TIMI Risk Score Research Articles

Assessment of In-hospital Outcome of Acute Myocardial Infarction in Correlation with “Thrombolysis in Myocardial Infarction” Risk Score

Cardiovascular diseases are the leading cause of death with Myocardial infarction resulting in most of the complications and mortality. A descriptive study was undertaken to assess the in-hospital outcome of acute myocardial infarction in correlation with “thrombolysis in myocardial infarction” risk score in a selected hospital Guwahati, Assam. Descriptive survey approach was used for the study and 30 samples irrespective of any age were selected by convenient sampling technique. “Thrombolysis in Myocardial Infarction” (TIMI) tool was used to assess risk and rate of complications and mortality of the acute Myocardial Infarction patients. The study result showed that majority of the MI patients were male and half of them belong to the risk age group of more than 64 years. Majority (60%) of the patients were at moderate risk and very less i.e. only 16.67% were at low risk. Complications of cardiac arrest and shock was observed at follow up in both low and moderate risk category and even 2 deaths were observed in the moderate risk category. Age is significantly associated with TIMI risk score predicting the risk associated with advance age.

TIMI RISK SCORES

Background: Thrombolysis In Myocardial Infarction (TIMI) risk score predictsadverse clinical outcomes in patients with non–ST-elevation acute coronary syndromes(NSTEACS). Whether this score correlates with the coronary anatomy is unknown. Objective:To determine the frequency of low, moderate and high TIMI risk score in patients of NSTEACSand to compare the frequency of two vessel coronary artery disease on angiography withlow, moderate and high TIMI risk scores in patients of NSTE-ACS. Study design: This was across sectional study. Setting: Department of Cardiology, Gulab Devi Chest Hospital, Lahore.Duration: Six months. Patients and Methods: Total 170 patients were included in the study.Patients’ selection was done with the help of a pre-defined inclusion and exclusion criteria. TIMIrisk score was calculated for each patient and patients were categorized into low, moderate andhigh risk groups (as per operational definition). Patients were further evaluated with coronaryangiograms to assess the double vessel CAD. All angiographies were performed by a singlephysician. Data analysis was done on SPSS version 17. Results: Mean age of our patients was54.81±10.55 years. Gender distribution shows that there were 106(62%) male and 64(38%)female patients. TIMI score risk classification showed that among 50(29.4%) patients TIMI riskscore was low, among 107(62.9%) patients it was moderate and in 13(7.6%) patients it washigh. There were 105(62%) patients who had two vessel coronary artery disease. Among 105patients who had two vessel coronary artery disease, 25(23.8%) had low TIMI score, 69(65.7%)had moderate and 11(10.5%) of the patients had high TIMI score. Conclusion: In patientswith non-ST-elevation acute coronary syndrome undergoing cardiac catheterization, the TIMIrisk score is significantly associated with two vessel coronary artery disease. So it should berecommended that a routine invasive strategy be carried in patients with moderate or higherTIMI risk score.

Acute coronary syndromes

Acute coronary syndromes

EARLY CLINICAL PROGNOSIS FOR HIGH-RISK CHEST PAIN PATIENTS USING SMART TEXTILES

According to statistics, up to 40% of emergency admissions are due to chest tightness or chest pain. However, merely based on the patient’s current symptoms such as chest pain, it is difficult for a physician to give an instant diagnosis as most cardiovascular diseases are chronic. To address this issue, it is necessary to provide a set of tools to indicate the patient’s status during hospitalization to help the physician in diagnosis. It is thus our primary objective to design and develop a wearable heart rate monitoring system and prediction tool that can measure the patient’s heart rate parameters, allow him/her to move around easily, and which also can effectively improve the medical personnel’s working efficiency. This research utilizes conductive filament to design textile to integrate electric circuit with clothing. Using a conductive vest and chest belt that can be worn comfortably, our system can continuously record patients’ physiological index parameters during their hospitalization. Physiological index parameters of multiple patients can then be transmitted wirelessly and recorded in a physician-end computer. At the end of their hospitalization, the patient’s original physiological indices together with the recorded heart rate variability (HRV) parameters can then be summarized to assess the risk score of their discharging from hospital. This paper adopts the concept of TIMI risk score, while adding every index of HRV measured when subjects are hospitalized. The risk score can hence be used to provide emergency physicians as a basis for an early prognosis and subsequently a better hospital-discharging assessment of patients with chest pain. The accuracy of the proposed prognosis has been verified with the 3-day and 30-day recall rate of the patients and the result has been shown to be promising for chest pain patients in emergency admission units.

Abstract 13647: Comparison of the HEART and TIMI Risk Scores for Suspected Acute Coronary Syndrome in the Emergency Department

Introduction: The emergency department (ED) evaluation for suspected acute coronary syndrome (ACS) is common, costly, and challenging. Risk scores may facilitate clinical care and screening for research studies. The Thrombolysis in Myocardial Infarction (TIMI) score is perhaps the best known example, but the HEART score demonstrates promise specifically in ED settings. Hypothesis: We tested the null hypothesis that the TIMI and HEART risk scores have equivalent test characteristics in the ED evaluation of suspected ACS. Methods: We analyzed data from the Internet Tracking Registry of Acute Coronary Syndromes (i*trACS) from 9 EDs on patients with suspected ACS, 1999-2001. We excluded patients with an ED diagnosis of ACS, or without sufficient data to calculate TIMI and HEART scores. The primary outcome was 30-day major adverse cardiovascular events (MACE), including all-cause death, acute myocardial infarction, and urgent revascularization. We describe test characteristics of the TIMI and HEART risk scores. Results: The study cohort included 8,255 patients with 508 (6.2%) 30-day MACE. Receiver operating curve analysis favored HEART (c-statistic: 0.75, 95%CI 0.73-0.77) over TIMI (c-statistic: 0.68, 95%CI 0.66-0.70). A HEART score >3 (negative predictive value[NPV] 0.98, 95%CI 0.98-0.99; positive predictive value [PPV] 0.10, 95%CI 0.09-0.11) demonstrates equivalent or superior NPV/PPV compared to TIMI>0 (NPV 0.98, 95%CI;0.97-0.98; PPV 0.08, 95%CI 0.07-0.08) and TIMI>1 (NPV 0.96, 95%CI 0.96-0.97; PPV 0.1, 95%CI 0.09-0.11). Conclusions: The HEART score is more accurate than TIMI and specifically outperforms TIMI at “low-risk” thresholds.

Abstract 9739: Predictive Values of ST-segment Elevation in Lead aVR for the Diagnosis of Left Main or 3-Vessel Disease in Patients With Non-ST-segment Elevation Acute Coronary Syndrome

Introduction: In patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), early identification of left main or 3-vessel disease (LM/3VD) is important in selecting the optimal treatment strategy. Hypothesis: ST-segment elevation in lead aVR (ST↑aVR) at presentation is considered a useful predictor of LM/3VD; however, time from symptom onset to presentation may influence its predictive value. Methods: We studied 835 patients with NSTE-ACS undergoing coronary angiography during hospitalization. We evaluated ECG findings and troponin T (TnT), estimated glomerular filtration rate (eGFR), brain natriuretic peptide (BNP), high-sensitivity C-reactive protein (hsCRP), and TIMI risk score on admission. Results: The prevalence of LM/3VD was 21%. Patients with LM/3VD were older (70±11 vs 66±11 yrs), had higher rates of hypertension (72% vs 64%), diabetes mellitus (51% vs 30%), Killip class ≥2 (31% vs 6%), positive-troponin T (≥0.1 ng/ml) (57% vs 29%), and ST↑aVR ≥0.5 mm (79% vs 15%), and had higher levels of BNP (367±407 vs 184±398 pg/ml), hsCRP (0.908±2.564 vs 0.371±1.425 mg/dl), and summed ST-segment depression (9±7 vs 2±3 mm), and TIMI risk score (3.7±1.2 vs 2.6±1.4) and a lower eGFR (54±27 vs 66±24 ml/min/1.73 m2), and a higher rate of in-hospital death, (re)infarction, or urgent revascularization (36% vs 9%) than did those without LM/3VD (all p<0.05). Multivariate analysis showed that ST↑aVR (OR 10.8, 95%CI 3.88-20.1, p<0.01) was the strongest predictor of LM/3VD, and followed by positive-troponin T (OR 2.20, 95%CI 1.26-4.01, p<0.01). When patients were subdivided according to the 6-h time window from symptom onset, the predictive values of ST↑aVR for the diagnosis of LM/3VD were significantly higher than those of positive-troponin T, except the sensitivity in delayed presentation (Table). Conclusions: In patients with NSTE-ACS, ST↑aVR on admission strongly predicted LM/3VD; however, its sensitivity decreased in delayed (>6 h) presentation.

Abstract 17338: Development of a TIMI Risk Score for Stable Ischemic Heart Disease

Patients (pts) with stable ischemic heart disease (SIHD) who have had a prior myocardial infarction (MI) demonstrate a range of residual risk for recurrent CV events. A risk prediction tool may be useful to identify high risk pts who have the greatest potential for benefit from intensive treatment. Methods: The integer-based TIMI Risk Score for SIHD (Prior MI) was derived in 8,200 placebo-treated pts who were stable with a history of MI (2 wks to 12 mo) in the TRA 2°P-TIMI 50 trial. The score was developed to predict CV death, MI or ischemic stroke (CVD/MI/iCVA; n=676 events, median 2.5y follow-up). The score was validated in 8,274 vorapaxar-treated pts from the trial. Differential efficacy and safety (GUSTO severe bleeding) response to randomized treatment was assessed among pts with prior MI without a history of TIA or stroke for whom there is a clinical indication for vorapaxar. Results: The risk score predictors were age, CHF, smoking, diabetes mellitus, hypertension, prior stroke, peripheral arterial disease, family history of CAD, prior CABG, and eGFR (Fig 1a). The TIMI Risk Score showed a strong graded relationship with the rate of CVD/MI/iCVA as well as the individual components (p-trend<0.001 for all), a pattern that was confirmed in the validation cohort (p<0.001). In pts eligible for clinical use, those at intermediate (score 2-3) and high (score ≥4) risk had a 2.4% and 3.6% absolute risk reduction in CVD/MI/iCVA with vorapaxar, translating to a number needed to treat (NNT) of 41 and 28 in the intermediate and high risk groups (Fig 1b). Bleeding increased across risk groups (Fig 1b); however, net clinical outcome was increasingly favorable with vorapaxar with an increasing TIMI Risk Score. ICH was 0.5 vs 0.6% and fatal bleeding was 0.3 vs 0.5% with vorapaxar vs placebo in those with a score ≥4. Conclusions: The TIMI Risk Score for SIHD (Prior MI) identifies a strong gradient of increasing risk for recurrent CV events and may be useful as a basis for therapeutic decision-making.

Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review.

About 10% of patients with acute chest pain are ultimately diagnosed with acute coronary syndrome (ACS). Early, accurate estimation of the probability of ACS in these patients using the clinical examination could prevent many hospital admissions among low-risk patients and ensure that high-risk patients are promptly treated. To review systematically the accuracy of the initial history, physical examination, electrocardiogram, and risk scores incorporating these elements with the first cardiac-specific troponin. MEDLINE and EMBASE were searched (January 1, 1995-July 31, 2015), along with reference lists from retrieved articles, to identify prospective studies of diagnostic test accuracy among patients admitted to the emergency department with symptoms suggesting ACS. We identified 2992 unique articles; 58 met inclusion criteria. Sensitivity, specificity, and likelihood ratio (LR) of findings for the diagnosis of ACS. The reference standard for ACS was either a final hospital diagnosis of ACS or occurrence of a cardiovascular event within 6 weeks. The clinical findings and risk factors most suggestive of ACS were prior abnormal stress test (specificity, 96%; LR, 3.1 [95% CI, 2.0-4.7]), peripheral arterial disease (specificity, 97%; LR, 2.7 [95% CI, 1.5-4.8]), and pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]). The most useful electrocardiogram findings were ST-segment depression (specificity, 95%; LR, 5.3 [95% CI, 2.1-8.6]) and any evidence of ischemia (specificity, 91%; LR, 3.6 [95% CI,1.6-5.7]). Both the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) risk scores performed well in diagnosing ACS: LR, 13 (95% CI, 7.0-24) for the high-risk range of the HEART score (7-10) and LR, 6.8 (95% CI, 5.2-8.9) for the high-risk range of the TIMI score (5-7). The most useful for identifying patients less likely to have ACS were the low-risk range HEART score (0-3) (LR, 0.20 [95% CI, 0.13-0.30]), low-risk range TIMI score (0-1) (LR, 0.31 [95% CI, 0.23-0.43]), or low to intermediate risk designation by the Heart Foundation of Australia and Cardiac Society of Australia and New Zealand risk algorithm (LR, 0.24 [95% CI, 0.19-0.31]). Among patients with suspected ACS presenting to emergency departments, the initial history, physical examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores, which incorporate the first cardiac troponin, provided more diagnostic information.

Abstract 13600: Patients Identified as Low Risk May Be Safely Discharged From the Emergency Department After Presentation With Chest Pain

Background: Chest pain accounts for over 8 million visits to the emergency department (ED) annually in the United States. However, only a minority of these patients are eventually diagnosed with acute myocardial infarction. Hypothesis: A protocol may be safely utilized to identify and evaluate low risk patients upon presentation to the ED with chest pain. Methods: A prospective study at a large academic medical center evaluated the safety of a protocol to schedule outpatient stress testing and follow-up for low risk patients discharged from the ED after presenting with chest pain. Patients were low risk if they were pain-free in the ED, had negative cardiac enzymes, non-ischemic electrocardiogram and TIMI risk score < 1, or if a cardiologist deemed patient low risk for acute myocardial infarction. Selected patients were discharged from the ED and scheduled for stress testing within 1-3 business days. Patients with positive test results were evaluated by a cardiologist for medical management or coronary angiography as needed. Results: A total of 1,735 patients were enrolled in the protocol. Of the 1,036 patients completing a follow-up stress test, only 6.4% (66/1,036) had an abnormal result. Forty-two of these 66 patients (63.6%) were either determined to be false positive by the cardiologist or underwent medical management. The remaining 24 (36.4%) had coronary angiography, of which only 20.8% (5/24) had significant coronary artery disease requiring percutaneous coronary intervention. All patients were followed for 30 days after their ED visit. During this period, 1.9% (33/1735) of patients returned to the ED per protocol, and 1% (18/1735) were admitted to the hospital for chest pain or other cardiovascular presentation. Only 3 patients (0.2%) had myocardial infarction. No mortality was recorded during this period. With this protocol, patients and insurers avoided over $16 million in professional and facility charges and over $3 million in payments. Estimated cost savings from reducing hospitalization in our patient population was about $3.77 million. Conclusions: Our data support that an outpatient evaluation protocol for low risk patients presenting to the ED with chest pain is safe, avoids unnecessary hospitalization and reduces healthcare cost.

Abstract 13594: Impact on Clinical Outcomes of Randomization at Community Hospitals Versus Pre-hospital location in STEMI Patients: Insights From the STREAM Study

Objectives: The STREAM study randomized STEMI pts <3 hrs from symptom onset to primary PCI (pPCI) or a fibrinolysis pharmacoinvasive approach (PI) with rescue for failed fibrinolysis and scheduled angiography for the remainder within 24h. Although most pts were randomized pre-hospital (PH) and admitted to pPCI centres, selected community hospitals (CH) within STEMI networks also participated. Given the inherent delays with inter-hospital transfer, we examined outcomes accordingly to randomization location. Methods: CH pts 358/1866 (19.2%) were compared to PH pts. Results are further categorized according to pts receiving pPCI, PI rescue, PI with scheduled angiography (%’s and medians with 25th-75th percentiles). Results: Overall compared to PH, CH pts had more diabetes (17.8% vs. 11.5%, p=0.001), higher Killip Class >1 (9.4% vs. 5.0%, p=0.002) and TIMI Risk Score ≥5 (18.2% vs. 12.4%, p=0.005). 30-day primary composite endpoint (death, CHF, shock, re-infarction) for CH was 14.9% vs. PH 13.2% (p=0.403). PI pts within CH received less rescue PCI than PH pts (35.1% vs. 42.8%, p=0.062) (table) and it was delayed by approximately 43 min. CH pts undergoing pPCI also had an approximate 31 min delay. After adjusting for TIMI risk score and time from symptom onset, CH pts requiring rescue had worse outcomes compared to PH (OR 2.3, 95% CI, 1.2-4.6); However no difference in outcomes existed between CH and PH pts in those undergoing pPCI (p interaction=0.027). PI pts receiving scheduled cath from CH and PH had comparable times to cath (17.7 vs. 18.7 hours) and low primary composite event rates (6.2% vs 8.0%). Conclusion: Within STREAM CH pts had higher baseline risk but overall similar outcomes to those randomized PH. Despite higher baseline risk, CH pts with successful fibrinolysis and scheduled angiography or those who underwent primary PCI had similar outcomes to PH. The worse outcomes in CH rescue pts emphasizes the need to identify and expeditiously treat those pts needing rescue PCI.

The impacts of prolonged emergency department length of stay on clinical outcomes of patients with ST-segment elevation myocardial infarction after reperfusion.

Emergency department and hospital crowding have become an increasing problem. The clinical outcomes of prolonged emergency department (ED) length of stay in acute ST-segment elevation myocardial infarction (STEMI) patients after reperfusion are still unknown. Between January 2008 and December 2011, 432 consecutive patients with STEMI undergoing primary PCI were recruited. Patients were divided into two groups: the immediate admission group (length of ED stay <8 h; IA group) and the prolonged ED stay group (length of ED stay ≧8 h; PS group). The median lengths of ED stay of the patients in both groups were 29.97 h in the PS group (n = 145, 33.6%) and 1.78 h in the IA group (n = 287, 66.4%), respectively. The age, gender, risk factors of coronary artery disease, characteristic of coronary angiography, and TIMI risk score did not differ between the two groups. During nearly 4-year clinical follow-up, the short-term and long-term clinical outcomes were similar between the two groups. B-blocker and statins were used infrequently in the ED. In addition, patients with high TIMI risk score in the PS group had higher incidence of 1-year re-MI (6.8 vs. 1.8%; p = 0.045). In the era of primary PCI for STEMI patients after reperfusion, prolonged ED length of stay may not influence clinical outcomes. Patients with high TIMI risk score in the PS group still had a trend toward worse clinical outcome after long ED stays.

116 Acute Care Diagnostic Collaboration: Assessment of Diagnostic Quality of TIMI versus HEART Risk Score Integrating Coronary Computed Tomography Angiography in a Bayesian Statistical Model

116 Acute Care Diagnostic Collaboration: Assessment of Diagnostic Quality of TIMI versus HEART Risk Score Integrating Coronary Computed Tomography Angiography in a Bayesian Statistical Model

Predictive value of APACHE II combined with TIMI risk score for prognosis of acute coronary syndrome

Objective To investigate the predictive value of acute physiology and chronic health score (APCHE Ⅱ) scoring system on the patients with acute coronary syndrome (ACS), and to demonstrate whether the predictive value combined with TIMI risk score impact on prognosis. Methods We calculated APACHE Ⅱ, TIMI risk score and total score of these two for 198 patients with acute coronary syndrome (ACS) in CCU, and compared the discriminative power of the three scores by the area under the receiver operating characteristic curve (AUROCC). Results The APACHE Ⅱ scores of survival group (9.42±3.38) and death group (14.77±3.27) were statistically significant (t=-8.018, P 0.05); for the total ACS, the score of APACHE Ⅱ was (10.23±3.86) and predicted mortality 11.62% (23/198) and actually mortality 15.15%(30/198) (χ2=29.892, P<0.01). The ROC curve area of 3 score methods had been compared and found out TIMI had the biggest ROC curve area and the best predicted livability and mortality. Conclusions APACHE Ⅱ score can not predict mortality satisfactorily in patients with ACS well, and the method of APACHE Ⅱ combined with TIMI risk score is not better than TIMI risk score showed in the study. The TIMI risk score is a quick, convenient and effective method to evaluate patients with ACS. Key words: Acute coronary syndrome; Acute physiology and chronic health score; TIMI risk score

53 An audit of heart-type fatty acid-binding protein (H-FABP) in acute cardiac admissions

Introduction Heart-type Fatty Acid-Binding Protein (H-FABP) has previously been assessed for early diagnosis of ACS. H-FABP has a sensitivity of 85.3% 3 to 6 h after chest pain onset. 1 H-FABP (>6.48 ng/ml) has been associated with significantly increased event rates. With the introduction of highly sensitive troponin T (hsTnT), Body et al . assessed 1,171 patients with suspected cardiac chest pain using a combination of H-FABP, hsTnT and ECG to rule-out ACS with a sensitivity of 99.1% and a NPV of 99.7%. Methodology We prospectively evaluated H-FABP in early detection of ACS. Patients admitted with cardiac chest pain within 6 h onset were recruited. Baseline demographics, cardiac risk factors and a TIMI risk score were recorded. STEMI patients were excluded. Baseline blood samples were taken for H-FABP and hsTnT. A 6 h hsTnT was taken to confirm or exclude ACS diagnosis. ACS was denoted as chest pain with or without ECG changes and a hsTnT rise of >20% from baseline sample or a delta rise of 7 ng/l (normal 6.32 ng/ml (99 th centile, IT assay) could predict ACS. Results We enrolled 69 patients, 45 (65%) were male. Mean age was 66.8 years. ACS was diagnosed in 23 (32.9%) patients. Mean TIMI score was 3.29 in the ACS group and 3.07 in the non-ACS group. At baseline, median H-FABP was 8.61 vs. 6.45 (p = 0.01), median baseline hsTnT was 48 vs. 9 (p Baseline H-FABP had the same sensitivity but was less specific than hsTnT for single sample diagnosis. H-FABP has a role in early diagnosis of ACS, with a combination approach enabling identification of ACS in a select number of patients with baseline negative hsTnT/6 h positive hsTnT patients. H-FABP correctly identified 3 (33.3%) patients with both hsTnT negative results that had significant coronary disease requiring intervention.

Microalbuminuria in non-diabetic patients with unstable angina/non ST-segment elevation myocardial infarction.

BackgroundMicroalbuminuria (MAU) is defined as an urinary albumin excretion rate between 20–200 mg/l or 30–300 mg/day. It is a surrogate marker for endothelial dysfunction and is independently associated with atherosclerotis in diabetic and in non-diabetic patients. We assessed the prevalence of MAU in non-diabetic patients who presented with UA/NSTEMI and the relation of MAU to the severity of coronary artery disease in patients at a cardiac care center in Iraq.MethodsSeventy non-diabetic patients referred to the Iraqi Center for Heart Disease, Baghdad, between November 1st 2010 and June 1st 2011 with the diagnosis of UA/NSTEMI were included in this study. Physical examination, ECG and echocardiography were performed on all patients. TIMI (“Thrombolysis in Myocardial Infarction”) risk score was obtained. Urine samples were collected and sent for quantitative determination of MAU. All patients underwent diagnostic coronary angiography. Data are give as mean (quantitative and percent) ± SD.ResultsFifty-three men (76 %) and 17 (24 %) women (mean age 56 ± 12 years) were investigated. Overall 37 (53 %) individuals presented with arterial hypertension and 41 (59 %) with a history of smoking. 58 patients (83 %) had ischemic ECG changes (defined as ST segment depression more than 1 mm from baseline, and/or T wave inversion), 52 (74 %) had echocardiographic findings indicative of ischemia (defined as segmental wall motion abnormalities). Twenty-one (30 %) patients tested positive for MAU. There was a significant correlation of echocardiographic signs of ischemia and MAU, (n = 20 (38 %), p < 0.01). There was a clear relationship between MAU and TIMI risk score. Additionally, MAU was more common in patients with multivessel coronary artery disease (CAD) (p < 0.001). There was no statistically significant correlation between MAU and mean age, sex, smoking, and blood pressure.ConclusionIn this analysis of patients with UA/NSTEMI we found a strong correlation of microalbuminuria with echocardiographic changes and findings in coronary angiography.

Correlation of NLRP3 with severity and prognosis of coronary atherosclerosis in acute coronary syndrome patients

We decided to assess the prognostic value of NLRP3 inflammasome level in acute coronary syndrome (ACS) patients and whether it was related to coronary atherosclerotic severity. Study population included one-hundred and twenty-three (123) subjects. Peripheral blood monocyte NLRP3 protein level was correlated with clinical presentation, angiographic characteristics and its scoring systems as well as GRACE and TIMI risk scores. Follow-up for major adverse cardiac events (MACE) was carried out at 180days. Peripheral blood monocyte NLRP3 was found to be elevated in ACS patients (P<0.05) and showed positive correlation with GRACE score (r=0.619), TIMI score (r=0.580), SYNTAX score (r=0.550), Clinical SYNTAX score (r=0.564) and Gensini score (r=0.516). NLRP3 was also increased with increasing number of vessels, the number of lesions present and the presence bifurcation lesions (P<0.05). Multivariate Cox regression analysis showed NLRP3 to be an independent predictor of MACE (P=0.043). Kaplan-Meier analysis and receiver operating characteristic curves for NLRP3 showed good predictive value for MACE. There is a positive correlation of NLRP3 level with severity of coronary atherosclerosis. NLRP3 level is a promising prognostic utility and is efficient in event prediction for MACE.

Gender-Related Differences in Patients Presenting with Suspected Acute Coronary Syndromes: Clinical Presentation, Biomarkers and Diagnosis

Objectives: Gender differences in patients presenting with suspected acute coronary syndromes (ACS) have not yet been fully characterized. The aim of this study was to assess gender-related disparities in clinical profiles, biomarkers and diagnoses of patients with suspected ACS. Methods: This single-centre, prospective cohort study included 377 consecutive patients presenting with suspected ACS to the emergency department. Suspected ACS was defined as a request for conventional troponin T (c-cTnT) measurements on clinical grounds. Results: Women were older than men (p = 0.004), and had a lower prevalence of known coronary artery and peripheral vascular disease (p < 0.05). c-cTnT was positive in 8% of female and in 14% of male patients (p = 0.16), TIMI risk score and cardiac biomarkers including c-cTnT, hs-cTnT, myoglobin, creatine kinase, N-terminal pro-brain natriuretic peptide, myeloid-related protein 8/14 and pregnancy-associated plasma protein A were lower in women (p < 0.05). Women were less frequently diagnosed with ACS (30 vs. 51%), and were not referred for urgent coronary angiography as often as men (p < 0.001). In multivariate analysis, female gender was associated with a lower referral for coronary angiography (HR 0.41, 95% CI 0.23-0.78, p = 0.006). Conclusions: In patients with suspected ACS, women presented with different biomarker profiles, and were less often diagnosed with ACS and referred to coronary angiography.

Additive prognostic value of coronary artery calcium score and renal function in patients with acute chest pain without known coronary artery disease: up to 5-year follow-up.

Long-term incremental prognostic value of renal function over coronary artery calcium score (CACS) in symptomatic patients without known coronary artery disease (CAD) is unclear. The objective of this study was to examine additive prognostic value of renal function over CACS in patients with acute chest pain suspected of CAD. Renal function and CACS were assessed in patients without known CAD who presented to the emergency department with chest pain from 2005 to 2008. Renal function was assessed using estimated glomerular filtration rate (eGFR), and chronic kidney disease (CKD) was defined as eGFR < 60 mL/min/1.73 m(2). A total of 949 patients (804 non-CKD and 145 CKD, age 54 ± 13 years) were included. During the follow-up period of up to 5.3 years, major adverse cardiac events (MACE) occurred in 5.7% of patients (19 cardiac deaths, 6 myocardial infarction and 29 late coronary revascularization). Annualized MACE rate was higher in patients in higher CACS categories with and without CKD (p = 0.011 and p < 0.001 respectively). In multivariate logistic regression analysis, CACS categories (CACS 1-100: HR 3.17, p = 0.005; CACS 101-400: HR 7.68, p < 0.001; CACS > 400: HR 8.88, p < 0.001) and CKD (HR 10.18, p < 0.001) were independent predictors for MACE. Both adding renal function and CACS significantly improved the overall predictive performance (p < 0.001 for global Chi square increase) from Framingham risk categories or thrombolysis in myocardial infarction (TIMI) risk score. Both CACS and renal function were independent predictors for future cardiac events and provided additive prognostic value to each other and over either Framingham risk categories or TIMI risk score.

Physicians' perceptions of the Thrombolysis in Myocardial Infarction (TIMI) risk score in older adults with acute myocardial infarction

ObjectivesTo evaluate physician-perceived strengths and limitations of the Thrombolysis in Myocardial Infarction (TIMI) risk scores for use in older adults with acute myocardial infarction (AMI). BackgroundThe TIMI risk scores are risk stratification models developed to estimate mortality risk for patients hospitalized for AMI. However, these models were developed and validated in cohorts underrepresenting older adults (≥75 years). MethodsQualitative study using semi-structured telephone interviews and the constant comparative method for analysis. ResultsTwenty-two physicians completed interviews ranging 10–30 min (mean = 18 min). Median sample age was 37 years, with a median of 11.5 years of clinical experience. TIMI strengths included familiarity, ease of use, and validation. Limitations included a lack of risk factors relevant to older adults and model scope and influence. ConclusionsPhysicians report that the TIMI models, while widely used in clinical practice, have limitations when applied to older adults. New risk models are needed to guide AMI treatment in this population.

Evaluación del impacto clínico y la seguridad de una unidad de dolor torácico en pacientes con probabilidad baja e intermedia de síndrome coronario agudo

BackgroundChest pain units (CPU) are an accepted method to assess patients admitted to an emergency department with chest pain with a potential ischemic origin. Yet in Colombia, the customary admission to a CPU in a standardized fashion is scarce and, to our knowledge, the outcome of implementing recognized protocols for chest pain has not been evaluated. ObjectiveTo assess the clinical impact and security of CPU, in patients with, low and intermediate probability of acute coronary syndrome, in Medellín, Colombia. MethodsA descriptive study comprising 277 subjects who were consecutively admitted to the CPU. Variables included demographics, and performance measures to assess the process of care (timely action and process completion). A 30 days follow-up included survival and new admissions compatible with coronary syndromes. ResultsFrom the whole sample, 13.0% of patients were referred for hospitalization. However, only 2.5% had a final diagnosis of an acute coronary syndrome. Median time between reception and an electrocardiogram acquisition was 10minutes TIMI score and acute coronary syndrome probability were reported in 85.5 and 73.9% of subjects respectively. Comparison between early implementation and consolidation phases showed a sensible improvement of performance measure indicators (p<0.05). In addition, 30-day follow-up showed neither fatalities nor new coronary events. ConclusionChest pain observation unit based on clinical assessment of thoracic pain, TIMI risk score and ST segment changes interpretation in the ECG is a safe and efficacious way to stratify low and intermediate chest pain leading to a safe patient discharge with very low risk of cardiovascular complications.