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How do I use a TIMI risk score in the patient with Non–ST-Elevation Acute Coronary Syndromes (NSTE-ACS), that is, unstable angina/non–ST-elevation myocardial infarction (UA/NSTEMI)?

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The thrombolysis in myocardial infarction (TIMI) risk score is used for prognostication and therapeutic decision making in patients with Non–ST-Elevation Acute Coronary Syndromes (NSTE-ACS).

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HPI: Symptoms of chest pain, dyspnea, diaphoresis.

PMH: Coronary artery disease (CAD), prior myocardial infraction (MI), hypertension (HTN), hyperlipidemia, diabetes.

FH: Premature CAD or MI.

SH: Smoking, alcohol.

Labs: Elevated troponin or CKMB.

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ST-segment depression of >0.5 mm in two or more contiguous ECG leads.

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NSTE-ACS = Non–ST-Elevation Acute Coronary Syndromes (Unstable Angina/Non–ST-Elevation MI)

PCI = Refer for Percutaneous Coronary Intervention.

MED-TX = MEDical management = oxygen, aspirin, clopidogrel/ticagrelor/prasugrel (prasugrel only if going for PCI), nitroglycerine, morphine, metoprolol, unfractionated heparin, or enoxaparin (see chapter on initial management of US/NSTEMI).

GP2 B3 A = GlycoProtein IIb/IIIa (2 B3 A) inhibitors = use either of these:

Eptifibatide: 180 mcg/kg bolus (maximum 20 mg) IV over 2 minutes, then 2 mcg/kg/min infusion) (maximum 15 mg/hr) for up to 72 hours. Reduce maintenance dose to 1 mcg/kg/min if creatinine clearance <50 mL/min; contraindicated if creatinine clearance <20 mL/min.

Tirofiban: loading infusion: 0.4 mcg/kg/min over 30 minutes, then 0.1 mcg/kg/min infusion for up to 72 hours. Reduce loading and maintenance infusion by 50% in patients with creatinine clearance <30 mL/min.

HIGHR = HIGH Risk: patients with non–ST-elevation acute coronary syndromes with one or more of the following characteristics are at a high risk for an adverse cardiovascular event: hemodynamic instability or cardiogenic shock; severe LVD or HF (ejection fraction <40%); recurrent/refractory angina despite medical therapy; new or worsening mitral regurgitation or VSD; or sustained ventricular arrhythmias.

TIMI = TIMI risk score calculated by assigning 1 point for each of the following factors (pneumonic AMERICA):

  • Age ≥65 years

  • Markers elevated (cTn-I or CKMB)

  • ECG ST deviation (new or transient) ≥0.5 mm

  • Risk factors ≥3 {HTN (>140/90 or on Rx), DM, Hyperlipidemia (LDL ≥190 mg/dL/TC ≥240/HDL <40/TG ≥200), active smoker, fam Hx premature CAD = fatal/nonfatal MI, coronary revascularization, or sudden death <55 years old [father/1st degree male rel] or <65 years old [female/1st deg rel]}

  • HTN, DM, H/lipid, active smoker, FamHx premature CAD = myocardial infarction, coronary revascularization, or sudden death <55 years old (father/1st degree male rel) or <65 years old (female/1st deg rel)

  • Ischemia: ≥2 anginal episodes in past 24 hours

  • CAD (known stenosis ≥50%)

  • Aspirin use in prior 7 days

TIMI LOW = TIMI LOW risk: score between 0 and 2.

TIMI MODHIGH = TIMI MODerate or HIGH risk: score between 3 and 7.

NO TIME = patients with high-risk features not adequately pretreated with clopidogrel or ticagrelor, that is, NO TIME for adequate treatment with these oral agents.

SRT = Refer patient for stress imaging study to evaluate for inducible ischemia.

SRT-POS = StRess Testing POSitive: imaging study showing significant reversible ischemia, left ventricular dysfunction, ejection fraction <0.35, or other high-risk findings.

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NSTE-ACS + HIGHR = MED + PCI

NSTE-ACS + HIGHR + NOTIME = MED + GP2 B3 A + PCI

NSTE-ACS + TIMI LOW = MED + SRT

NSTE-ACS + TIMI LOW + SRT-POS = MED ...

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