A 2-hour thrombolysis in myocardial infarction score outperforms other risk stratification tools in patients presenting with possible acute coronary syndromes: comparison of chest pain risk stratification tools

Am Heart J. 2012 Oct;164(4):516-23. doi: 10.1016/j.ahj.2012.06.025.

Abstract

Background: Accelerated diagnostic pathways for risk stratification of patients presenting to the emergency department with potential acute coronary syndromes may identify very-low-risk patients safe for early discharge to outpatient care.

Methods: Patients presenting with potential acute coronary syndrome to the emergency department were prospectively enrolled between November 2007 and April 2010. Patient characteristics in conjunction with 0- and 2-hour biomarkers and electrocardiograms were analyzed according to a 2-hour thrombolysis in myocardial infarction (TIMI) score and 9 other accelerated diagnostic pathways. The primary outcome was acute coronary syndrome by 30 days.

Results: Of 1,000 patients, 362 (36.2%) had a primary outcome. A pathway comprising electrocardiogram, prior ischemic heart disease, 0/2-hour troponin/creatine kinase MB fraction/myoglobin identified the highest proportion (25.0%) as low risk, with 96.1% sensitivity for the primary outcome. A pathway comprising electrocardiogram, history of ischemic heart disease, typical vs atypical symptoms, 0/2-hour troponin was the safest, with 99.7% sensitivity for the primary outcome, but only 9.0% were low risk. A pathway comprising the TIMI score with 0/2-hour troponin and electrocardiograms identified 15.5% as low risk, with a sensitivity of 99.2% for the primary outcome. This compares with standard care in which none were for outpatient care but, 3.3% had a primary outcome postdischarge within 30 days.

Conclusion: In this relatively high-risk population, a 2-hour TIMI score safely identified significant numbers of patients suitable for early discharge to outpatient care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome / diagnosis*
  • Acute Coronary Syndrome / therapy
  • Aged
  • Angina, Unstable / diagnosis
  • Biomarkers / blood
  • Chest Pain / etiology
  • Creatine Kinase / blood
  • Electrocardiography
  • Emergency Service, Hospital
  • Female
  • Humans
  • Male
  • Middle Aged
  • Myocardial Infarction / diagnosis*
  • Myocardial Infarction / therapy
  • Myocardial Revascularization
  • Myoglobin / blood
  • New Zealand
  • Patient Discharge*
  • Prospective Studies
  • Risk Assessment / methods
  • Sensitivity and Specificity
  • Time Factors
  • Troponin T / blood

Substances

  • Biomarkers
  • Myoglobin
  • Troponin T
  • Creatine Kinase