Relation between thrombolysis in myocardial infarction risk score and one-year outcomes for patients presenting at the emergency department with potential acute coronary syndrome

A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Streptokinase in the Management of Myocardial Infarction in Developing Countries

Myocardial infarction (MI) is a significant cause of morbidity and mortality in low- and middle-income countries. Fibrinolytic agents and percutaneous coronary intervention (PCI) are the main approaches for the recanalization and reperfusion of the myocardium following MI. Many studies have shown that PCI is superior to thrombolytics due to better outcomes and decreased mortality. Nevertheless, PCI's mortality gain over thrombolysis decreases as the time between presentation and PCI procedure increases. Furthermore, PCI is not widely available in most developing countries; thus, it cannot be delivered promptly. Most patients in developing countries cannot afford the cost of PCI. Thus, thrombolytic therapy remains essential to managing MI in developing countries and should not be disregarded. Tenecteplase (TNK) and streptokinase (SK) are the two most widely used fibrinolytics in managing MI in underdeveloped nations. Despite their widespread availability, comparative studies on them have been inconclusive. This study aims to review the available literature on the effectiveness and safety of TNK versus SK in managing MI in resource-poor nations. The study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search for studies comparing TNK and STK was conducted on EMBASE, Cochrane Library, Web of Science, CINAHL, Scopus, Google Scholar, and Ovid version of MEDLINE databases. A reference list of the eligible articles and systematic reviews was also screened. A narrative synthesis of the available data was done by representing the data on the effect direction plot, followed by vote counting. Of the 2284 references retrieved from the databases, only 17 studies met the inclusion criteria and were selected for final analysis. The study suggested that TNK is more effective in complete ST-segment resolution (80% vs 10% on the effect direction plot) and symptom relief (80% vs 20%) than SK. SK and TNK were comparable in achieving successful fibrinolysis (50% vs 50%). For the safety parameters, TNK is associated with a lesser risk of major bleeding than SK (88.9% vs 11.1%) and minor bleeding (25% vs 75%). SK was linked with a higher risk of hypotension/shock (77.8% vs 11.1%) and anaphylaxis/allergy (100% vs 0%). Long-term mortality was higher in the SK arm (100% vs 0%). In-hospital mortality is comparable between the two agents (37.5% vs 37.5%). There is conflicting evidence regarding other safety and efficacy endpoints. Compared to SK, TNK results in better complete ST-segment resolution and symptom relief. A higher risk of long-term mortality, increased risk of major and minor bleeding, hypotension, and allergy/anaphylaxis was observed in patients who received SK. Both agents were comparable in terms of in-hospital mortality and successful fibrinolysis. Controversy exists regarding which agent is linked with increased risk of 30-35-day mortality benefit and stroke. Randomized controlled trials (RCTs) with large sample sizes are needed to establish TNK vs SK superiority in efficacy and safety. The long-term duration of follow-up of the mortality rate of the two agents is also essential, as most patients in these regions cannot afford the recommended PCI post-fibrinolysis.

Predictive Value of Hematological Parameters in Non-ST Segment Elevation Myocardial Infarction and Their Relationship with the TIMI Risk Score

Background: Hematological parameters, such as white blood cell count (WBC), mean platelet volume (MPV), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and WBC to MPV ratio (WMR), could provide data in prognosis, risk stratification, and optimal management in patients with acute coronary syndromes. Aim: We aimed to investigate the prognostic value of hematological parameters and their relationship with the TIMI risk score in non-ST elevation myocardial infarction (NSTEMI) patients. Material and Methods: A total of 259 adult patients with NSTEMI were included in this retrospective and observational cohort study. During a 1-year follow-up period, the efficacy of the main hematological parameters in predicting major adverse cardiovascular events (MACE) and their correlation with the TIMI risk score was analyzed. Results: Among the 259 patients, 188 (72.6%) were male, and the mean age was 60.4 ± 11.9 years. MACE was observed in 60 patients (23.2%). Elevated baseline levels of WBC, neutrophils, NLR, PLR, and WMR were associated with MACE development throughout the 1-year follow-up. Moreover, WBC, WMR, and NLR were correlated with the TIMI risk score. When the predictive power of these parameters for MACE was evaluated by ROC analysis, the AUC values for WBC, WMR, and NLR were 0.670 (95% CI 0.590–0.750), 0.666 (95% CI 0.582–0.746), and 0.689 (95% CI 0.610–0.767), respectively. Conclusion: WBC, NLR, and WMR predicted MACE in NSTEMI patients and were consistent with the TIMI risk score. On this basis, they could provide supportive data for early risk stratification and optimized therapeutic approach, particularly in high-risk patients.

Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study

BACKGROUND

Evaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays.

OBJECTIVE

Our aim was to assess whether an immediate exercise stress echocardiogram (IESE) in the ED will allow safe, efficient, and cost-effective evaluation and discharge of patients with low-risk CP.

METHODS

Low-risk CP patients (TIMI [Thrombolysis in Myocardial Infarction] score 0-1) presenting to the ED with normal electrocardiogram, no history of coronary artery disease, and negative troponin T received IESE. We followed these patients for major adverse cardiac events and compared them to a control cohort of similar-risk patients admitted with traditional care at 1 and 6 months.

RESULTS

We enrolled 216 patients, 117 IESE and 109 control. We obtained follow-up at 1 and 6 months in 94% of the IESE group and 88% in the control group. There was no difference in diagnostic catheterization or percutaneous coronary intervention between the 2 groups (6.0% and 1.7% vs. 6.4% and 1.8%; p = 0.89). Median time from triage to discharge was significantly shorter with IESE (572.6 min vs. 1466.0 min), resulting in significantly lower cost ($4380.50 vs. $6191.70). There were no adverse events related to IESE or early discharge.

CONCLUSIONS

In our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and more cost effective than admission to an observation unit.

Novel Emergency Department Risk Score Discriminates Acute Coronary Syndrome Among Chest Pain Patients With Known Coronary Artery Disease

BACKGROUND

Patients with known coronary artery disease presenting to the emergency department (ED) with chest pain are often admitted, yet may not be having an acute coronary syndrome (ACS).

METHODS

We assessed whether the use of a novel risk score and a modified thrombolysis in myocardial infarction risk score obtained in the ED could discriminate which of these high-risk patients have ACS. Chart review was performed on a cohort of 285 patients with known coronary artery disease presenting to the ED with chest pain thought to be of ischemic origin and admitted to the hospital. The ED variables were assessed with logistic regression for their association with eventual ACS diagnosis at hospital discharge. ACS was diagnosed in 74 (26%) of the patients.

RESULTS

Non-ACS patients had a 2-day median length of stay and $6875 median inpatient (post ED) hospital charges (not including physician fees), totaling 566 hospital bed days and $1,871,250 for the 211 (74%) non-ACS patients. A novel risk score, including (1) history of prior revascularization, (2) comorbid chronic kidney disease, (3) onset of chest discomfort at rest, (4) dynamic electrocardiogram changes in the ED, (5) elevated troponin I (>0.05 ng/mL) in the ED, and (6) associated illness at presentation, discriminated ACS and non-ACS with a c statistic of 0.767; the c statistic for a modified thrombolysis in myocardial infarction risk score was 0.712.

CONCLUSIONS

Application of these risk scores may reduce the number of potentially avoidable admissions and their associated hazards and costs.

Prognostic values of 4 risk scores in Chinese patients with chest pain: Prospective 2-centre cohort study

Four risk scores for stratifying patients with chest pain presenting to emergency departments (EDs) (namely Thrombolysis in myocardial infarction [TIMI], Global registry for acute coronary events [GRACE], Banach and HEART) have been developed in Western settings but have never been compared and validated in Chinese patients. We aimed to find out to the number of MACE within 7 days, 30 days, and 6 months after initial ED presentation, and also to compare the prognostic performance of these scores in Chinese patients with suspected cardiac chest pain (CCP) to predict 7-day, 30-day, and 6-month major adverse cardiac events (MACE).A prospective 2-center observational cohort study of consecutive patients presenting with chest pain to the EDs of 2 university hospitals in Guangdong and Hong Kong from 17 March 2012 to 14 August 2013 was conducted. Patients aged ≥18 years with suspected CCP but without ST-segment elevation myocardial infarction (STEMI) were recruited.Of 833 enrolled patients (mean age 65.1 years, SD14.5; 55.6% males), 121 (14.5%) experienced MACE within 6 months (4.8% with safety outcomes and 10.3% with effectiveness outcomes). The HEART score had the largest area under the receiver operating characteristic (ROC) curve for predicting MACE at 7-day, 30-day, and 6-month follow-up [area under curve (AUC) = 0.731, 0.726, and 0.747, respectively. The HEART score also had the largest AUC for predicting effectiveness outcome (AUC = 0.715, 0.704, and 0.721, respectively). However, there was no significant difference in AUC between HEART and TIMI scores. Banach had the largest AUC for predicting safety outcome (AUC = 0.856, 0.837, and 0.850, respectively).The HEART score performed better than the GRACE and Banach scores to predict total MACE and effectiveness outcome in Chinese patients with suspected CCP, whereas the Banach score best predicted safety outcomes.

Discrepancy between clinician and research assistant in TIMI score calculation (TRIAGED CPU)

Introduction

Several studies have attempted to demonstrate that the Thrombolysis in Myocardial Infarction (TIMI) risk score has the ability to risk stratify emergency department (ED) patients with potential acute coronary syndromes (ACS). Most of the studies we reviewed relied on trained research investigators to determine TIMI risk scores rather than ED providers functioning in their normal work capacity. We assessed whether TIMI risk scores obtained by ED providers in the setting of a busy ED differed from those obtained by trained research investigators.

Methods

This was an ED-based prospective observational cohort study comparing TIMI scores obtained by 49 ED providers admitting patients to an ED chest pain unit (CPU) to scores generated by a team of trained research investigators. We examined provider type, patient gender, and TIMI elements for their effects on TIMI risk score discrepancy.

Results

Of the 501 adult patients enrolled in the study, 29.3% of TIMI risk scores determined by ED providers and trained research investigators were generated using identical TIMI risk score variables. In our low-risk population the majority of TIMI risk score differences were small; however, 12% of TIMI risk scores differed by two or more points.

Conclusion

TIMI risk scores determined by ED providers in the setting of a busy ED frequently differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider.

Salhi R, Hollander JE. Relationship between body mass index and prognosis of patients presenting with potential acute coronary syndromes

OBJECTIVES

Studies examining the relationship between obesity and acute coronary syndrome (ACS) have been limited to patients with confirmed diagnoses. The authors sought to determine the relationship between body mass index (BMI) and 30-day cardiovascular events in emergency department (ED) patients with potential ACS.

METHODS

This was a secondary analysis of a prospective cohort study of patients who presented to the ED with potential ACS. Patients were stratified according to their BMI: underweight (BMI < 18.49 kg/m(2) ), normal weight (BMI = 18.5 to 24.99 kg/m(2) ), overweight (BMI = 25 to 29.99 kg/m(2) ), obese (BMI = 30 to 34.99 kg/m(2) ), and very obese (BMI > 35 kg/m(2) ). The primary outcome was acute myocardial infarction (AMI), death, or revascularization within 30 days of presentation. A logistic regression analysis was used to adjust for confounding variables and adjusted odds ratios (aOR) with 95% confidence intervals (CIs) are presented for cardiac events and readmission outcomes.

RESULTS

Of the 3,946 patients included in this study, 73 (1.9%) were underweight, 911 (23%) were normal weight, 1,199 (30.4%) were overweight, 872 (22.1%) were obese, and 891 (22.6%) were very obese. Although increased levels of obesity were associated with a greater number of cardiac risk factors, there was no difference in 30-day cardiovascular events between those of normal weight and underweight (aOR = 1.1; 95% CI = 0.4 to 2.7), overweight (aOR = 1.0; 95% CI = 0.7 to 1.4), obese (aOR = 1.2; 95% CI = 0.8 to1.7), or very obese (aOR = 0.8; 95% CI = 0.5 to 1.3). Those who were underweight were more likely to be readmitted within 30 days (aOR = 1.9; 95% CI = 1.0 to 3.7), and those who were very obese were less likely to be readmitted within 30 days (aOR = 0.7; 95% CI = 0.5 to 0.9).

CONCLUSIONS

Among patients who present to the ED with potential ACS, BMI is not associated with higher risk of cardiovascular outcomes at 30 days.

HEART score to further risk stratify patients with low TIMI scores

OBJECTIVE

The ability to risk stratify patients presenting to the emergency department (ED) with potential acute coronary syndrome (ACS) is critical. The thrombolysis in myocardial infarction (TIMI) risk score can risk stratify ED patients with potential ACS but cannot identify patients safe for ED discharge. The symptom-based HEART score identifies very low-risk patients. Our hypothesis was that patients with a TIMI score of 0 or 1 may be stratified further with the HEART score to identify a group of patients at less than 1% risk of 30-day cardiovascular events.

METHODS

We conducted a secondary analysis of a prospective cohort study in a tertiary care hospital ED. Patients with potential ACS who were >30 years of age were included. Data collected included demographics, history, electrocardiogram, laboratories, and components of the TIMI and HEART scores. Follow-up was conducted by structured record review and phone. The main outcome was a composite of death, acute myocardial infarction, or revascularization at 30 days.

RESULTS

There were 8815 patients enrolled (mean age, 52.8 ± 15.1 years; 57% women, and 69% black). At 30 days, the composite event rate was 8.0% (660 patients): 108 deaths, 410 acute myocardial infarction, and 301 revascularizations. Of the 485 patients with both a TIMI score of 0 and a HEART score of 0, there were no cardiovascular events (95% confidence interval, 0-0.8%); but no other score combination had an upper limit confidence interval less than 1%.

CONCLUSION

At all levels of TIMI score, the HEART score was able to further substratify patients with respect to 30-day risk. A HEART score of 0 in a patient with a TIMI of 0 identified a group of patients at less than 1% risk for 30-day adverse events.

Thrombolysis in myocardial infarction risk score in an observation unit setting

OBJECTIVE

The Thrombolysis in Myocardial Infarction (TIMI) score is a validated tool for risk stratification of acute coronary syndrome. We hypothesized that the TIMI risk score would be able to risk stratify patients in observation unit for acute coronary syndrome.

METHODS

STUDY DESIGN

Retrospective cohort study of consecutive adult patients placed in an urban academic hospital emergency department observation unit with an average annual census of 65,000 between 2004 and 2007. Exclusion criteria included elevated initial cardiac biomarkers, ST segment changes on ECG, unstable vital signs, or unstable arrhythmias. A composite of significant coronary artery disease (CAD) indicators, including diagnosis of myocardial infarction, percutaneous coronary intervention, coronary artery bypass surgery, or death within 30 days and 1 year, were abstracted via chart review and financial record query. The entire cohort was stratified by TIMI risk scores (0-7) and composite event rates with 95% confidence interval were calculated.

RESULTS

In total 2228 patients were analyzed. Average age was 54.5 years, 42.0% were male. The overall median TIMI risk score was 1. Eighty (3.6%) patients had 30-day and 119 (5.3%) had 1-year CAD indicators. There was a trend toward increasing rate of composite CAD indicators at 30 days and 1 year with increasing TIMI score, ranging from a 1.2% event rate at 30 days and 1.9% at 1 year for TIMI score of 0 and 12.5% at 30 days and 21.4% at 1 year for TIMI ≥ 4.

CONCLUSIONS

In an observation unit cohort, the TIMI risk score is able to risk stratify patients into low-, moderate-, and high-risk groups.

Prospective evaluation of the use of the thrombolysis in myocardial infarction score as a risk stratification tool for chest pain patients admitted to an ED observation unit

BACKGROUND

The Thrombolysis in Myocardial Infarction (TIMI) score has shown use in predicting 30-day and 1-year outcomes in emergency department (ED) patients with potential acute coronary syndrome. Few studies have evaluated the TIMI score in risk stratifying patients selected for the ED observation Unit (EDOU). Risk stratification of patients in this group could identify those at risk for significant cardiac events. Our goal was to evaluate TIMI use for risk stratification in this population and compare outcomes among differing scores.

METHODS

A prospective observational study with 30-day telephone follow-up for a 12 month period. Baseline data, outcomes related to EDOU stay, admission, and 30-day outcomes were recorded. TIMI scores were calculated for each patient placed in EDOU. TIMI score was not utilized in the decision to place patients in observation.

RESULTS

N = 552. Composite outcomes recorded were myocardial infarction, revascularization, or death either during the EDOU stay, inpatient admission, or the 30-day follow-up. Eighteen composite outcomes were recorded: stent (12 patients), coronary artery bypass graft (3 patients), myocardial infarction and stent (2 patients), and myocardial infarction, and coronary artery bypass graft (1 patient). Distribution by TIMI score was: 0 (102 patients), 1 (196), 2 (142), 3 (72), 4 (27), and 5 (5). Risk of composite outcome increased by score: 0 (1%), 1 (2.6%), 2 (2.1%), 3 (6.9%), 4 (11.1%), and 5 (20%). Those with an intermediate risk score (3-5) were also more likely to require admission (15.4% vs 9.8%, P = .048).

CONCLUSION

The TIMI risk score may serve as an effective risk stratification tool among chest pain patients selected for EDOU placement. Patients with intermediate-risk by TIMI may be considered for inpatient admission and/or more aggressive evaluation and therapy.

Comparison of cardiac risk scores in ED patients with potential acute coronary syndrome

OBJECTIVE

: The ability to risk stratify patients presenting to the emergency department (ED) with potential acute coronary syndrome (ACS) is critical. Several risk scores for patients with definite ACS have been developed, but only the TIMI risk score has been shown to risk stratify ED patients with potential ACS. We compared the prognostic value of the GRACE and PURSUIT risk scores to the TIMI score in the broader ED patient population presenting with potential ACS.

METHODS

: We performed a secondary analysis of a prospective cohort study that enrolled patients who presented to the ED with potential ACS. Demographics, history, and components of the TIMI, GRACE, and PURSUIT scores were obtained. Follow-up was conducted by structured record review and phone. The main outcome was a composite of 30-day death, nonfatal acute myocardial infarction, and revascularization. The GRACE scores ranged from 0 to 330 and PURSUIT scores ranged from 0 to 18 and were subsequently divided into 8 equivalent strata to correspond with TIMI score range and to facilitate comparison. For each of the 3 risk scores, receiver operating characteristic (ROC) curves were used to compare prediction of 30-day event rates.

RESULTS

: There were 4743 patients enrolled (mean age: 52.5 ± 13.3; 56% female; 65% black). By 30 days, there were 59 deaths, 172 acute myocardial infarctions, and 175 revascularizations. The area under the curve for TIMI was 0.757 (95% CI: 0.728-0.785); GRACE, 0.728 (95% CI: 0.701-0.755); and PURSUIT, 0.691 (95% CI: 0.662-0.720).

CONCLUSION

: In this large cohort of ED patients, the TIMI risk score had the best discriminatory ability to predict 30-day cardiovascular events.