Objectives: Patients presenting with chest pain or related symptoms suggestive of myocardial ischemia, without ST-segment elevation (NSTE) on their presenting electrocardiograms, often present a diagnostic challenge in the emergency department (ED). Prompt and accurate risk stratification to identify those patients with NSTE chest pain who are at highest risk for adverse events is essential, however, to optimal management. Although validated and used frequently in patients already enrolled in acute coronary syndrome trials, the Thrombolysis in Myocardial Infarction (TIMI) risk score never has been examined for its value in risk stratification in an all-comers, non-trial-based ED chest pain population.Methods: An analysis of an ED-based prospective observational cohort study was conducted in 3,929 adult patients presenting with chest pain syndrome and warranting evaluation with an electrocardiogram. These patients had TIMI risk scores determined at ED presentation. The main outcome was the composite of death, acute myocardial infarction (MI), and revascularization within 30 days.Results: The TIMI risk score at ED presentation successfully risk-stratified this unselected cohort of chest pain patients with respect to 30-day adverse outcome, with a range from 2.1%, with a score of 0, to 100%, with a score of 7. The highest correlation of an individual TIMI risk indicator to adverse outcome was for elevated cardiac biomarker at admission. Overall, the score had similar performance characteristics to that seen when applied to other databases of patients enrolled in clinical trials and registries using a 14-day end point.
Conclusions:The TIMI risk score may be a useful tool for risk stratification of ED patients with chest pain syndrome.
ACADEMIC EMERGENCY MEDICINE 2006; 13:13-18 ª 2006 by the Society for Academic Emergency MedicineKeywords: acute coronary syndrome, complications, risk stratification, emergency department, TIMI risk score, chest pain R isk stratification for patients who present to the emergency department (ED) with chest pain syndromes, in the absence of diagnostic electrocardiographic (ECG) findings, remains an inexact science.Clinical acumen, ECG results, and biomarker assays generally may be helpful, but in the ED, 2% to 5% of patients with myocardial infarction (MI) still go undetected.
1Quick and accurate risk stratification of chest pain patients in the ED is essential to evidence-based initiation of early, aggressive medical and interventional management of non-ST-segment-elevation (NSTE) acute coronary syndrome (ACS).
2Across populations of patients, risk in patients presenting with unstable angina and NSTEMI has been assessed by using multivariable regression techniques in several large clinical trials. These models have not yet been validated in large prospective studies of NSTE ACS patients. Boersma et al.3 analyzed the connection between baseline characteristics and the incidence of death and death-plus-myocardial (re)infarction at 30 days. The