Correlation between the TIMI risk score and high-risk angiographic findings in non–ST-elevation acute coronary syndromes: Observations from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) trial

doi:10.1016/j.ahj.2004.08.042

American Heart Journal

Volume 149, Issue 5, May 2005, Pages 846-850

https://doi.org/10.1016/j.ahj.2004.08.042 Get rights and content

Background

The TIMI risk score for unstable angina and non-ST elevation myocardial infarction is an effective tool for predicting the risk of death and ischemic events among patients with non-ST elevation acute coronary syndromes, as well as for identifying those who are likely to benefit most from low-molecular-weight heparin and glycoprotein IIb/IIIa inhibition.

Methods

To explore the pathobiologic basis for this interaction, we evaluated the relationship between the risk score, assessed at presentation, and angiographic findings among patients with non-ST elevation acute coronary syndromes. Angiographic data regarding thrombus, epicardial flow, and lesion severity were available for 1491 patients from the angiographic substudy of PRISM-PLUS.

Results

Patients with risk scores of 5 to 7 (N = 435) were more likely to have a severe culprit stenosis (81% vs 58%, P < .001) and multivessel disease (80% vs 43%, P < .001) compared to those with scores of 0 to 2 (N = 220). The probability of left main disease (P = .01), visible thrombus, and impaired flow in the culprit lesion also increased progressively with rising risk scores (P < .001). Of the risk indicators that comprise the score, history of coronary disease, advanced age, and ST changes showed the strongest association with severe epicardial disease. Positive biomarkers of necrosis, ST changes, and prior aspirin use emerged as stronger correlates of visible thrombus and/or impaired culprit artery flow.

Conclusions

The TIMI risk score identifies patients who are more likely to have intracoronary thrombus, impaired flow, and increased burden of coronary atherosclerosis. These findings likely explain in part the particular benefit of potent antithrombin and antiplatelet agents among patients with higher risk scores.

Section snippets

Study population

PRISM-PLUS was a multicenter, randomized trial performed in 72 hospitals in 14 countries. The design and results of PRISM-PLUS have been described.⁸ Briefly, 1915 patients with NSTEACS were enrolled within 12 hours of presentation with severe rest angina (prolonged pain or repetitive episodes), given aspirin, and randomized to 1 of 3 treatment groups: tirofiban plus heparin, tirofiban placebo plus heparin, or tirofiban plus heparin placebo. The protocol required infusion of the study medication

Patients

Core Laboratory interpretation of angiographic data was available for 1491 patients. Angiography was performed a mean of 65 hours after randomization. The baseline risk profile of the population in this substudy was similar to the overall population enrolled in PRISM-PLUS, as assessed using the TIMI risk score⁴; 15% (n = 220) of patients were in the low-risk (0-2), 56% (n = 836) in the intermediate-risk (3-4), and 29% (n = 435) in the high-risk (5-7) groups. The allocation to each treatment

Discussion

The TIMI risk score is a simple integer score that integrates information from multiple clinical predictors to aid in producing a quantitative estimate of the risk of death and recurrent ischemic events.¹ Our present analysis demonstrates associations that may reflect the pathobiologic underpinnings of the TIMI risk score. Specifically, the risk score identified patients who were more likely to have intracoronary thrombus, impaired angiographic flow, and increased burden of coronary

References (20)

B.M. Scirica et al.
Validation of the thrombolysis in myocardial infarction (TIMI) risk score for unstable angina pectoris and non–ST-elevation myocardial infarction in the TIMI III registry
Am. J. Cardiol.
(2002)
D.A. Morrow
New insight into clinical risk scores for patients with acute coronary syndromes
Am. Heart J.
(2003)
S.H. Litovsky et al.
Effect of age, race, body surface area, heart weight and atherosclerosis on coronary artery dimensions in young males
Atherosclerosis
(1996)
M. Cohen et al.
Usefulness of ST-segment changes in greater than or equal to 2 leads on the emergency room electrocardiogram in either unstable angina pectoris or non–Q-wave myocardial infarction in predicting outcome
Am. J. Cardiol.
(1991)
C.P. Miranda et al.
Correlation between resting ST segment depression, exercise testing, coronary angiography, and long-term prognosis
Am. Heart J.
(1991)
H. Benamer et al.
Elevated cardiac troponin I predicts a high-risk angiographic anatomy of the culprit lesion in unstable angina
Am. Heart J.
(1999)
G. Dangas et al.
Correlation of angiographic morphology and clinical presentation in unstable angina
J. Am. Coll. Cardiol.
(1997)
J. Santopinto et al.
Prior aspirin users with acute non–ST-elevation coronary syndromes are at increased risk of cardiac events and benefit from enoxaparin
Am. Heart J.
(2001)
E.M. Antman et al.
The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making
JAMA
(2000)
E.M. Antman et al.
Enoxaparin prevents death and cardiac ischemic events in unstable angina/non–Q-wave myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) 11B trial
Circulation
(1999)

There are more references available in the full text version of this article.

Cited by (46)

Accuracy of the TIMI and GRACE scores in predicting coronary disease in patients with non-ST-elevation acute coronary syndrome
2018, Revista Portuguesa de Cardiologia
Citation Excerpt :
Previous studies have been limited to demonstrating an association between the TIMI or GRACE scores and the number of arteries affected. In our study we set out to assess the extent of CAD quantitatively using the SYNTAX score.11–15 We showed that diabetes (OR 3.4) and troponin elevation (OR 7.1) are strong predictors of obstructive CAD and that TIMI and GRACE scores are significantly higher in patients with significant coronary lesions.
The GRACE and TIMI scores have been well validated for assessment of prognosis in non-ST-elevation acute coronary syndrome (NSTE-ACS). However, their value in predicting coronary artery disease (CAD) has been little studied. We aimed to assess the relationship between these scores and the extent of coronary disease.
We analyzed 238 consecutive patients admitted for NSTE-ACS and undergoing a coronary angiogram during hospitalization. The severity of CAD was assessed using the SYNTAX score. Obstructive CAD was defined as ≥50% stenosis in the left main or ≥70% stenosis in other vessels. Severe CAD was defined as a SYNTAX score >32. The Pearson test was used to assess the correlation between scores.
The SYNTAX score was higher in patients at high risk (GRACE score: p<0.001 and TIMI score: p=0.001). Moreover, there was a significant positive correlation between the GRACE and SYNTAX scores (r=0.23, p<0.001) as well as between TIMI and SYNTAX (r=0.2, p=0.002). Both clinical scores can predict obstructive CAD moderately well (area under the curve [AUC] for GRACE score: 0.599, p=0.015; TIMI score: AUC 0.639, p=0.001) but not severe disease. A GRACE score of 120 and a TIMI score of 2 were predictive of obstructive CAD with, respectively, a sensitivity of 57% and 75.7% and a specificity of 61.8% and 47.9%.
The GRACE and TIMI scores correlate moderately with the extent of coronary disease assessed by the SYNTAX score. They can predict obstructive CAD but not severe disease.
Os scores GRACE e TIMI foram convenientemente validados na avaliação do prognóstico de síndrome coronária aguda sem elevação do segmento-ST (NSTE-ACS). No entanto, o seu valor na previsão de doença coronária (DC) está mal estudado. O nosso objetivo é avaliar a relação entre esses scores e a extensão da doença coronária.
Foram consecutivamente avaliados 238 doentes admitidos para NSTE-ACS e submetidos a angiografia coronária durante o internamento. A gravidade da DC foi avaliada durante o score Syntax. Definimos DC obstrutiva quando a obstrução da DC é ≥ 50% no tronco comum e ≥ 70% nos outros vasos. Uma DC grave é definida por um score syntax >32. O teste Pearson foi usado para avaliar a correlação entre os scores.
O valor do score Syntax foi superior nos doentes de alto risco (escore GRACE: p<0,001 e o score TIMI: p=0,001). Além disso, houve uma correlação significativa positiva entre os scores GRACE e Syntax (r=0,23, p<0,001), assim como entre os scores TIMI e Syntax (r=0,2, p=0,002). Ambos os scores clínicos podem de certo modo prever DC obstrutiva (score GRACE: AUC=0,599 (p=0,015); score TIMI: AUC=0,639 (p=0,001), mas não uma doença grave. Um score GRACE=120 e um score TIMI=2 foram fatores preditores da DC obstrutiva com uma sensibilidade de 57% e de 75,7% respetivamente e uma especificidade de 61,8% e de 47,9%.
Os scores GRACE e TIMI estão ligeiramente correlacionados com a extensão da doença coronária avaliada pelo score Syntax. Podem prever uma DC obstrutiva, mas não uma doença grave.
Unstable Angina: Presentation, Diagnosis, and Management
2017, Encyclopedia of Cardiovascular Research and Medicine
The acute coronary syndromes represent a critical instability in coronary atherosclerotic disease. Unstable angina reflects one end of the spectrum of ACS, and is distinguished from myocardial infarction by the presence of elevated cardiac biomarkers in the latter setting. Aggressive medical therapy should be initiated early in patients with UA with a combination of antiplatelet, antithrombotic, and antianginal agents, as well as cholesterol lowering therapies. Early risk stratification should be performed to both inform prognosis and guide the consideration of invasive evaluation with catheterization and subsequent coronary revascularization. With the advances in therapies described above, there has been substantial improvement in the natural history of this ominous condition.
Non-ST-Elevation Acute Coronary Syndrome Prognosis
2017, Encyclopedia of Cardiovascular Research and Medicine
Ischemic heart disease remains a major cause of mortality and morbidity worldwide. Over the past three decades, advances in prevention, diagnosis, and pharmacotherapy coupled with increased rates of revascularization have substantially improved outcomes in patients with acute coronary syndromes (ACS). These trends have led to the emergence of non-ST elevation ACS (NSTE-ACS) with increasingly heterogeneous risk profiles as the predominant presentation of ACS in contemporary cohorts. Accurate early risk assessment of ACS patients represents an ongoing clinical challenge, with underappreciation of risk posing a major barrier to the optimal use of evidence-based therapies. Following a survey of the evolution of NSTE-ACS outcomes over the past three decades, this article will review the prognostic value of individual clinical indicators generally available to physicians at initial presentation, compare validated bedside clinical risk prediction tools, and consider the role of further testing during hospitalization.
non-st-segment elevation acute coronary syndromes
2012, Cardiovascular Therapeutics: A Companion to Braunwald's Heart Disease: Fourth Edition
Usefulness of contrast echocardiography for predicting the severity of angiographic coronary disease in nonST-elevation myocardial infarction
2011, American Journal of Cardiology
Citation Excerpt :
In a retrospective study in 2,624 patients with acute coronary syndrome who underwent coronary angiography, a good correlation between TIMI risk score and extent of CAD was demonstrated.6 However, in the present prospective but much smaller study in patients with NSTEMI, TIMI risk score was unable to identify patients with angiographically severe CAD, adding to previous publications demonstrating that TIMI risk score has limitations in discriminating angiographic CAD severity.7–9 Similar limitations have been documented for other risk score models such those bye Goldman and Sanchus,27 suggesting the need for additional risk stratification tools in patients with NSTEMI.
Guidelines recommend coronary angiography in patients with non–ST-elevation myocardial infarction (NSTEMI) within 24 to 72 hours, a requirement that cannot always be met. The aim of this study was to evaluate the potential use of contrast echocardiography in prioritizing these patients by identifying those with NSTEMI and angiographically severe coronary artery disease (CAD). Echocardiography was performed before coronary angiography in 110 patients with NSTEMI (67 ± 12 years old, 31% women). Segmental myocardial perfusion and wall motion was scored using a 17-segment left ventricular model. CAD was assessed by quantitative coronary angiography. In the total study population, median troponin T level was 0.27 μg/L (0.13 to 0.86) and Thrombolysis In Myocardial Infarction risk score 3.1 ± 1.5. By quantitative coronary angiography 15% had normal coronary angiographic findings, whereas 1-, 2-, and 3-vessel disease were present in 35%, 27%, and 23%, respectively. Severe CAD (left main stem stenosis, 3-vessel disease, or multivessel disease including proximal stenosis in left anterior descending artery) was found in 42%. Number of segments with hypoperfusion increased with CAD severity from 4.1 ± 2.0 in patients with normal coronary arteries to 5.9 ± 2.4, 7.8 ± 3.5, and 10.4 ± 2.8 in patients with 1-, 2-, and 3-vessel disease, respectively (p <0.01). In multiple logistic regression analysis risk of severe CAD increased by 39% for every additional hypoperfused segment by echocardiography independent of wall motion abnormalities and Thrombolysis In Myocardial Infarction risk score. In conclusion, contrast echocardiography may be used for prediction of angiographic CAD severity in patients with NSTEMI awaiting coronary angiography.
Correlation of TIMI risk score with angiographic extent and severity of coronary artery disease in non-ST-elevation acute coronary syndromes
2011, Annales de Cardiologie et d'Angeiologie
Étudier la corrélation du score TIMI avec l’étendue et la sévérité de l’atteinte coronaire chez des patients explorés par coronarographie à la suite d’un syndrome coronarien aigu sans sus-décalage de ST.
Étude rétrospective des dossiers de 239 patients explorés par coronarographie entre 2002 et 2006 à la suite d’un syndrome coronarien aigu sans sus-décalage de ST. Les patients ont été classés en trois groupes selon la valeur du score TIMI : score TIMI de 0 à 2 (groupe 1 : n = 121), score TIMI de 3 à 4 (groupe 2 : n = 100) et score TIMI de 5 à 7 (groupe 3 : n = 18). Nous avons comparé les données angiographiques des trois groupes.
Les patients du groupe 1 ont présenté plus fréquemment des coronaires angiographiquement normales ou une atteinte coronaire non significative que les patients du groupe 2 (36,3 % vs 13 %, p < 0,001) et que ceux du groupe 3 (36,3 % vs 0 %, p = 0,002). Une atteinte monotronculaire était plus souvent observée chez les patients avec score de 0 à 2 que chez les patients avec score de 5 à 7 (28,9 % vs 0 % ; p = 0,01) et chez les patients avec score de 3 à 4 que chez les patients avec score de 5 à 7 (35 % vs 0 % ; p = 0,006). Au contraire, la fréquence d’une atteinte monotronculaire était comparable entre les groupes 1 et 2. Une atteinte bitronculaire a été notée de façon comparable quel que soit le niveau du score TIMI. Une atteinte tritronculaire ou du tronc commun coronaire gauche a été plus fréquemment retrouvée chez les patients du groupe 3 que chez les patients du groupe 2 (66,7 % vs 26 % ; p = 0,01) et que ceux du groupe 1 (66,7 % vs 13,2 % ; p < 0,001). Les occlusions coronaires chroniques et les calcifications coronaires étaient aussi plus fréquemment observées chez les patients avec score de 5 à 7.
Le score TIMI est parfaitement corrélé à l’étendue et la sévérité de l’atteinte coronaire chez les patients victimes d’un syndrome coronarien aigu sans sus-décalage de ST.
To determine whether the TIMI risk score correlates with the angiographic extent and severity of coronary artery disease in patients with non-ST-elevation acute coronary syndrome undergoing cardiac catheterization.
We conducted a retrospective review of 239 medical records of patients who underwent coronary angiography secondary to non-ST-elevation acute coronary syndrome between 2002 and 2006. Patients were classified into three groups according to TIMI risk score: TIMI scores 0 to 2 (group 1: n = 121), 3 to 4 (group 2: n = 100), and 5 to 7 (group 3: n = 18). We compared the coronary angiography findings of the three groups.
Patients of group 1 had a greater likelihood of normal or non significant CAD than patients of group 2 (36.3 % vs 13 %, P < 0.001) and than patients of group 3 (36.3 % vs 0 %, P = 0.002). One-vessel disease was found more often in patients with TIMI score 0 to 2 than in patients with TIMI score 5 to 7 (28.9 % vs 0 %; P = 0.01), and in patients with TIMI score 3 to 4 than in those with score 5 to 7 (35 % vs 0 %, P = 0.006). However, 1-vessel disease was found in patients of group 1 as often as in patients of group 2. The frequency of two-vessel disease was similar whatever the level of TIMI score was low, intermediate or high. Three-vessel or left main disease was more likely found in patients of group 3 than in patients of group 2 (66.7 % vs 26 %; P = 0.01), and than patients of group 1 (66.7 % vs 13.2 %; P < 0.001). Chronic coronary occlusions and coronary calcifications were also more likely found in patients with TIMI score 5 to 7.
In patients with non-ST-elevation acute coronary syndrome undergoing cardiac catheterization, the TIMI risk score correlated with the extent and severity of coronary artery disease.

View all citing articles on Scopus

: The PRISM-PLUS trial was supported by Merck & Co, Inc.

View full text

Clinical InvestigationCorrelation between the TIMI risk score and high-risk angiographic findings in non–ST-elevation acute coronary syndromes: Observations from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) trial

Background

Methods

Results

Conclusions

Section snippets

Study population

Patients

Discussion

Am. J. Cardiol.

Am. Heart J.

Atherosclerosis

Am. J. Cardiol.

Am. Heart J.

Am. Heart J.

J. Am. Coll. Cardiol.

Am. Heart J.

The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making

JAMA

Enoxaparin prevents death and cardiac ischemic events in unstable angina/non–Q-wave myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) 11B trial

Circulation

Clinical Investigation
Correlation between the TIMI risk score and high-risk angiographic findings in non–ST-elevation acute coronary syndromes: Observations from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) trial