TIMI Risk Score Research Articles

Corrected QT interval prolongation: A new predictor of cardiovascular risk inpatients with non-ST-elevation acute coronary syndrome. Algerian cohort

Recently, we reported that prolongation of the corrected QT (CTc) interval is an independent risk factor inpatients with unstable angina and acute ischemic changes. The aim of this study was to determine the prognostic value of the corrected QT (CTc) interval inpatients with non-ST-segment elevation acute coronary syndrome who do not exhibit acute ischemic changes on admission ECG. The study included 195 patients with this syndrome. On admission, a standard 12-lead ECG was recorded, the cardiac troponin-T was measured and a thrombolysis in myocardial infarction (TIMI) risk score was calculated. The primary endpoint was the combination of nonfatal acute myocardial infarction, percutaneous or surgical revascularization, and cardiac death up to 30 days after discharge. Two independent investigators measured the QT interval manually and the corrected value was derived using Bazett's formula. In the statistical analysis, the following cutoff points were used: the median TIMI risk score, a cardiac troponin-T level of 0.04 ng/mL, and a QTc of 0.458 s. Of the 74 patients (38%) who reached the primary endpoint, 59 (80%) had QTc prolongation. Binary logistic regression analysis showed that QTc prolongation was an independent predictor of the combined endpoint. This study shows that QTc prolongation is an independent predictor of cardiovascular risk inpatients with non-ST-segment elevation acute coronary syndrome but without acute ischemic changes on admission ECG.

Prognostic Value of N-terminal B-type Natriuretic Peptide in Patients with Acute Myocardial Infarction: A Multicenter Study

Background: Several models have been developed to help the clinician in risk stratification for Acute Coronary Syndrome (ACS),such as the TIMI and GRACE risk scores. However, there is conflicting evidence for the prognostic value of NT-ProBNP in acute myocardial infarction (AMI). Objective: (1) To explore the association of NT-proBNP with 30-day clinical outcome in AMI patients. (2) To compare the prognostic value of NT-proBNP with TIMI and GRACE risk scores in AMI patients. Methods: We conducted a multicenter, prospective observational study recruiting patients presented with AMI between 29-October-2015 and 14-January-2017, involving 1 cardiology referral centre and 4 non-cardiology hospitals. NT-proBNP level (Alere Triage®, US)was measured within 24 hours fromthe diagnosis of AMI. Patientswere followed-up for 1 month. Results: A total of 186 patients were recruited, 143 from tertiary cardiology centre and 43 from non-cardiology hospitals. Mean age was 54.7±10.0 years, 87.6% male and 64% were STEMI. The NT-proBNP level ranged from 60 to 16700pg/ml, with a median of 714pg/ml. Using the 75th centile as the cutoff, Kaplan-Meier survival analysis for the 30-day cardiac related mortality was significantly higher for patient with NT-proBNP level of ≥1600pg/ml (6.4% vs. 0.7%, p=0.02). Cox-regression analysis showed that NT-proBNP level of ≥1600pg/ml was an independent predictor of 30-day cardiac related mortality, regardless of TIMI risk score, GRACE score, LV ejection fraction and study hospitals (HR 9.274, p=0.054, 95%CI 0.965, 89.161). Readmission for heart failure at 30-day was also higher for patient with NT-proBNP level of ≥1600pg/ml (HR 9.308, p=0.053, 95%CI 0.969, 89.492). NT-proBNP level was not associated with all-cause mortality, risk of readmission for ACS, arrhythmia and stroke (pN0.05). By adding 50 score to GRACE risk score for NT-proBNP level of ≥1600pg/ml, combination of GraceNT-proBNP scores of more than 200 appeared to be a better independent predictor for 30-day cardiac related mortality (HR:28.28, p=0.004, 95%CI 2.94, 272.1). ROC analysis showed that this new score had 75% sensitivity and 91.2% specificity in predicting 30-day cardiac related mortality (AUC 0.791, p=0.046). Conclusions: NT-proBNP is a useful point-of-care risk stratification biomarker in AMI. It can be combined to the current risk score model for better risk stratification in AMI patients.

Risk Assessment in Patients With Diabetes With the TIMI Risk Score for Atherothrombotic Disease.

OBJECTIVEImproved risk assessment for patients with type 2 diabetes and elevated cardiovascular (CV) risk is needed. The Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS 2°P) predicts a gradient of risk in patients with prior myocardial infarction (MI) but has not been evaluated in patients with type 2 diabetes.RESEARCH DESIGN AND METHODSCV event rates were compared by baseline TRS 2°P in 16,488 patients enrolled in SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus–Thrombolysis in Myocardial Infarction 53) with type 2 diabetes and high CV risk or established CV disease. Calibration was tested in the diabetes cohort from the REACH (REduction of Atherothrombosis for Continued Health) Registry.RESULTSTRS 2°P revealed a robust risk gradient for the composite of CV death, MI, and ischemic stroke in the full trial population, with 2-year event rates of 0.9% in the lowest- and 19.8% in the highest-risk groups (Ptrend < 0.001). A clear risk gradient was present within the subgroups of all coronary artery disease (CAD), CAD without prior MI, CAD with prior MI, peripheral artery disease, and prior stroke (Ptrend < 0.001 for each), with consistent risk relationships across subgroups. The C-statistic (0.71 for CV death and 0.66 for the composite end point) was consistent in each subgroup. There was close calibration with the type 2 diabetes cohort from the REACH Registry (goodness-of-fit P = 0.78).CONCLUSIONSThe expanded TRS 2°P provides a practical and well-calibrated risk prediction tool for patients with type 2 diabetes.

The comparative correlation of TIMI risk score versus grace risk score with coronary angiographic findings in varied spectrum of patients with non ST elevation myocardial infarction

The comparative correlation of TIMI risk score versus grace risk score with coronary angiographic findings in varied spectrum of patients with non ST elevation myocardial infarction

Comparison of the GRACE and TIMI Risk Scores in Predicting the Angiographic Severity of Coronary Artery Disease in Patients with non STelevation Myocardial Infarction

Background: The superiority of the GRACE and TIMI risk scores in predicting the angiographic severity of coronary artery disease in patients with non ST-elevation myocardial infarction (NSTEMI) has not yet been established. This study was done to compare the GRACE and TIMI risk scores in predicting the angiographic severity of coronary artery disease in this group of patients.Method: The cross sectional study done in the Department of Cardiology, NICVD, Dhaka. The patients admitted with NSTEMI were evaluated to calculate the GRACE and TIMI risk score from April, 2015 to April, 2016.Coronary angiogram was done during index hospitalization and the severity of the coronary artery disease was assessed by vessel score and Gensini score.Results: Of 115 patients assessed, a positive correlation of the vessel score and Gensini score was observed with both the GRACE and TIMI risk scores (p=&lt;0.001) and the GRACE score (r=0.59) correlated better than the TIMI score (r=0.52). The GRACE score presented area under the Receiver Operating Characteristic (ROC) curve of 0.844(95% CI = 0.774 – 0.914) significantly superior to the area under the ROC curve of 0.752(95% CI =0.658– 0.846) of the TIMI score for the difference between the two scores.Conclusion: Both the GRACE and TIMI scores had good predictive value in predicting the severity of coronary artery disease in the patients with NSTEMI but when both the scores were compared, the GRACE score was found to be superior and correlated better with the severity of coronary artery disease.Cardiovasc. j. 2017; 10(1): 45-51

Machine Learning Improves Risk Stratification After Acute Coronary Syndrome

The accurate assessment of a patient’s risk of adverse events remains a mainstay of clinical care. Commonly used risk metrics have been based on logistic regression models that incorporate aspects of the medical history, presenting signs and symptoms, and lab values. More sophisticated methods, such as Artificial Neural Networks (ANN), form an attractive platform to build risk metrics because they can easily incorporate disparate pieces of data, yielding classifiers with improved performance. Using two cohorts consisting of patients admitted with a non-ST-segment elevation acute coronary syndrome, we constructed an ANN that identifies patients at high risk of cardiovascular death (CVD). The ANN was trained and tested using patient subsets derived from a cohort containing 4395 patients (Area Under the Curve (AUC) 0.743) and validated on an independent holdout set containing 861 patients (AUC 0.767). The ANN 1-year Hazard Ratio for CVD was 3.72 (95% confidence interval 1.04–14.3) after adjusting for the TIMI Risk Score, left ventricular ejection fraction, and B-type natriuretic peptide. A unique feature of our approach is that it captures small changes in the ST segment over time that cannot be detected by visual inspection. These findings highlight the important role that ANNs can play in risk stratification.

Short and long-term outcome in very old patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention

BackgroundAlthough octogenarians constitute a fast-growing portion of cardiovascular patients, few data are available on the outcome of patients aged ≥85 years with ST-Elevation Myocardial Infarction (STEMI). Methods and ResultsWe analyzed 126 consecutive patients aged ≥85 years (age 88±2 years) with STEMI, undergoing primary percutaneous coronary intervention (pPCI) within 12 hours from symptoms onset.Long-term follow-up (median 898 days) was obtained for the 102 patients surviving the index-hospitalization. In-hospital mortality rate was 19%. Nonagenarians, diabetes mellitus, severe left ventricular systolic dysfunction and intra-aortic balloon pumping were significantly and independently correlated to in-hospital mortality at the multivariate analysis. A low rate of complications was detected. Among patients surviving the index hospitalization, 32 (31%) patients died during follow-up. 55 patients (54%) had re-hospitalization due to cardiovascular causes. The univariate analysis identified chronic renal failure, Killip class ≥ 3, TIMI Risk Score >8 and very high risk of bleeding as predictors of long-term overall mortality. At the multivariate analysis only chronic renal failure and very high risk of bleeding were significantly and independently correlated to long-term all-cause mortality. Renal function and anterior myocardial infarction were significantly and independently associated with the combined end-point of cardiac mortality and re-hospitalization due to cardiovascular disease at the multivariate analysis. ConclusionsPPCI in patients ≥85 years old is relatively safe. In this population, pPCI is associated with a good long-term survival, although still worse than in younger patients, despite a considerable incidence of re-hospitalization due to cardiovascular events.

Association between gender and short-term outcome in patients with ST elevation myocardial infraction participating in the international, prospective, randomised Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery (ATLANTIC) trial: a prespecified analysis

ObjectivesTo evaluate gender differences in outcomes in patents with ST-segment elevation myocardial infarction (STEMI) planned for primary percutaneous coronary intervention (PPCI).SettingsA prespecified gender analysis of the multicentre, randomised, double-blind Administration...

P5576Prognostic capacity of strain echocardiography for 30-day mortality in patients with STEMI after primary PCI: comparison with TIMI risk score and GRACE risk score

P5576Prognostic capacity of strain echocardiography for 30-day mortality in patients with STEMI after primary PCI: comparison with TIMI risk score and GRACE risk score

P5581GRACE and TIMI risk scores in hospitalized patients with ST-elevation acute myocardial infarction undergoing pharmaco invasive therapy: are they similar?

P5581GRACE and TIMI risk scores in hospitalized patients with ST-elevation acute myocardial infarction undergoing pharmaco invasive therapy: are they similar?

Cardiovascular complications in nonreperfused acute ST segment elevation myocardial infarction

BACKGROUND: Cardiovascular diseases are currently the leading cause of death in industrialized countries. Among them, coronary artery disease is the most prevalent manifestation and is associated with high morbidity and mortality worldwide. In Mexico, ischemic heart disease is the leading cause of death in older than 60s and the second cause in the general population. OBJECTIVE: To evaluate cardiovascular complications in patients with acute ST segment elevation myocardial infarction who did not receive acute reperfusion therapy. MATERIAL AND METHOD: Descriptive, cross-sectional, retrospective study in which 35 medical files of patients with acute ST segment elevation myocardial infarction without reperfusion treatment who were admitted to the Hospital Central Militar from january 1st to december 31st in 2013. Cardiovascular complications and their association with clinical variables were quantified, as well as the quantification of time in the care system. RESULTS: The complications were: heart failure 68.2%, arrhythmias 17.1% and death 17.1%. Variables associated with a higher proportion of total cardiovascular complications and heart failure were age ? 65 years, location of extensive anterior infarction, and TIMI risk score ? 7. Variables such as type 2 diabetes, location of extensive anterior infarct, TIMI risk score ? 7, Killip &gt; 2 and arrhythmias were associated with a higher proportion of deaths. Patients who underwent late angioplasty with adequate indication had a lower proportion of deaths. The patient-first medical contact time had a median of 8 hours, the first medical-diagnostic contact time had a median of 11.5 hours and the diagnostic-admission time to the hospital had a median of 3 hours. CONCLUSIONS: All patients admitted for acute myocardial infarction with ST segment elevation without reperfusion therapy had at least one cardiovascular risk factor and a characteristic symptom of acute coronary syndrome at the time of first medical contact.

Prediction of hospital mortality of ST elevation myocardial infarction using TIMI score

Thrombolysis in myocardial infarction risk score (TIMI-RS) was designed to predict early mortality in patients with a ST elevation acute myocardial infarction (STEAMI). To evaluate the predictive capacity for hospital mortality of TIMI-RS. 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. 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. 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.

Long-term prognostic value of peak exercise echocardiogram in patients hospitalized with acute chest pain

Peak exercise echocardiogram (EEcho) has shown reasonable sensitivity and specificity in detecting significant coronary artery disease (CAD). The objective was to evaluate the prognostic value of EEcho in patients hospitalized for acute chest pain (CP) and its additional prognostic information regarding exercise electrocardiogram test (EECG). Prospective observational study performed between May 2011 and September 2013, including 250 patients consecutively admitted for acute CP with normal cardiac biomarkers and nondiagnostic electrocardiogram. All patients were prospectively followed for 1year, and major adverse cardiovascular events (MACE) were recorded: cardiac death, nonfatal myocardial infarction (MI), or angina with coronary revascularization. EEcho was positive in 16%. Patients with positive EEcho had a higher incidence of hypertension and higher TIMI risk score, showing significant CAD in 66%. We observed contradictory results (EECG-EEcho) in 20%. Patients with positive EEcho and negative EECG had significant CAD in the 66%, and patients undergoing coronary angiography with negative EEcho and positive EECG did not show significant coronary artery disease. Only positive EEcho (P<.001, HR 0.169; 95% CI, 0.088-0.250) and atrial fibrillation (P<.025, HR 0.125; 95% CI, 0.016-0.233) were independently associated with MACE during follow-up. In patients with negative EEcho, the presence of MACE was 2%. EEcho in patients hospitalized for acute chest pain presents good ability to diagnose acute coronary syndrome, while providing additional information when combined with an EECG in up to 20% of cases. Moreover, a negative EEcho in this cohort seems to provide prognostic information beyond the acute event to predict long-term MACE.

TCTAP C-131 Entanglement of Embolized Undeployed Stent with Underdeployed Coronary Stent and Its Successful Management

### Patient initials or identifier number DA ### Relevant clinical history and physical exam A 50 year old very active gentleman with no coronary risk factors presented with Non ST Elevation Myocardial Infarction. His TIMI risk score was 2/7. He had no previous cardiac history. He was non

Original research. The Assessment of Epicardial Adipose Tissue in Acute Coronary Syndrome Patients. A Systematic Review

Abstract Background: This systematic review seeks to evaluate the role of epicardial adipose tissue (EAT), quantified either by thickness, assessed by transthoracic echocardiography, or by volume, assessed by cardiac computed tomography (CT), in the follow-up of patients with acute coronary syndromes (ACS). Method: One-hundred forty-four articles were screened, from which 56 were reviewed in full-text. From those, 47 studies were excluded for the following reasons: they did not meet the inclusion criteria; they were either reviews or meta-analyses; the study cohorts included only stable coronary artery disease patients; they did not state a clear and concise study design, endpoints, or follow-up. The final draft included nine studies for systematic evaluation. Results: Of the 2,306 patients included in the review, 170 underwent cardiac CT while the remaining 2,136 underwent transthoracic echocardiography for the measurement of EAT. The analysis found that the EAT thickness was significantly associated with major adverse cardiovascular events (MACE) rates during hospitalization (OR: -1.3, 95% CI: 1.05-1.62, p = 0.020) and at three years (HR: 1.524, 95% CI: 1.0-2.2, p = 0.038). The included studies found that EAT was correlated with the following clinical and angiographic risk scores for ACS: GRACE (r = 0.438, p &lt;0.001), TIMI risk score (r = 0.363, p = 0.001), SYNTAX score (r = 0.690, p &lt;0.0001; r = 0.610, p &lt;0.01), and Gensini score (r = 0.438, p = 0.001). There was an inverse correlation between ST-segment resolution of &lt;70% after revascularization and EAT (r = −0.414, p = 0.01), and the myocardial blush grade (r = −0.549, p &lt;0.001). The EF aggregation ranged between 2.65 mm and 4.7 mm within the included studies. Conclusions: EAT, evaluated either by echocardiography or cardiac CT, correlates with the severity of coronary lesions, with the clinical and angiographic risk scores for acute coronary syndromes, with indicators for coronary reperfusion, and with short- and long-term MACE rates. Further studies are required to fully elucidate the role of this extensively studied but still novel cardiovascular biomarker as part of a risk prediction tool.

Predictive values of D-dimer assay, GRACE scores and TIMI scores for adverse outcome in patients with non-ST-segment elevation myocardial infarction

PurposeTo determine the predictive values of D-dimer assay, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk scores for adverse outcome in patients with non-ST-segment elevation myocardial infarction (NSTEMI).Patients and methodsA total of 234 patients (mean age: 57.2±11.7 years, 75.2% were males) hospitalized with NSTEMI were included. Data on D-dimer assay, GRACE and TIMI risk scores were recorded. Logistic regression analysis was conducted to determine the risk factors predicting increased mortality.ResultsMedian D-dimer levels were 349.5 (48.0–7,210.0) ng/mL, the average TIMI score was 3.2±1.2 and the GRACE score was 90.4±27.6 with high GRACE scores (>118) in 17.5% of patients. The GRACE score was correlated positively with both the D-dimer assay (r=0.215, P=0.01) and TIMI scores (r=0.504, P=0.000). Multivariate logistic regression analysis revealed that higher creatinine levels (odds ratio =18.465, 95% confidence interval: 1.059–322.084, P=0.046) constituted the only significant predictor of increased mortality risk with no predictive values for age, D-dimer assay, ejection fraction, glucose, hemoglobin A1c, sodium, albumin or total cholesterol levels for mortality.ConclusionSerum creatinine levels constituted the sole independent determinant of mortality risk, with no significant values for D-dimer assay, GRACE or TIMI scores for predicting the risk of mortality in NSTEMI patients.

RISK STRATIFICATION WITH THE TIMI RISK SCORE FOR SECONDARY PREVENTION AMONG PATIENTS WITH DIABETES AND ELEVATED CARDIOVASCULAR RISK

Background: Improved risk assessment for patients with diabetes and elevated CV risk is needed. The TIMI Risk Score for Secondary Prevention (TRS 2°P) predicts a gradient of risk in patients with prior MI, including recent ACS. TRS 2°P has not been evaluated in diabetic patients without prior MI

Difference in the Mortality Between Weekend and Non-Weekend Coronary Artery Disease Admissions

AbstractBackground: Acute coronary syndrome requires urgent diagnostic and therapeutic procedures, which may not be uniformly available throughout the week. So, we sought to examine the effects of admission on clinical outcomes in patients with wide spectrum coronary artery diseases.Methods: A retrospective analysis of ICCU Inpatient sample database of 17 months from 2015 to 2016 used to compare differences in in-hospital mortality between patients admitted on a non-weekday versus weekend for wide spectrum ACS which include STEMI, NSTEMI and unstable angina and patients with cardiogenic shock. Out of these 75% had higher TIMI risk score (5-7).Results: Total 2700 patients with ACS were included in the present study with wide spectrum coronary artery diseases. Out of that 20 % (n=541) were admitted in weekends and 79.9% (n=2159) were admitted in non-weekends. Total 804 females admitted on non-weekend had a mean age of 61.05±12 years and 162 females admitted on weekend had mean age 58.5±13.3 years (p value=0.025). Out of 2159 admitted on non-weekend, 1355 were males with mean age of 57.65±15.55 years and 379 were males admitted on weekend out of 541 patients with mean age of 56.85±13.1 years (p value =0.314). In-hospital mortality rate of these patients admitted on non-weekends was 9.4% (n=204) and those admitted on weekends was 5.9% (n=32) with statistically significant difference (95% CI; p= 0.003). The mortality rate of ACS without STEMI in non-weekend group was 8.6% (n=170) which was statistically significant (p = 0.006) with mortality of weekend group 5.3% (n=26).Conclusion: Our study shows that there is no added mortality in patients with coronary artery disease on weekend days compared with non-weekend days. As the patients admitted during non-weekend were elder and sicker than the weekend admissions (having the high risk score), the in-hospital mortality is higher on non-weekends. Efforts to improve health care system should ensure comparable outcomes for patients irrespective of time of hospital admission.

Drop-out from cardiovascular magnetic resonance in a randomized controlled trial of ST-elevation myocardial infarction does not cause selection bias on endpoints.

The extent of selection bias due to drop-out in clinical trials of ST-elevation myocardial infarction (STEMI) using cardiovascular magnetic resonance (CMR) as surrogate endpoints is unknown. We sought to interrogate the characteristics and prognosis of patients who dropped out before acute CMR assessment compared to CMR-participants in a previously published double-blinded, placebo-controlled all-comer trial with CMR outcome as the primary endpoint. Baseline characteristics and composite endpoint of all-cause mortality, heart failure and re-infarction after 30days and 5years of follow-up were assessed and compared between CMR-drop-outs and CMR-participants using the trial screening log and the Eastern Danish Heart Registry. The drop-out rate from acute CMR was 28% (n = 92). These patients had a significantly worse clinical risk profile upon admission as evaluated by the TIMI-risk score (3.7 (± 2.1) vs 4.0 (± 2.6), p = 0.043) and by left ventricular ejection fraction (43 (± 9) vs. 47 (± 10), p = 0.029). CMR drop-outs had a higher incidence of known hypertension (39% vs. 35%, p = 0.043), known diabetes (14% vs. 7%, p = 0.025), known cardiac disease (11% vs. 3%, p = 0.013) and known renal function disease (5% vs. 0%, p = 0.007). However, the 30-day and 5-years composite endpoint rate was not significantly higher among the CMR drop-out ((HR 1.43 (95%-CI 0.5; 3.97) (p = 0.5)) and (HR 1.31 (95%-CI 0.84; 2.05) (p = 0.24)). CMR-drop-outs had a higher incidence of cardiovascular risk factors at baseline, a worse clinical risk profile upon admission. However, no significant difference was observed in the clinical endpoints between the groups.

Atherothrombotic Risk Stratification and Ezetimibe for Secondary Prevention

BackgroundEzetimibe improves cardiovascular (CV) outcomes in patients stabilized after acute coronary syndrome (ACS) when added to statin therapy. After ACS, patients vary considerably in their risk for recurrent CV events. ObjectivesThis study tested the hypothesis that atherothrombotic risk stratification may be useful to identify post-ACS patients who have the greatest potential for benefit from the addition of ezetimibe to statin therapy. MethodsThe TIMI (Thrombolysis In Myocardial Infarction) Risk Score for Secondary Prevention (TRS 2°P) is a simple 9-point risk stratification tool, previously developed in a large population with atherothrombosis to predict CV death, myocardial infarction (MI), and ischemic stroke (CV death/MI/ischemic cerebrovascular accident [iCVA]). The current study applied this tool prospectively to 17,717 post-ACS patients randomized either to ezetimibe and simvastatin or to placebo and simvastatin in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial). Treatment efficacy was assessed by baseline risk for CV death/MI/iCVA, the IMPROVE-IT composite endpoints (CE), and individual component endpoints at 7 years. ResultsAll 9 clinical variables in the TRS 2°P were independent risk indicators for CV death/MI/iCVA (p < 0.001). The integer-based scheme showed a strong graded relationship with the rate of CV death/MI/iCVA, the trial CE, and the individual components (p trend <0.0001 for each). High-risk patients (n = 4,393; 25%), defined by ≥3 risk indicators, had a 6.3% (95% confidence interval: 2.9% to 9.7%) absolute risk reduction in CV death/MI/iCVA at 7 years with ezetimibe/simvastatin, thus translating to a number-needed-to-treat of 16. Intermediate-risk patients (2 risk indicators; n = 5,292; 30%) had a 2.2% (95% confidence interval: −0.3% to 4.6%) absolute risk reduction. Low-risk patients (0 to 1 risk indicators; n = 8,032; 45%) did not appear to derive benefit from the addition of ezetimibe (p interaction = 0.010). Similar findings were observed for the IMPROVE-IT primary CE. ConclusionsAtherothrombotic risk stratification using the TRS 2°P identifies high-risk patients who derive greatest benefit from the addition of ezetimibe to statin therapy for secondary prevention after ACS. (Improved Reduction of Outcomes: Vytorin Efficacy International Trial [IMPROVE-IT]; NCT00202878)