables. The extent and severity of CAD were evaluated using the SS and Gensini scores. The patients were divided into low (TRI ⩽19), intermediate (TRI 19-30), and high (TRI ⩾30) risk groups. A Pearson correlation analysis was used for the relationship between TRI, GRS, Gensini score and SS. There were significant differences in the mean age (p < 0.001), admission heart rate (p < 0.001), admission systolic blood pressure (p = 0.009), SS (p < 0.001), GRS (p < 0.001) and in-hospital major adverse cardiac events (MACE) in all patients between the low, intermediate and high TRI risk groups. There was a positive significant correlation between TRI and SS (r = 0.24, p < 0.001), Gensini score(r = 0.18, p = 0.002), GRS (r = 0.74, p = 0.001) and in-hospital MACE (r = 0.29, p < 0.001). TRI is significantly related to SS and Gensini score in predicting the extent and severity of CAD in patients with STEMI. © The Author(s), 2015.

The association between elevated admission systolic blood pressure in patients with acute coronary syndrome and favorable early and late outcomes

Article

Dec 2014

In patients with acute coronary syndrome (ACS), the predictive potential of admission systolic blood pressure (SBP) on early and late outcomes is not entirely clear. We investigated the association between admission SBP in patients hospitalized for ACS and subsequent morbidity and mortality in a real world setting. The study population comprised 7645 ACS patients enrolled in the Acute Coronary Syndromes Israeli Survey (ACSIS) between 2002 and 2010. We analyzed the association between admission SBP, and the rates of 7-day and 1-year all-cause mortality and of 30-day major cardiovascular adverse events (MACE). Admission SBP was categorized as low (<110 mm Hg), normal (110-140 mm Hg), high (141-160 mm Hg), and very high (>160 mm Hg). Compared with patients with normal admission SBP, those with low SBP had a significantly increased hazard ratios (HRs) for 7-day and 1-year mortality, and MACE of 2.37, 1.92, and 1.51, respectively (all P < .001). In contrast, patients with very high admission SBP had significantly decreased HRs for 7-day and 1-year mortality, and MACE of 0.46, 0.65, and 0.84, respectively (P = .004, <.001, and .07, respectively). In patients with ACS, elevated admission SBP is associated with favorable early and late outcomes. Copyright © 2015 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Short-term follow-up of tirofiban as alternative therapy for urgent surgery patients with an implanted coronary drug-eluting stent after ST-elevation myocardial infarction

Article

Sep 2013

Patients with a recently diagnosed ST-elevation myocardial infarction (STEMI) and implanted coronary drug-eluting stent (DES) who need urgent surgery are at increased risk of surgical bleeding unless aspirin and clopidogrel are discontinued beforehand. However, discontinuation of aspirin and clopidogrel is associated with a high rate of recurrent myocardial infarction, heart failure, and malignant arrhythmias because of stent thrombosis. The main point of debate is how to treat these patients. We hypothesized that perioperative intravenous administration of tirofiban, a GPIIb/IIIa inhibitor, would allow the safe withdrawal of aspirin and clopidogrel without increasing the risk of surgical bleeding. Twenty-one patients implanted with a coronary DES after STEMI who underwent urgent surgery were selected for this clinical trial. Tirofiban was used to replace aspirin and clopidogrel (dual antiplatelet drugs) before and after urgent surgery. Major adverse cardiovascular and bleeding events were observed during hospitalization and within 3 months of discharge. Twenty-one patients with recently diagnosed STEMI and implanted DES [median (range) 6 (3-8) months] and high-risk characteristics for stent thrombosis underwent urgent major surgery. Tirofiban was used to replace aspirin and clopidogrel 5 days before surgery, stopped 4 h before surgery, and resumed until oral aspirin and clopidogrel was resumed after surgery. There were no deaths, myocardial infarction, stent thrombosis, or surgical re-exploration because of bleeding during hospitalization and within 3 months of discharge. There was one case of acute left ventricular failure during hospitalization. In patients who need urgent surgery after recently diagnosed STEMI and implanted DES, a strategy using tirofiban may allow temporary withdrawal of dual antiplatelet drugs without increasing the risk of bleeding. This conclusion needs to be further confirmed by large-scale randomized clinical trials.

Le profil de risque dans l’infarctus du myocarde : une évaluation indispensable pour la comparaison des populations

Article

Feb 2009
ANN CARDIOL ANGEIOL

Objective The aim of this study is to show that differences of mortality, in acute myocardial infarction, observed between hospitals are not necessarily linked to a bad application of guidelines but can be linked to differences in the risk profile of the populations.

Impact of Cardiac Care Variation on ST-Elevation Myocardial Infarction Outcomes in Malaysia

Article

Feb 2013

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention [P-PCI]). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved.

The VLDL receptor promotes lipotoxicity and increases mortality in mice following an acute myocardial infarction

Article

Full-text available

Jun 2011
J CLIN INVEST

Impaired cardiac function is associated with myocardial triglyceride accumulation, but it is not clear how the lipids accumulate or whether this accumulation is detrimental. Here we show that hypoxia/ischemia-induced accumulation of lipids in HL-1 cardiomyocytes and mouse hearts is dependent on expression of the VLDL receptor (VLDLR). Hypoxia-induced VLDLR expression in HL-1 cells was dependent on HIF-1α through its interaction with a hypoxia-responsive element in the Vldlr promoter, and VLDLR promoted the endocytosis of lipoproteins. Furthermore, VLDLR expression was higher in ischemic compared with nonischemic left ventricles from human hearts and was correlated with the total lipid droplet area in the cardiomyocytes. Importantly, Vldlr-/- mice showed improved survival and decreased infarct area following an induced myocardial infarction. ER stress, which leads to apoptosis, is known to be involved in ischemic heart disease. We found that ischemia-induced ER stress and apoptosis in mouse hearts were reduced in Vldlr-/- mice and in mice treated with antibodies specific for VLDLR. These findings suggest that VLDLR-induced lipid accumulation in the ischemic heart worsens survival by increasing ER stress and apoptosis.

Predictive scoring in non-trauma emergency patients: A scoping review

Article

Full-text available

Sep 2011
EMERG MED J

This study is an inclusive scoping review of the literature relating to outcome prediction in adult non-trauma emergency patients, in order to identify the number and range of risk scores developed for acutely ill adults and to identify the outcomes these scores predict. The data source used was Medline 1950-2009. To be eligible for inclusion, papers had to detail an assessment tool, wholly or predominantly clinical, applied at the point of patient presentation to unscheduled healthcare services with outcome measures up to 30 days after presentation. Papers detailing trauma, paediatrics, purely obstetric or psychiatric presentations, tools wholly applied in a critical care setting, tools requiring an algorithm not freely available, biomarkers or tests not routinely available in an Emergency Department (ED) setting were excluded. 192 papers were reviewed. Within 17 broad disease categories, 80 inclusion criteria were used, 119 tools were assessed (25 of which were non-disease specific), and 51 outcome measures were used (30 of which were disease-specific). The areas under the receiver-operator characteristic curve (AUROCs) varied from 0.44 to 0.984. The multiplicity of tools available presents a challenge in itself to the acute clinician. Many tools require a specific diagnosis, which is not immediately available, and the authors advocate ED development of tools for case-mix adjustment and clinical risk stratification.

Hospitals with and without percutaneous coronary intervention capability: considerations for treating acute coronary syndromes

Article

Jul 2009

The crucial aim in the emergency management of patients presenting with chest pain is the identification of acute coronary syndromes (ACS) and the initiation of appropriate treatment. Institution-specific triage to initial medical or interventional therapies is influenced by the availability of percutaneous coronary intervention (PCI) facilities. Although the use of invasive strategies has increased, most US hospitals do not have PCI facilities. Pharmacological management is an integral part of all treatment strategies, regardless of the availability of interventional capability. Given the growing importance of invasive management strategies, a therapy that is compatible with both medical and invasive therapy options is becoming increasingly important. Aspirin and clopidogrel are recommended for patients with ACS regardless of the conservative or invasive management strategy. With enoxaparin, patients with ACS can seamlessly transition from the medical management phase to the interventional management phase without the need for introducing a second anticoagulant in the cardiac catheterization laboratory. Fondaparinux can be used for patients with ACS treated medically, but should not be used alone during PCI because of the risk of catheter thrombosis. Bivalirudin can be used in non-ST-segment elevation myocardial infarction patients who are managed invasively.

Thrombolysis in Myocardial Infarction (TIMI) Risk Index predicts long-term mortality and heart failure in patients with ST-elevation myocardial infarction in the TIMI 2 clinical trial

Article

May 2009

TIMI (Thrombolysis in Myocardial Infarction) Risk Index (TRI) is a simple bedside score that predicts 30-day mortality in patients with ST-elevation myocardial infarction (MI). We sought to evaluate whether TRI was predictive of long-term mortality and clinical events. In the TIMI 2 trial, 3,153 patients (mean age 57 +/- 10 years, 82% men) were randomized to invasive (n = 1,583) versus conservative (n = 1,570) strategy postfibrinolysis with median follow-up of 3 years. TIMI Risk Index was divided into 5 groups. The primary end point was all-cause mortality. Secondary analyses included recurrent MI, congestive heart failure (CHF), and combined end points. When compared with group 1, mortality in group 5 was more than 5-fold higher (hazard ratio [HR] 5.83, P < .0001) and was also increased in group 4 (HR 2.80, P < .0001) and group 3 (HR 1.96, P = .002) (c statistic 0.69). No difference was seen between groups 1 and 2 (P = .74). A similar increasing gradient effect was seen across TRI strata with group 5 having the highest risk for CHF (HR 4.13, P < .0001) and the highest risk for composite death/CHF (HR 4.35, P < .0001) over group 1. There was no difference in recurrent MI between the groups (P = .22). After controlling for other risk indicators, the relationship between TRI and mortality remained significant: group 5, HR 4.11, P < .0001; group 4, HR 2.14, P = .0009; group 3, HR 1.69, P = .02. When stratified by TRI groups, no differences in mortality or composite death/MI were found between treatment strategies. The simple TRI can predict increased long-term mortality, CHF, and composite death/CHF.

[Risk profile in acute myocardial infarction: a necessary assessment for the population's comparisons].

Article

Nov 2008

The aim of this study is to show that differences of mortality, in acute myocardial infarction, observed between hospitals are not necessarily linked to a bad application of guidelines but can be linked to differences in the risk profile of the populations. Two populations admitted for ST and non-ST elevation myocardial infarction in the same region in 2006 were compared: the population of Chalon-sur-Saône's hospital with a standard population from the observatoire des Infarctus de Côte d'Or (RICO). The risk profile of the two populations has been realised with the risk scores GRACE, EMMACE and the Simple Risk Index (SRI). The three scores are applicable for our populations according to the "C statistic". Moreover, there is a significant difference of in-hospital mortality between Chalon-sur-Saône and RICO. But, the population of Chalon-sur-Saône presents a higher risk. Finally, in-hospital rate mortality expected by the three scores is not different from the actual mortality. GRACE, EMMACE and SRI are valid scores for the comparison of risk profile of populations in acute myocardial infarction. Comparisons between hospitals are only possible after risk adjustment of the populations.

Predictors of in-hospital mortality for patients admitted with ST-elevation myocardial infarction: A real-world study using the Myocardial Infarction National Audit Project (MINAP) database

Article

Full-text available

Jul 2008
HEART

Although early thrombolysis reduces the risk of death in STEMI patients, mortality remains high. We evaluated factors predicting inpatient mortality for patients with STEMI in a "real-world" population. Analysis of the Myocardial Infarction National Audit Project (MINAP) database using multivariate logistic regression and area under the receiver operating curve analysis. All acute hospitals in England and Wales. 34 722 patients with STEMI from 1 January 2003 to 31 March 2005. Inpatient mortality was 10.6%. The highest odds ratios for inpatient survival were aspirin therapy given acutely and out-of-hospital thrombolysis, independently associated with a mortality risk reduction of over half. A 10-year increase in age doubled inpatient mortality risk, whereas cerebrovascular disease increased it by 1.7. The risk model comprised 14 predictors of mortality, C index = 0.82 (95% CI 0.82 to 0.83, p<0.001). A simple model comprising age, systolic blood pressure (SBP) and heart rate (HR) offered a C index of 0.80 (0.79 to 0.80, p<0.001). The strongest predictors of in-hospital survival for STEMI were aspirin therapy given acutely and out-of-hospital thrombolysis, Previous STEMI models have focused on age, SBP and HR We have confirmed the importance of these predictors in the discrimination of death after STEMI, but also demonstrated that other potentially modifiable variables impact upon the prediction of short-term mortality.

High-risk Acute Coronary Syndrome Patients with Non-ST-Elevation Myocardial Infarction: Definition and Treatment

Article

Aug 2008

Marc Cohen

Early risk stratification of patients with acute coronary syndromes (ACS), unstable angina, or non-ST-elevation myocardial infarction ensures patients receive appropriate care. Many risk-stratification models have been developed to identify high-risk ACS patients who would benefit most from an early invasive strategy and to determine patients at greater risk for bleeding complications. Although high-risk patients seem to benefit most from a combination of aggressive antithrombotic and early invasive therapies, stratification for risk of bleeding also helps in the choice and dosing of appropriate medical therapy. The effective use of glycoprotein IIb/IIIa inhibitors, in particular, is dependent on accurate risk assessment, whereas the risk-to-benefit ratio of direct thrombin inhibitors in high-risk versus low-risk patients as part of an initial therapy plan requires clarification. Nevertheless, use of the same anticoagulant throughout the care pathway may reduce the rates of death or recurrent myocardial infarction, and bleeding complications.

The TIMI risk scores for unstable angina/non-ST elevation MI

Article

Full-text available

Aug 2000

Context 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.Objective 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.Design, Setting, and Patients 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.Main Outcome Measures 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.Results 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 χ2 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).Conclusions 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.

The Meaning and Use of the Area Under a Receiver Operating Characteristic (ROC) Curve

Article

Full-text available

May 1982

A representation and interpretation of the area under a receiver operating characteristic (ROC) curve obtained by the "rating" method, or by mathematical predictions based on patient characteristics, is presented. It is shown that in such a setting the area represents the probability that a randomly chosen diseased subject is (correctly) rated or ranked with greater suspicion than a randomly chosen non-diseased subject. Moreover, this probability of a correct ranking is the same quantity that is estimated by the already well-studied nonparametric Wilcoxon statistic. These two relationships are exploited to (a) provide rapid closed-form expressions for the approximate magnitude of the sampling variability, i.e., standard error that one uses to accompany the area under a smoothed ROC curve, (b) guide in determining the size of the sample required to provide a sufficiently reliable estimate of this area, and (c) determine how large sample sizes should be to ensure that one can statistically detect differences in the accuracy of diagnostic techniques.

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

Article

Full-text available

Aug 2000

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

The Risk Score Profile: A novel approach to characterising the risk of populations enrolled in clinical studies

Article

Full-text available

Jul 2004

Interpreting the results and practice implications of clinical studies requires accurate characterisation of the baseline risk of the population. We evaluated the Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI as a tool to describe and compare the risk profile of populations enrolled in three clinical trials (InTIME-II, ASSENT-2 and MAGIC) and the National Registry of Myocardial Infarction. The risk score was calculated for each patient (N=121,085) and the frequency distribution plotted for each population. The Risk Score Profiles were compared using the Kolmogorov-Smirnov test. The Risk Score Profile demonstrated a striking concordance between the baseline risk of patients in InTIME-II and ASSENT-2 (median scores in each= 3[1,4], P=0.11). In contrast, the distributions in MAGIC (designed to enroll high risk) and NRMI (registry) were shifted significantly toward higher risk (median scores=4[3,5] for MAGIC and 4[2,6] in NRMI, P < 0.0001 for each vs. InTIME-II). A graded relationship between the risk score and mortality was evident in each study (P<0.0001). The frequency distribution of the TIMI Risk Score, or similar tools for risk assessment, may be used to quantify and readily compare the risk profile of populations enrolled in clinical studies.

Predictors of Hospital Mortality in the Global Registry of Acute Coronary Events

Article

Full-text available

Nov 2003
ARCH INTERN MED

Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk. To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice. A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001. Validation data sets included a subsequent cohort of 3972 patients enrolled in GRACE and 12 142 in the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial. The following 8 independent risk factors accounted for 89.9% of the prognostic information: age (odds ratio [OR], 1.7 per 10 years), Killip class (OR, 2.0 per class), systolic blood pressure (OR, 1.4 per 20-mm Hg decrease), ST-segment deviation (OR, 2.4), cardiac arrest during presentation (OR, 4.3), serum creatinine level (OR, 1.2 per 1-mg/dL [88.4- micro mol/L] increase), positive initial cardiac enzyme findings (OR, 1.6), and heart rate (OR, 1.3 per 30-beat/min increase). The discrimination ability of the simplified model was excellent with c statistics of 0.83 in the derived database, 0.84 in the confirmation GRACE data set, and 0.79 in the GUSTO-IIb database. Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.

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

Article

Jan 2000

Myocardial infarction redefined - A consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial InfarctionThe Joint European Society of Cardiology/American College of Cardiology CommitteeEur Heart J2000211502151310.1053/euhj.2000.230510973764

Article

Sep 2000
J AM COLL CARDIOL

Definition of MI. Criteria for acute, evolving or recent MI. Either one of the following criteria satisfies the diagnosis for an acute, evolving or recent MI: 1) Typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of biochemical markers of myocardial necrosis with at least one of the following: a) ischemic symptoms; b) development of pathologic Q waves on the ECG; c) ECG changes indicative of ischemia (ST segment elevation or depression); or d) coronary artery intervention (e.g., coronary angioplasty). 2) Pathologic findings of an acute MI. Criteria for established MI. Any one of the following criteria satisfies the diagnosis for established MI: 1) Development of new pathologic Q waves on serial ECGs. The patient may or may not remember previous symptoms. Biochemical markers of myocardial necrosis may have normalized, depending on the length of time that has passed since the infarct developed. 2) Pathologic findings of a healed or healing MI.

Predictors of Hospital Mortality in the Global Registry of Acute Coronary Events

Article

Feb 2004

A simple risk index for rapid initial triage of patients with ST-elevation myocardial infarction: an InTIME II substudy

Article

Mar 2002

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

Article

Feb 2001

Myocardial Infarction Redefined – A Consensus Document of The Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction

Article

Sep 2000

Definition of MI. Criteria for acute, evolving or recent MI. Either one of the following criteria satisfies the diagnosis for an acute, evolving or recent MI: 1) Typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of biochemical markers of myocardial necrosis with at least one of the following: a) ischemic symptoms; b) development of pathologic Qwaves on the ECG; c) ECG changes indicative of ischemia (ST segment elevation or depression); or d) coronary artery intervention (e.g., coronary angioplasty). 2) Pathologic findings of an acute MI. Criteria for established MI. Any one of the following criteria satisfies the diagnosis for established MI: 1) Development of new pathologic Q waves on serial ECGs. The patient may or may not remember previous symptoms. Biochemical markers of myocardial necrosis may have normalized, depending on the length of time that has passed since the infarct developed. 2) Pathologic findings of a healed or healing MI.

A bootstrap resampling procedure for model building: Application to the cox regression model

Article

Dec 1992

A common problem in the statistical analysis of clinical studies is the selection of those variables in the framework of a regression model which might influence the outcome variable. Stepwise methods have been available for a long time, but as with many other possible strategies, there is a lot of criticism of their use. Investigations of the stability of a selected model are often called for, but usually are not carried out in a systematic way. Since analytical approaches are extremely difficult, data-dependent methods might be an useful alternative. Based on a bootstrap resampling procedure, Chen and George investigated the stability of a stepwise selection procedure in the framework of the Cox proportional hazard regression model. We extend their proposal and develop a bootstrap-model selection procedure, combining the bootstrap method with existing selection techniques such as stepwise methods. We illustrate the proposed strategy in the process of model building by using data from two cancer clinical trials featuring two different situations commonly arising in clinical research. In a brain tumour study the adjustment for covariates in an overall treatment comparison is of primary interest calling for the selection of even 'mild' effects. In a prostate cancer study we concentrate on the analysis of treatment-covariate interactions demanding that only 'strong' effects should be selected. Both variants of the strategy will be demonstrated analysing the clinical trials with a Cox model, but they can be applied in other types of regression with obvious and straightforward modifications.

Myocardial infarction redefined: a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction

Article

Oct 2000
J AM COLL CARDIOL

Definition of MI. Criteria for acute, evolving or recent MI. Either one of the following criteria satisfies the diagnosis for an acute, evolving or recent MI: 1) Typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of biochemical markers of myocardial necrosis with at least one of the following: a) ischemic symptoms; b) development of pathologic Qwaves on the ECG; c) ECG changes indicative of ischemia (ST segment elevation or depression); or d) coronary artery intervention (e.g., coronary angioplasty). 2) Pathologic findings of an acute MI. Criteria for established MI. Any one of the following criteria satisfies the diagnosis for established MI: 1) Development of new pathologic Q waves on serial ECGs. The patient may or may not remember previous symptoms. Biochemical markers of myocardial necrosis may have normalized, depending on the length of time that has passed since the infarct developed. 2) Pathologic findings of a healed or healing MI.

TIMI Risk Score for ST-Elevation Myocardial Infarction: A Convenient, Bedside, Clinical Score for Risk Assessment at Presentation An Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial Substudy

Article

Nov 2000
CIRCULATION

Considerable variability in mortality risk exists among patients with ST-elevation myocardial infarction (STEMI). Complex multivariable models identify independent predictors and quantify their relative contribution to mortality risk but are too cumbersome to be readily applied in clinical practice. We developed and evaluated a convenient bedside clinical risk score for predicting 30-day mortality at presentation of fibrinolytic-eligible patients with STEMI. The Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI was created as the simple arithmetic sum of independent predictors of mortality weighted according to the adjusted odds ratios from logistic regression analysis in the Intravenous nPA for Treatment of Infarcting Myocardium Early II trial (n=14 114). Mean 30-day mortality was 6.7%. Ten baseline variables, accounting for 97% of the predictive capacity of the multivariate model, constituted the TIMI risk score. The risk score showed a >40-fold graded increase in mortality, with scores ranging from 0 to >8 (P:<0.0001); mortality was <1% among patients with a score of 0. The prognostic discriminatory capacity of the TIMI risk score was comparable to the full multivariable model (c statistic 0. 779 versus 0.784). The prognostic performance of the risk score was stable over multiple time points (1 to 365 days). External validation in the TIMI 9 trial showed similar prognostic capacity (c statistic 0.746). The TIMI risk score for STEMI captures the majority of prognostic information offered by a full logistic regression model but is more readily used at the bedside. This risk assessment tool is likely to be clinically useful in the triage and management of fibrinolytic-eligible patients with STEMI.

A simple risk index for rapid initial triage of patients with ST-elevation myocardial infarction: An InTIME II substudy

Article

Dec 2001

Rapid, effective triage is integral to emergency cardiac care of patients with ST-elevation myocardial infarction (STEMI). Available models for predicting mortality in STEMI include up to 45 variables, but have consistently shown advanced age, increased heart rate, and decreased blood pressure to be among the strongest predictors. On the basis of observed risk relations among 13,253 patients with STEMI from the InTIME II trial, we developed and assessed a simple risk index using age, heart rate, and systolic blood pressure (SBP) for predicting mortality over 30 days: (heart rate x [age/10](2))/SBP. The risk index was a strong (c statistic=0.78) and independent predictor of mortality risk (p<0.0001). When the risk index was categorised into quintiles for convenient clinical use, it revealed a more than 20-fold gradient of increasing mortality from 0.8 to 17.4%, p<0.0001. The risk index was also a robust predictor of very early events, including death by 24 h (c statistic=0.81). External validation in patients with STEMI from the TIMI 9 trials (n=3659) showed both a high discriminatory capacity (c statistic=0.79), and excellent concordance between the observed 30-day mortality in each of the five risk groups and the predictions based on InTIME II (goodness-of-fit, p=0.7). A simple risk index based on characteristics easily assessed by any paramedical or clinical personnel captures most of the information from more complex tools, and is likely to be useful in the rapid triage of patients with STEMI outside hospital or on first arrival in the hospital.

Validity of a Simple ST-Elevation Acute Myocardial Infarction Risk Index: Are Randomized Trial Prognostic Estimates Generalizable to Elderly Patients?

Article

Feb 2003
CIRCULATION

Risk-stratification scores derived from randomized clinical trial (RCT) data should be evaluated in community-based populations. A simple risk-stratification index for patients with ST-segment elevation myocardial infarction derived from an RCT population was recently proposed, but it has not been validated in a community-based cohort. We evaluated the simple risk index using data from 49 711 patients > or =65 years of age hospitalized with ST-elevation myocardial infarction. We evaluated the distribution of patients in the 5 simple risk index groups, compared observed and published 30-day mortality rates, and assessed the score's discrimination and calibration. The simple risk index provided poor discrimination (c=0.62) and calibration (goodness of fit P<0.001) for survival at 30 days. Risk score distribution was skewed, because two thirds (66.1%) of all patients were classified in the highest-risk group, whereas fewer than 11.0% were classified in the 3 lowest-risk groups. Thirty-day mortality estimates were lower than those observed in the cohort (risk group 2 to 5: 1.9% to 17.4% versus 5.3% to 27.9%). Risk index discrimination, calibration, score distribution, and mortality estimates were worse among patients who did not receive acute reperfusion therapy than among those who did. The limited performance of the simple risk index highlights the limitations of applying prognostic models derived in RCT populations to the general population of patients 65 years and older. Prognostic scores must be validated in community-based cohorts before integration into clinical practice.

“Routine invasive” versus “selective invasive” approaches to non–ST-segment elevation acute coronary syndromes management in the post-stent/platelet inhibition era

Article

Mar 2003
J AM COLL CARDIOL

William E Boden

Is a "routine invasive" or "selective invasive" strategy the best approach for patients with non-ST-segment elevation acute coronary syndrome (ACS)? A "selective invasive" strategy incorporates ischemia-guided use of aggressive medical therapy followed by angiography and revascularization for angina or stress-induced myocardial ischemia. The "routine invasive" strategy (cardiac catheterization followed by percutaneous coronary intervention within 24 to 48 h of symptom-onset) is frequently employed, but no randomized, controlled trials have demonstrated improved clinical outcomes. Recently, the second Fragmin and fast Revascularization during InStability in Coronary artery disease (FRISC-II) and the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction (TACTICS TIMI-18) trials found significant reductions in death, recurrent myocardial infarction, or hospitalization for biomarker-positive ACS. Also, the third Randomized Intervention Trial of unstable Angina (RITA-3) recently reported a halving of refractory angina and reduction in the use of antianginal medication with early intervention. Early trials failed to demonstrate the superiority of the "routine invasive" approach, presumably because of fewer revascularizations, unavailability of stents, and more recent use of glycoprotein IIb/IIIa inhibitors and low-molecular-weight heparins. The FRISC-II, TACTICS TIMI-18, and RITA-3 studies indicate that higher-risk patients benefit from early revascularization, but that aggressive antiplatelet, antithrombin, and anti-ischemic therapy are also important. While all three trials support an "early invasive" approach in intermediate- and high-risk patients, other trials support a more "conservative" approach in those without electrocardiographic changes or enzyme elevations. Optimal management should incorporate both strategies.

Invasive therapy along with glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival in non-ST-segment elevation acute coronary syndromes: A meta-analysis and review of the literature

Article

May 2004
AM J CARDIOL

Current evidence suggests that routine invasive therapy in the setting of unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) reduces the incidence of composite end points (i.e., death, myocardial infarction, or angina.). The 2002 American College of Cardiology/American Heart Association guidelines recommend invasive therapy in high-risk patients, although it is unknown if such an approach improves survival. We conducted a meta-analysis on 5 studies in 6,766 UA/NSTEMI patients who were randomized to either routine invasive versus conservative therapy in the era of glycoprotein IIb/IIIa inhibitors and intracoronary stents. Compared with conservative therapy, an invasive approach suggested a reduction in mortality at 6 to 12 months (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.63 to 1.03) and at 24 months (RR 0.77, 95% CI 0.60 to 0.99). The composite end point of death or myocardial infarction was reduced throughout all periods of follow-up: at 30 days (RR 0.61, 95% CI 0.45 to 0.84), at 6 months (RR 0.75, 95% CI 0.63 to 0.89), and at 12 months (RR 0.78, 95% CI 0.65 to 0.92). For the same composite end point at 6 to 12 months, men benefited from invasive therapy (RR 0.68, 95% CI 0.57 to 0.81), as did troponin-positive patients (RR 0.74, 95% CI 0.59 to 0.94). The results for women (RR 1.07, 95% CI 0.82 to 1.41) and troponin-negative patients (RR 0.82, 95% CI 0.59 to 1.14) were equivocal. Routine invasive therapy in UA/NSTEMI patients along with adjunctive use of glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival. Enhanced risk stratification is needed in women and troponin-negative patients so that invasive therapy may be more effectively recommended in these groups.

The thrombolysis in myocardial infarction risk index - A formula with a future

Article

Sep 2004
J AM COLL CARDIOL

Thomas John Ryan

It is generally agreed that one of the most important contributions made in medicine during the past century was the establishment of the coronary care unit in the early 1960s. Although Herrick ([1][1]) had clearly defined the clinical entity of acute myocardial infarction (MI) some 50 years earlier

Performance of the thrombolysis in Myocardial Infarction Risk Index in the National Registry of Myocardial Infarction-3 and -4: A simple index that predicts mortality in ST-segment elevation myocardial infarction

Article

Aug 2004
J AM COLL CARDIOL

We sought to evaluate a simple risk index based on age and vital signs in a community sample of patients with ST-segment elevation myocardial infarction (STEMI). A simple risk index based on age and vital signs (heart rate x [age/10](2)/systolic blood pressure) developed from patients with STEMI accurately predicts mortality in clinical trials of fibrinolysis. The application of such a tool in an unselected population is necessary to evaluate its utility in clinical practice. To evaluate the Thrombolysis In Myocardial Infarction (TIMI) risk index for routine practice, we tested it in the National Registry of Myocardial Infarction (NRMI)-3 and -4. The risk index was evaluated as a continuous variable in patients with STEMI from NRMI and in subgroups based on age and reperfusion status. A total of 153,486 patients with STEMI were eligible. As anticipated, STEMI patients in NRMI had a higher risk index profile, as compared with those in the clinical trial (median 26.9 vs. 20, p < 0.0001). Classification of NRMI patients with STEMI into risk groups revealed a significant graded relationship with mortality (0.9% to53.2%, p(trend) < 0.0001, c statistic 0.79). The discriminatory capacity of the risk index was particularly strong in the 81,679 patients receiving reperfusion therapy (0.6% to60%, p(trend) < 0.0001, c statistic 0.81). For the 71,807 patients not receiving reperfusion therapy, a strong graded relationship remained (1.9% to 52.2%, p(trend) < 0.0001, c statistic 0.71). Among the elderly, although the distribution of scores was shifted toward higher risk, the performance remained (0% to 53.1%, p(trend)< 0.0001, c statistic 0.71). A simple risk index from baseline clinical variables routinely obtained at the first patient encounter predicted mortality in a large unselected heterogeneous group of patients with STEMI.

Usefulness of the TIMI Risk Index in Predicting Short- and Long-Term Mortality in Patients With Acute Coronary Syndromes

Article

Oct 2005
AM J CARDIOL

In a cohort of 710 patients with acute coronary syndromes (ACSs), we demonstrated that the Thrombolysis In Myocardial Infarction Risk Index--a predictor of 30-day mortality in clinical trial patients with ST-elevation myocardial infarction (STEMI)--is a strong predictor of short- and long-term mortality with good discrimination ability (c statistics 0.77 to 0.79) among all subtypes of ACSs (STEMI, non-STEMI, and unstable angina pectoris). These results verify the utility of the Risk Index in unselected patients with STEMI, broaden its application to other types of ACSs, and extend its utility to stratification of long-term mortality risk.

Quality of Cardiac Care in Ontario. EFFECT (Enhanced Feedback for Effective Cardiac Treatment)

Dec 2004

Tu Jv Donovan
Lr
Lee
Ds

Tu JV, Donovan LR, Lee DS, et al. Quality of Cardiac Care in Ontario. EFFECT (Enhanced Feedback for Effective Cardiac Treatment), 2004. <www.ccort.ca/effect.asp> (Version current at November 10, 2006).

Validation of the Thrombolysis In Myocardial Infarction (TIMI) risk index for predicting early mortality in a population-based cohort of STEMI and non-STEMI patients

Abstract

No full-text available

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