TIMI Risk Score Research Articles

TCTAP A-022 Comparison of PCI Procedure and Outcomes in Patients with STEMI (Differences in TIMI Risk Score)

TCTAP A-022 Comparison of PCI Procedure and Outcomes in Patients with STEMI (Differences in TIMI Risk Score)

Demographics of Acute Coronary Syndrome (ACS) Egyptian patients admitted to Assiut University Hospital: Validation of TIMI and GRACE scores

AimsThis prospective cross-sectional observational study aimed at reporting the demographics of ACS patients admitted to Assiut University Hospital, Egypt, and validating both TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores in the prediction of both in-hospital MACE and 30-day mortality and recurrent MI in both ST-elevation myocardial infarction (STEMI) and unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) patients. MethodsData were collected from all admitted patients over one year from April 1, 2011. ResultsThe study included 795 patients, 270 (34%) with STEMI and 525 (66%) with UA/NSTEMI with a comparable mean age (58±11 vs 57±12years, respectively). The STEMI patients had higher rates of male gender (75% vs 64%), smoking (51% vs 38%), and familial predisposition (16% vs 7%). The UA/NSTEMI patients had higher rates of a history of previous ischemia (70% vs 24%), hypertension (59% vs 33%), and diabetes (45% vs 34%). STEMI was associated with a higher in-hospital MACE (23.3% vs 13.7%) and a higher 30-day all-cause mortality rate (9% vs 2%) and recurrent non-fatal MI (35% vs 15%). ConclusionACS occurs at a relatively young age in our locality, in patients sharing common known coronary risk factors. STEMI patients, in our locality, represent approximately one-third of ACS patients and are associated with worse in-hospital as well as 30-day outcomes. Both TIMI and GRACE risk scores are valid for use in ACS patients in the Assiut governorate (c-statistics 0.72–0.97), with a better discriminative ability for the GRACE score, especially in UA/STEMI patients.

0148: Corrected QT interval prolongation: a new predictor of cardiovascular risk in patients 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 in patients with unstable angina and acute ischemic changes. The aim of this study was to determine the prognostic value of the corrected QT (CTc) interval in patients with non-ST-segment elevation acute coronary syndrome who do not exhibit acute ischemic changes on admission ECG. The study included 105 patients with this syndrome. On admission, a standard 12-lead ECG was recorded, the cardiac troponin-T was measured and aTIMI (Thrombolysis in Myocardial Infarction) 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 cut-off 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 40 patients (38%) who reached the primary endpoint, 32 (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 in patients with non-ST-segment elevation acute coronary syndrome but without acute ischemic changes on admission ECG.

Prognostic Value of the Leuko-glycemic Index in Acute Myocardial Infarction. Results from the SCAR Multicenter Registry

Background: Leukocytosis and hyperglycemia correlate with worse short-term prognosis in patients with acute coronarysyndrome, but their new relationship, called leuko-glycemic index (LGI), has been scarcely evaluated.Objectives: The aim of this study was to analyze the prognostic value of LGI in patients with ST-segment-elevation acutemyocardial infarction (STEMI) and its added value to classical risk scores.Methods: Patients diagnosed with STEMI from the SCAR (Acute Coronary Syndromes in Argentina) Multicenter Registrywere analyzed. The final endpoint was death or in-hospital Killip-Kimball 3-4 (KK 3-4). The LGI was analyzed as a continuousvariable and in quartiles according to 25, 50 and 75 percentile values.Results: The study evaluated 405 out of 476 patients with final STEMI diagnosis. Presence of the primary endpoint significantlyincreased per LGI quartile: 0%, 7.60%, 9.30% and 30.60% (p < 0.0001). The LGI area under the ROC curve for the compositeendpoint was 0.77 [(95% CI 0.71-0.88); p = 0.0001]; the best prognostic cut-off value was 1000. Presence of death or KK 3-4was 0% and 13% in STEMI patients with LGI below or above 1000, respectively. In a multivariate logistic regression model,LGI was independently associated with death or KK 3-4. The area under the ROC curve of the TIMI risk score for STEMIwas 0.58. The addition of LGI increased its discriminatory capacity to 0.66 (p = 0.001).Conclusions: The LGI was an independent predictor of adverse outcome in STEMI patients (death or KK 3-4), adding prognosticvalue to the TIMI risk score.

PT162 Prediction of Major Adverse Cardiac Events of Patients With Acute Coronary Syndrome In Hospital Using Timi Risk Score And Timi Risk Index

PT162 Prediction of Major Adverse Cardiac Events of Patients With Acute Coronary Syndrome In Hospital Using Timi Risk Score And Timi Risk Index

O112 How much does a non-physician healthcare worker based model of care for cardiovascular disease management cost?

Introduction: In patients with non-ST-elevation acute coronary syndrome (ACS), early risk stratification is of critical importance. Among others, the Thrombolysis in Myocardial Infarction (TIMI) risk score is the most validated and the most extensively used in patients with non-ST-elevation ACS. However, this score does not utilize results of evaluation of early markers of myocardial necrosis such as heart-type fatty acidbinding protein (hFABP). Objectives: The aim of this study was to estimate the effectiveness of new cardiac marker hFABP in the protocol of early risk stratification during rendering emergency medical care for patients with suspected non-ST-elevation acute coronary syndromes (NSTEACS). Methods: The study included two groups of patients. The first group included 442 patients (67 13 years) with suspected NSTEACS who underwent early risk stratification and the second (control group) consist of 491 patients (59 16 years) with suspected NSTEACS but without pre-operative risk stratification. We stratificated patient from first group accordind Modified TIMI risk score which was constructed with included results of hFABP evaluation. This evaluation was provided by a novel, sensitive assay that is based on the immunochromatographic test-strip technique has been recently developed for rapid qualitative detection of hFABP in whole blood (BioTest Co., Novosibirsk, Russia). The procedure requires approximately 100 microliters of whole blood and can be completed within 20 min in any in-patient or out-patient settings without any special equipment. The analytical sensitivity of this test is 15 ng/ml. Results: A preliminary diagnosis of myocardial infarction (MI) was adjudged in 52 (11.8%) patients from the first group and 64 (13.0%) from the second, and a preliminary diagnosis of unstable angina was adjudged in 390 (88.2%) and 427 (87.0%) patients, respectively. The accuracy of diagnosis of myocardial infarction in the first group was higher in the first group than the second (86,5% and 60,9% respectively, p1⁄40,003). The sensitivity of the hFABP assay within the first 12 hours was 84% for the detection of MI and the corresponding specificity was 93%. Conclusion: Using of new cardiac marker hFABP is effective in early risk stratification for patients with suspected non-ST-elevation acute coronary syndromes during rendering emergency medical care. Disclosure of Interest: None Declared

Comparison of Prediction Between TIMI (Thrombolysis in Myocardial Infarction) Risk Score and Modified TIMI Risk Score in Discharged Patients From Emergency Department With Atypical Chest Pain

Background:Chest pain is one of the most common causes of the admission to the emergency departments. It, however, can be due to numerous diseases some of which are life threatening.Objectives:In the current study, we evaluated the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) and Modified TIMI risk scores to stratify the risk for patients with atypical chest pain being discharged from the emergency department.Patients and Methods:In a prospective-analytic study, we collected data from 1020 patients with atypical chest pain enrolled to the study. All eligible patients were visited by the emergency medicine residents who were trained for this study. Based on the criteria in both systems, the emergency medicine attending decided on either discharging or hospitalizing patients. Patients were allocated into 2 equal groups randomly. In order to predict the opposing accidents in 30 days (coronary revascularization, myocardial infarction, and all-cause death) TIMI risk scores and Modified TIMI risk scores were assessed based on TIMI risk score (0 or 1) and Modified TIMI risk score (0 or 1).Results:No significant difference could be observed between both groups regarding demographic characteristics, ejection fraction, left ventricle hypertrophy, TRS criteria, risk factors and the history of coronary artery stenosis. None of the atypical chest pain patients discharged based on TIMI and modified TIMI risk scores experienced any adverse events.Conclusions:The results obtained from this study support the idea that the TIMI and modified TIMI risk scores might be valuable tools that could be used to stratify the risk of patients with atypical chest pain in the emergency department.

CRT-148 TIMI Risk Score Can Be Used for Choosing Treatment Strategy in Patients with Cocaine Associated Chest Pain

To determine value of TIMI risk score in evaluation of patients admitted with cocaine associated chest pain (CACP). It has been shown that in patients with unstable angina/Non-ST Elevation myocardial infarction (NSTEMI), the TIMI risk score categorizes a patient’s risk of death, ischemic events

Clinical Features, Use of Evidence‐Based Therapies, and Cardiovascular Outcomes Among Patients With Chronic Kidney Disease Following Non–ST‐Elevation Acute Coronary Syndrome

Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular events following acute coronary syndrome (ACS). The underlying pathobiology and optimal treatments for this population continue to be evaluated. Patients with CKD will receive fewer evidence-based therapies and experience high rates of adverse cardiovascular events in both the short- and long term. The MERLIN-TIMI 36 (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndromes-Thrombolysis in Myocardial Infarction 36) trial randomized non-ST-elevation ACS patients to ranolazine or placebo, with no exclusion for renal dysfunction (except dialysis). We conducted a prespecified analysis among 6543 patients based on the degree of CKD. Patients with worse renal function were older with more comorbidities (P < 0.0001 for each). They were less likely to receive evidence-based cardiovascular medicines (P < 0.04 for each). Rates of an early invasive management strategy varied based on renal function; however, among patients with the highest TIMI risk scores, the rates of an early invasive management strategy were similar regardless of glomerular filtration rate (GFR) (Pinteraction = 0.005). Lower GFR was associated with increased rates of cardiovascular disease or myocardial infarction in the short and long term, even after adjustment (GFR <30 vs ≥90 mL/min/1.73 m(2) ; hazard ratio [HR]: 3.24 [95% confidence interval {CI}: 1.26-8.38] through 7 days and HR: 2.12 [95% CI: 1.33-3.39] through 1 year). The effect of ranolazine vs placebo on clinical outcomes was similar among those with and without CKD (Pinteraction = not significant). Following ACS, patients with renal dysfunction had more cardiovascular risk factors but were less likely to receive evidence-based medical therapies. A strong graded, independent relationship between the degree of CKD and poor clinical outcomes was observed over time. Continued efforts to optimize ACS treatment strategies in patients with CKD are warranted.

Gender, TIMI risk score and in-hospital mortality in STEMI patients undergoing primary PCI: results from the Belgian STEMI registry

The relationship between the predictive performance of the TIMI risk score for STEMI and gender has not been evaluated in the setting of primary PCI (pPCI). Here, we compared in-hospital mortality and predictive performance of the TIMI risk score between Belgian women and men undergoing pPCI. In-hospital mortality was analysed in 8,073 (1,920 [23.8%] female and 6,153 [76.2%] male patients) consecutive pPCI-treated STEMI patients, included in the prospective, observational Belgian STEMI registry (January 2007 to February 2011). A multivariable logistic regression model, including TIMI risk score variables and gender, evaluated differences in in-hospital mortality between men and women. The predictive performance of the TIMI risk score according to gender was evaluated in terms of discrimination and calibration. Mortality rates for TIMI scores in women and men were compared. Female patients were older, had more comorbidities and longer ischaemic times. Crude in-hospital mortality was 10.1% in women vs. 4.9% in men (OR 2.2; 95% CI: 1.82-2.66, p<0.001). When adjusting for TIMI risk score variables, mortality remained higher in women (OR 1.47, 95% CI: 1.15-1.87, p=0.002). The TIMI risk score provided a good predictive discrimination and calibration in women as well as in men (c-statistic=0.84 [95% CI: 0.809-0.866], goodness-of-fit p=0.53 and c-statistic=0.89 [95% CI: 0.873-0.907], goodness-of-fit p=0.13, respectively), but mortality prediction for TIMI scores was better in men (p=0.02 for TIMI score x gender interaction). In the Belgian STEMI registry, pPCI-treated women had a higher in-hospital mortality rate even after correcting for TIMI risk score variables. The TIMI risk score was effective in predicting in-hospital mortality but performed slightly better in men. The database was registered with clinicaltrials.gov (NCT00727623).

Role of stromal cell-derived factor-1 in patients with non-ST elevation acute coronary syndrome.

The predictive value of stromal cell-derived factor-1 (SDF-1) has not been established in patients with non-ST elevation acute coronary syndrome (non-STEACS). A total of 678 consecutive patients with non-STEACS and moderate to high TIMI (Thrombolysis In Myocardial Infarction) risk scores were recruited. All patients underwent an early invasive strategy and then were followed-up for 18 months for clinical events. Left ventricular remodeling was assessed by echocardiography. Plasma concentrations of SDF-1 and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were analyzed. SDF-1 level was an independent predictor of left ventricular remodeling (OR = 2.95, 95% CI = 2.02-4.30, P < 0.001). Cox regression analysis demonstrated that both SDF-1 and NT-proBNP levels were significant independent predictors of death, myocardial infarction, or heart failure (HR = 2.45, 95% CI = 1.71-3.50, P < 0.001; HR = 3.71, 95% CI = 2.41-5.70, P < 0.001, respectively). The area under the ROC curves for SDF-1 (0.776) and NT-proBNP (0.817) were similar. The logistic model with both markers yielded a larger area under the ROC curve (0.862) than that of SDF-1 (P < 0.001) or NT-proBNP (P = 0.0001) alone. In patients stratified by NT-proBNP (above 615.4 pmol/L), SDF-1 (above 2175.1 pg/mL) was associated with poorer outcome (P < 0.001). Findings were similar for death and heart failure as individual endpoints. In non-STEACS, higher SDF-1 levels were a significant predictor of death, myocardial infarction, or heart failure independently of baseline clinical characteristics and NT-proBNP, and the combination of SDF-1 and NTproBNP significantly improved risk stratification. These data highlight the prognostic value of multiple, complementary biomarkers in non-ST elevation acute coronary syndrome.

Prognostic Performance of a High-Sensitivity Cardiac Troponin I Assay in Patients with Non–ST-Elevation Acute Coronary Syndrome

High-sensitivity assays for cardiac troponin enable more precise measurement of very low concentrations and improved diagnostic accuracy. However, the prognostic value of these measurements, particularly at low concentrations, is less well defined. We evaluated the prognostic performance of a new high-sensitivity cardiac troponin I (hs-cTnI) assay (Abbott ARCHITECT) compared with the commercial fourth generation cTnT assay in 4695 patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) from the EARLY-ACS (Early Glycoprotein IIb/IIIa Inhibition in NSTE-ACS) and SEPIA-ACS1-TIMI 42 (Otamixaban for the Treatment of Patients with NSTE-ACS) trials. The primary endpoint was cardiovascular death or new myocardial infarction (MI) at 30 days. Baseline cardiac troponin was categorized at the 99th percentile reference limit (26 ng/L for hs-cTnI; 10 ng/L for cTnT) and at sex-specific 99th percentiles for hs-cTnI. All patients at baseline had detectable hs-cTnI compared with 94.5% with detectable cTnT. With adjustment for all other elements of the TIMI risk score, patients with hs-cTnI ≥99th percentile had a 3.7-fold higher adjusted risk of cardiovascular death or MI at 30 days relative to patients with hs-cTnI <99th percentile (9.7% vs 3.0%; odds ratio, 3.7; 95% CI, 2.3-5.7; P < 0.001). Similarly, when stratified by categories of hs-cTnI, very low concentrations demonstrated a graded association with cardiovascular death or MI (P-trend < 0.001). Use of sex-specific cutpoints did not improve prognostic performance. Patients with negative fourth generation cTnT (<10 ng/L) but hs-cTnI ≥26 ng/L were at increased risk of cardiovascular death/MI compared to those with hs-cTnI <26 ng/L (9.2% vs 2.9%, P = 0.002). Application of this hs-cTnI assay identified a clinically relevant higher risk of recurrent events among patients with NSTE-ACS, even at very low troponin concentrations.

Interleukin-6 as a predictor of cardiovascular events in troponin-negative non-ST elevation acute coronary syndrome patients

Risk stratification in acute coronary syndrome without ST-segment elevation (NSTE-ACS) and troponin-negative remains a challenge. We evaluated the value of interleukin-6 (IL-6) and amino-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prognosis assessment of low-moderate risk NSTE-ACS and troponin-negative, and whether these biomarkers could improve the predictive performance of the established thrombolysis in myocardial infarction (TIMI) risk score. A total of 212 low-moderate risk patients with NSTE-ACS and troponin-negative were prospectively studied. Clinical follow up at 6months was performed for adverse endpoints. A total of 28 patients (13.5%) presented adverse clinical events. Those with adverse clinical events were associated with higher levels of IL-6 [8.58 (5.13-20.95)ng/l vs. 6.12 (4.16-9.14)ng/l, p=0.043] and NT-proBNP [275.3 (108.6-548.2)ng/l vs. 126.8 (55.97-430.20)ng/l, p=0.046]. In moderate risk group, we observed a higher event rate in patients with troponin-negative but elevated levels of IL-6 (p=0.024). Only elevated IL-6 (>12.40ng/l) was an independent predictor of adverse outcomes [hazard ratios: 3.62, 95% confidence interval (CI) 1.69-7.75, p=0.001]. The addition of IL-6 and history of ischaemic heart disease (IHD) to TIMI risk score significantly improved both the discrimination (integrated discrimination improvement, p=0.003) and reclassification (Clinical Net reclassification improvement, p=0.010) of the model for adverse events. Interleukin-6 is an independent predictor of adverse events in low-moderate risk patients with NSTE-ACS and troponin-negative. Its use identifies a higher risk population in moderate-risk patients. This provides together with history of IHD a better discrimination and reclassification beyond that achieved with clinical risk variables from TIMI risk score in these patients.

Association of epicardial fat thickness with TIMI risk score

We read the article“Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients” by Ozcan et al. [1] with great interest. The authors aimed to investigate the association between TIMI risk score and epicardial fat thickness (EFT) in patients with non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (USAP). They concluded that EFT is independently associated with TIMI risk score and may be an emerging risk factor for adverse events in NSTEMI/USAP patients. We thank the authors for their contribution of the present study, which is successfully designed and documented. EFT measurement with echocardiography has several advantages, including its low cost, easy accessibility, rapid applicability, and good reproducibility. EFT has a three-dimensional distribution, and two-dimensional echocardiography cannot give an adequate window of all cardiac segments, especially in obese subjects, and is highly dependent on acoustic windows [2]. It is widely recognized that an accumulation of EFT is strongly related to coronary artery disease (CAD). EFT amount may contribute to systemic inflammation beyond traditional cardiovascular risks and body fat composition. EFT measured by echocardiography has been known to be associated with metabolic syndrome [3]. Additionally, echocardiography-based EFT measurement was related to several metabolic abnormalities and independently associated with fatty liver disease [4]. Also, the duration of hormone therapy (HT) may be different in these patients. We think that the results of the study would be more robust if the authors had mentioned these factors including the duration of HT and liver function tests. EFT can also be affected by atherosclerotic risk factors such as alcohol consumption, hypothyroidism [5], and higher inflammatory status [3], for example, an inflammatory disease, cardiac syndrome X, and infection [6]. In the present study, the authors did not mention these possibly contributing factors. It would have been better if the authors had given information about these factors. Furthermore, the severity of CAD was evaluated by calculation of Gensini scores in the present study. However, the SYNTAX score (SS) may also be used for grading of coronary complexity based on angiographic visual assessment. The addition of clinical risk factors to the SS has been shown to potentially further augment its utility in the objective evaluation of the severity of CAD. The Logistic Clinical SXscore consisting of four continuous variables including SXscore, age, creatinine clearance, and left ventricular ejection fraction substantially enhances the risk stratification of CAD patients for the outcome of long-term all-cause death compared with the SXscore in isolation. The Logistic Clinical SXscore was able to accurately distinguish patients with or without a clinical outcome and could accurately predict individual patient risk without underor over-estimating risk [7]. Second, we strongly believe that it would be better to give interobserver and intraobserver variability for CAD severity in the current study. Finally, EFT itself without other inflammatory markers may not provide information to clinicians about systemic inflammation. Therefore, we think that it should be evaluated together with other serum inflammatory markers. We believe that these findings will help evaluate the results of further studies on EFT and TIMI risk score in acute coronary syndrome patients.

Is it possible to simplify risk stratification scores for patients with ST-segment elevation myocardial infarction undergoing primary angioplasty?

IntroductionThere are several risk scores for stratification of patients with ST-segment elevation myocardial infarction (STEMI), the most widely used of which are the TIMI and GRACE scores. However, these are complex and require several variables. The aim of this study was to obtain a reduced model with fewer variables and similar predictive and discriminative ability. MethodsWe studied 607 patients (age 62 years, SD=13; 76% male) who were admitted with STEMI and underwent successful primary angioplasty. Our endpoints were all-cause in-hospital and 30-day mortality. Considering all variables from the TIMI and GRACE risk scores, multivariate logistic regression models were fitted to the data to identify the variables that best predicted death. ResultsCompared to the TIMI score, the GRACE score had better predictive and discriminative performance for in-hospital mortality, with similar results for 30-day mortality. After data modeling, the variables with highest predictive ability were age, serum creatinine, heart failure and the occurrence of cardiac arrest. The new predictive model was compared with the GRACE risk score, after internal validation using 10-fold cross validation. A similar discriminative performance was obtained and some improvement was achieved in estimates of probabilities of death (increased for patients who died and decreased for those who did not). ConclusionIt is possible to simplify risk stratification scores for STEMI and primary angioplasty using only four variables (age, serum creatinine, heart failure and cardiac arrest). This simplified model maintained a good predictive and discriminative performance for short-term mortality.

Abstract 18257: Use of the TIMI Risk Score in the Emergency Department Discriminates Acute Coronary Syndrome Among Chest Pain Patients With Known Coronary Artery Disease

Background: Patients with known coronary artery disease (CAD) presenting to the Emergency Department (ED) with chest pain thought to be of ischemic origin are often admitted to the hospital, yet half or fewer are eventually diagnosed with acute coronary syndrome (ACS). We assessed whether the use of the TIMI risk score, developed for UA/NSTEMI prognostication, applied in the ED and modified to eliminate the “known CAD” variable, could discriminate which of these high-risk patients actually do and do not have ACS. Methods and Results: Chart review was performed on a prospectively defined cohort of 111 patients with known CAD (73% prior PCI, 42% prior CABG) presenting to the ED with chest pain thought to be of ischemic origin, all of whom were admitted to the hospital from December 2012 to April 2013. The composite TIMI risk score and its individual variables were assessed with logistic regression models for their association with ACS as determined by the inpatient attending physician at hospital discharge. ACS was eventually diagnosed in 36 (32.4%) of the patients. Non-ACS patients had a 2.8 day average length of stay and $9,290 average inpatient (post-ED) hospital charges, which is $696,773 for the 75 (67.6%) non-ACS patients. The odds of having ACS increased by 207% (p &lt;0.001) per 1 point increase in TIMI score. TIMI score discriminates ACS and non-ACS with an area under ROC curve (AUC) of 0.794. In a multi-variable model with the individual TIMI variables, elevated troponin (OR 8.00, p 0.002) and ST deviation (OR 8.38, p 0.007) in the ED, and 2 or more prior chest pain episodes (OR 3.89, p 0.061), were most predictive; AUC 0.834. In a multi-variable model with the TIMI variables and each of the CAD risk factors, elevated troponin (OR 6.95, p 0.008) and ST deviation (OR 9.54, p 0.007) in the ED, and 2 or more prior chest pain episodes (OR 3.90, p 0.067) remained most predictive, and diabetes was the most predictive risk factor (OR 2.03, p 0.282); AUC 0.850. Conclusions: A modified TIMI risk score is a valuable tool for discriminating between ACS and non-ACS among patients with known CAD presenting to the ED with chest pain. Application of this risk score, along with other clinical factors, may help avoid short, though potentially unnecessary admissions, and reduce associated costs.

Abstract 9262: Clinical Implication of ST-Segment Elevation in Lead aVR in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

Background: In patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), ST-segment depression (STD) has been shown to be associated with poor outcomes; however, lead aVR is not considered. Lead aVR is referred to as a “cavity lead,” and ST-segment elevation in this lead (STE-aVR) might reflect global subendocardial ischemia. Methods: We studied 818 patients with NSTE-ACS who underwent coronary angiography during hospitalization. ST-segment deviation was measured on admission ECG, and it was considered present if ≥ 0.5 mm. Troponin T (TnT), hemoglobin (Hb), estimated glomerular filtration rate (eGFR), high-sensitivity C-reactive protein (hsCRP), brain natriuretic peptide (BNP), and TIMI risk score were also measured on admission. Results: STD in 11 leads except aVR was observed in 568 patients. Among these patients, 225 patients had STE-aVR. In patients with no STD (n=250), isolated STD (n=343), and STD plus STE-aVR (n=225), age was 63±10, 67±11, and 70±11 years; the rates of diabetes mellitus were 25%, 32%, and 50%; Killip class ≥2 was 2%, 6%, and 27%; positive TnT was 22%, 34%, and 49%; the levels of Hb were 13.8±1.7, 13.9±1.9, and 12.7±2.2 g/dl; eGFR was 69.1±22.8, 65.8±24.7, and 56.8±27.5 ml/min/1.73m 2 ; hsCRP was 0.310±1.480, 0.499±1.249, and 0.899±1.820 mg/dl; BNP was 90±203, 200±359, and 431±575 pg/ml; TIMI risk core was 1.9±1.2, 3.1±1.3, and 3.6±1.2; the frequencies of left main/3-vessel disease were 4.0%, 8.5%, and 56.9%; and in-hospital adverse events (death, [re]infarction, or urgent revascularization) were 5.2%, 8.7%, and 31.6%, respectively (all p&lt;0.01). Multivariate analysis showed that STD plus STE-aVR (OR 3.56, 95%CI 1.13-7.99, p&lt;0.01) was the strongest predictor of in-hospital adverse events, followed by positive TnT (OR 1.33, 95%CI 1.03-2.99, p=0.048), but isolated STD was not. Conclusions: In patients with NSTE-ACS, STE-aVR in addition to STD on admission ECG was strongly associated with left main/3-vessel disease and in-hospital adverse outcomes, but isolated STD was not. Our findings suggest the importance of evaluation of ST-segment deviation in 12 leads including aVR in early risk stratification.

Utility of C-terminal Proendothelin in the Early Diagnosis and Risk Stratification of Patients With Suspected Acute Myocardial Infarction

BackgroundEndothelial dysfunction plays a major role in cardiovascular diseases, including acute myocardial infarction (AMI). However, its quantification has not been available as a clinical tool. MethodsIn a prospective international multicentre study, we analyzed the diagnostic and prognostic utility of endothelial dysfunction as quantified by C-terminal proendothelin-1 (CT-proET-1) in 658 consecutive patients presenting with suspected AMI. The final diagnosis was adjudicated by 2 independent cardiologists. Patients were followed long-term for mortality. ResultsThe adjudicated final diagnosis was AMI in 145 patients (22%). The diagnostic performance of CT-proET-1 for AMI was moderate; its area under the receiver operating characteristic (ROC) curve amounted to 0.66 (95% confidence interval [CI], 0.61-0.72; P < 0.001). There was no significant increase in the AUC when CT-proET-1 was added to either cardiac troponin T (cTnT) or high-sensitivity cTnT (hs-cTnT). Seventy four percent of patients who died during the first 24 months (n = 50) were in the fourth quartile of the CT-proET-1 presentation value (>82 pmol/L). The prognostic accuracy of CT-proET-1 regarding mortality was tantamount to that of N-terminal pro–B-type natriuretic peptide (NT-proBNP) and outperformed cTnT and hs-cTnT both in patients with AMI and in patients without acute coronary syndrome. CT-proET-1 at presentation yielded high prognostic accuracy that was similar to that of the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk scores. The TIMI risk score could be significantly improved by adding CT-proET-1 (integrated discriminatory improvement [IDI] of 0.074 P = 0.004). ConclusionsUse of CT-proET-1 improves risk stratification of unselected patients with suspected AMI. CT-proET-1 did not provide additional diagnostic value.

Is it possible to simplify risk stratification scores for patients with ST-segment elevation myocardial infarction undergoing primary angioplasty?

IntroductionThere are several risk scores for stratification of patients with ST-segment elevation myocardial infarction (STEMI), the most widely used of which are the TIMI and GRACE scores. However, these are complex and require several variables. The aim of this study was to obtain a reduced model with fewer variables and similar predictive and discriminative ability. MethodsWe studied 607 patients (age 62 years, SD=13; 76% male) who were admitted with STEMI and underwent successful primary angioplasty. Our endpoints were all-cause in-hospital and 30-day mortality. Considering all variables from the TIMI and GRACE risk scores, multivariate logistic regression models were fitted to the data to identify the variables that best predicted death. ResultsCompared to the TIMI score, the GRACE score had better predictive and discriminative performance for in-hospital mortality, with similar results for 30-day mortality. After data modeling, the variables with highest predictive ability were age, serum creatinine, heart failure and the occurrence of cardiac arrest. The new predictive model was compared with the GRACE risk score, after internal validation using 10-fold cross validation. A similar discriminative performance was obtained and some improvement was achieved in estimates of probabilities of death (increased for patients who died and decreased for those who did not). ConclusionIt is possible to simplify risk stratification scores for STEMI and primary angioplasty using only four variables (age, serum creatinine, heart failure and cardiac arrest). This simplified model maintained a good predictive and discriminative performance for short-term mortality.

Value of High-Sensitivity Troponin in Assessing the Extent of Benefit Provided by Ticagrelor Versus Clopidogrel in Non–ST-Segment Elevation Acute Coronary Syndromes

There is considerable evidence supporting an aggressive approach to the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS). This includes intensive medical therapy and an early invasive strategy. These tactics, alone or in combination, can reduce the rate of subsequent ischemic events though increase bleeding events. The challenge for clinicians is to efficiently identify those patients (from among the very large number of patients presenting to the hospital with chest pain) who will receive the greatest net benefit from an aggressive approach. Numerous methods for risk stratification of NSTE-ACS patients have emerged. Clinical risk assessments such as the TIMI risk score have been shown to predict adverse outcomes and, perhaps more importantly, identify patients most likely to benefit from an early invasive strategy or intensive antithrombotics. 1-2 Elevated levels of serum troponin have been found separately to predict adverse events and identify patients likely to benefit from intensive antiplatelet therapy. 3 Other biomarkers, such as B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP) predict adverse outcomes in the setting of NSTE-ACS, but have not consistently been shown to predict a response to a specific treatment regimen. 4 In this issue of Circulation , Wallentin et al 5 report their analysis of baseline levels of high-sensitivity troponin T (hs-TnT), NT-proBNP, and growth-differentiation factor-15 (GDF-15) in NSTE-ACS patients enrolled in the Platelet Inhibition and Patient Outcomes (PLATO) trial. 6