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New Decision Instruments That Predict Risk of Thrombolysis in Myocardial Infarction May Make TIMI Score Obsolete

Can you recite the elements of the TIMI Score—the Thrombolysis in Myocardial Infarction Risk Score for Unstable Angina/Non-ST Elevation Myocardial Infarction—from memory?1 If you still can, it’s not surprising. Over the last decade, this score has been drilled, dogmatically, into many specialties, including emergency medicine. Numerous studies have utilized it, attempting to define a low-risk cohort from unselected chest pain patients presenting to the emergency department. Fortunately for EM, but unfortunately for the brain cells sacrificially dedicated to its memory, the next wave of decision instruments promises to eliminate it from use.

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 The HEART Score is Better than the TIMI Score

The TIMI score was designed to identify high-risk patients, not intermediate or low-risk patients. The HEART score is different. It takes everybody who comes to the ER with chest pain and helps you risk stratify them to determine how to work them up.

Articles of Interest

Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis

Our analysis supports the consistent performance of the TIMI risk score in the risk stratification of patients in the emergency department with potential acute coronary syndromes. For every 1000 patients in the lowest risk category (TIMI score of zero), 20 will experience a cardiac event within 30 days of the visit to the emergency department. Although this rate may render the TIMI risk score an unacceptable single reason to dismiss patients from the emergency department, this rate highlights the potential utility of this score as an adjunct to clinical acumen, as a source of information for patient decision aids and as a benchmark for researchers developing new prognostic and disposition tools.

Review of the TACTICS-TIMI 18 trial

Patients with NSTEMI tend to be older and have more comorbidities, increasing procedural risks. This also means that they have competing risks for mortality, potentially reducing the benefit of PCI. Another key challenge is that NSTEMI patients frequently have multivessel disease, making it more difficult to identify the culprit lesion; since there is usually only partial occlusion of the culprit coronary artery. In contrast, there is usually complete occlusion of a coronary artery in STEMI and ST-segment elevation on the electrocardiogram helps localize the infarcted area, making it relatively easy to identify the culprit artery.

TIMI Risk Score for Unstable Angina or Non-ST Elevation MI (NSTEMI)

The TIMI risk score is an easy bedside calculation mostly based on the patient's medical history and a few initial tests (ECG and initial labs) in patients presenting to the emergency department (ED) with unstable angina or NSTEMI when trying to assess their risk for cardiac related ischemic events and death within the first 14 days after presenting to the ED.

TIMI Score: UA/NSTEMI and STEMI Risk Stratification

The TIMI score is really two different tools — a 7-factor, 0–7 UA/NSTEMI score and a separately-weighted, 0–14 STEMI score — each predicting a different outcome. How they’re built, what they predict, and how TIMI relates to the GRACE score in ACS triage.

TIMI Score: What It Means and What to Do with a High Score

The “TIMI” score stands for “thrombolysis in myocardial infarction” score. It is one way doctors predict the risk of a serious heart problem happening soon. Doctors can use a TIMI score to help plan the next steps of treatment.

Resources

The Cardiovascular

The TIMI risk score for unstable angina/NSTEMI was developed to provide a simple instrument that can be calculated at the bedside and requires no computer and no laboratory test beyond a cardiac marker. The score is intended to serve two purposes: to stratify prognosis and to guide the choice between an invasive and a conservative strategy.

TIMI Risk Score Calculator for UA/NSTEMI

Age ≥ 65 years? Yes (+1), ≥ 3 Risk Factors for CAD*? Yes (+1), Known CAD (stenosis ≥ 50%)? Yes (+1), ASA Use in Past 7d? Yes (+1), Severe angina (≥ 2 episodes w/in 24 hrs)? Yes (+1). ST changes ≥ 0.5mm? Yes (+1), + Cardiac Marker? Yes (+1). *Risk factors include family history of CAD, hypertension, hypercholesterolemia, diabetes, or being a current smoker.

TIMI Study Group

By leading large-scale, international, randomized controlled trials of novel therapeutics and performing sophisticated analyses, we have been privileged to help shape the very practice of cardiovascular medicine for nearly half a century.

TIMI Risk Score for UA/NSTEMI

Estimates mortality for patients with unstable angina and non-ST elevation MI.