The TIMI Risk Score program and a handheld organizer can help doctors diagnose and treat patients with chest pain (Source: www.TIMI.org)

Orlando, FL - A new program incorporating the TIMI Risk Score, for use with handheld organizers, may aid in the diagnosis of chest pain. The program allows physicians to risk-stratify patients using guidelines and clinical outcome information from major trials. Researchers from Brigham and Women's Hospital (Boston, MA), presented the new program at the American College of Cardiology 50th Annual Scientific Session.

Unstable angina (UA) and non-ST elevation MI (NSTEMI) include a large population of patients, and methods to stratify them according to risk could flag those who would be candidates for more aggressive and expensive therapies, said investigator Dr Christopher P Cannon (Brigham and Women's Hospital). "We think that tools like this may be very helpful in helping both to risk-stratify and identify patients who need aggressive treatment, give physicians the numbers in front of them, and link it to the guidelines so that we can potentially improve care," he said.

TIMI Risk Score

Although levels of cardiac enzymes such as the troponins have been very helpful in identifying those at risk, Cannon said, they still identify only about one third of patients who may benefit from more aggressive interventions.

In the August 16, 2000 issue of JAMA, Dr Elliott M Antman (Brigham and Women's Hospital) and colleagues published the TIMI Risk Score, a group of 7 independent risk factors that together allow accurate stratification of risk in patients with UA or NSTEMI. The factors include: age > 65 years, > 3 risk factors, prior CAD, aspirin taken in the last 7 days, > 2 anginal events < 24 hours, ST deviation, and elevated cardiac markers.

At this meeting, Cannon et al reported a study in which they sought to validate the TIMI Risk Score, applying it to data on patients enrolled in the TACTICS-TIMI 18 trial, presented at the AHA Scientific Sessions in November 2000 [as previously reported by heartwire]. (The main results of that trial showed that aggressive, invasive therapy with immediate tirofiban and cardiac catheterization within 4 to 48 hours after admission significantly reduced major cardiac events at 6 months among patients with UA and NSTEMI.)

In the present study, they showed that even borderline elevations of troponin I (< 0.1) conferred an increased risk, and also identified patients who benefited more from the early aggressive treatment, Cannon said. However, when troponin I measures were combined with the TIMI Risk Score incorporating clinical factors, even patients with low troponin I could have a significantly increased risk of 30-day death and MI. For example, a patient with troponin I of < 0.1, but a TIMI Risk Score of 5-6 had an odds ratio of 3.3.

	This would be about half of the patients who were troponin negative, who would have been missed if we hadn't used this simple scoring system.

"This expands to 75% of the population that we studied, patients who were identified at higher risk and who benefited from going quickly to the cath lab," Cannon said. "This would be about half of the patients who were troponin negative, who would have been missed if we hadn't used this simple scoring system."

Risk stratification in the palm of your hand

To make the risk score more useful, the researchers have developed over the last 2 months, a risk calculator program for doctors incorporating the TIMI Risk Score, intended for use in handheld organizers such as the Palm Pilot?. Once the score is ascertained, it is linked quickly with expected outcomes by treatment, gleaned from the results of some of the main clinical trials in this field: the merits of invasive versus conservative management from TACTICS-TIMI 18, the use of Gp IIb/IIIa inhibitors from PRISM-PLUS, and data on low molecular weight heparin from TIMI 11B.

The user can also view the ACC/AHA Guidelines for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction, as well as the Brigham and Women's Hospital Critical Pathway for Evaluating and Treating Chest Pain and UA/NSTEMI.

At a press conference here, Cannon used the example of America's "most famous patient," Vice President Dick Cheney, to illustrate their new technique. With five of the seven factors listed above, Cheney was a prime candidate for early intervention; indeed, he went expeditiously to the cath lab, Cannon said.

So simple it's "MD-proof"

Dr Robert M Califf (Duke University Medical Center, Durham, NC) called the program a "fascinating blend of technology and science." While moderating the press conference on this topic and others, Califf asked Cannon whether he knew what proportion of doctors now use these handheld organizers.

Cannon replied that a recent survey of 460 physicians showed about 80% of doctors use one of these devices. "Interestingly, this cuts across the full spectrum of younger and older physicians - those who've been in practice for 15-plus years, and those who are fellows and just joining the ranks of cardiologists. "I like to say that it's MD-proof," he added wryly.

[Dr Califf is a member of the editorial board of theheart.org]

Sources

1.Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000 Aug 16; 284(7):835-42.

Susan Jeffrey sjeffrey@conceptis.com

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