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    TIMI Risk Score for UA/NSTEMI

    Estimates mortality for patients with unstable angina and non-ST elevation MI.
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    When to Use
    Pearls/Pitfalls
    Why Use

    The TIMI Risk Score for Unstable Angina/NSTEMI can be used to help risk stratify patients with anginal symptoms, but is better-suited for patients with confirmed NSTEMI or unstable angina.

    • Even with 0 or 1 risk factors, the TIMI Score still suggests a 4.7% risk of bad outcome (although risk of death or non-fatal MI was 2.9% in these lowest risk categories).
    • TIMI is the first widely-used chest pain decision rule, and probably the most well known
      • However it was developed in the late 1990s and published in 2000
      • Newer risk scores using troponin-only have been developed (HEART, GRACE, EDACS) that provide better risk stratification
    • For risk stratification of patients with confirmed acute coronary syndrome, most experts recommend the GRACE Score for risk stratification, with higher risk levels receiving more aggressive medical intervention and/or receiving early invasive management.

    The HEART and EDACS scores are better suited for undifferentiated patients with possible acute coronary syndrome (experiencing undifferentiated chest pain or anginal equivalents, for example).

    The TIMI Risk Score for Unstable Angina/NSTEMI is the best known chest pain risk score tool, however newer ones exist that provide better risk stratification for low vs non-low risk patients (for example, the GRACE Score).

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    Next Steps
    Evidence
    Creator Insights

    Management

    If patients are in the 0 or 1 point group, they should be further risk stratified using another risk score or one’s own institutional practices, as risk is not low enough to safely discharge from the hospital. Many guidelines recommend higher risk levels receiving more aggressive medical intervention and/or receiving early invasive management.

    Critical Actions

    Acute coronary syndromes should be managed with medical therapies including aspirin and nitroglycerin when appropriate, along with considering anticoagulation and cardiology consultation and admission to the hospital.

    Formula

    Addition of the selected points:

    Facts & Figures

    See formula table, below:

    Criteria Value
    Age ≥ 65 +1
    ≥ 3 CAD risk factors* +1
    Known CAD (Stenosis ≥ 50%) +1
    ASA use in past 7 days +1
    Severe angina (≥ 2 episodes in 24 hrs) +1
    EKG ST changes ≥ 0.5mm +1
    Positive cardiac marker +1

    *Risk factors for CAD : Family history of CAD, Hypertension, Hypercholesterolemia, Diabetes, or Current Smoker (thanks to Jeff Geske at Mayo for this update!)

    Evidence Appraisal

    • In the study, “Elevated cardiac markers” were CK-MB fraction or troponin level.
    • If no catheterization had ever been performed, “significant coronary stenosis” was assigned a zero.
    • In one meta-analysis and comparison of different risk stratification scores, GRACE out-performed TIMI for risk stratification of patients with potential ACS.
    • Another paper also evaluated a large number of risk scores and concluded that the GRACE “is probably the best predictor of ischaemic risk in patients with ACS.”
    Dr. Elliott M. Antman

    About the Creator

    Elliott M. Antman, MD, is a professor and associate dean for Clinical/Translational Research at Harvard Medical School. He is also a senior physician in the Cardiovascular Division of the Brigham and Women's Hospital in Massachusetts and President of the American Heart Association (2014-2015). As a senior investigator in the TIMI Study Group, Dr. Antman has published on the use of serum cardiac markers for diagnosis and prognosis of patients with unstable angina and acute myocardial infarction, cyclooxygenase and cardiovascular risk, and antithrombotic therapy for acute coronary syndromes.

    To view Dr. Elliott M. Antman's publications, visit PubMed