Combining Thrombolysis in Myocardial Infarction risk score and clear-cut alternative diagnosis for chest pain risk stratification

Objective: The Thrombolysis in Myocardial Infarction (TIMI) risk score is a validated risk stratification tool useful in patients with definite and potential acute coronary syndromes (ACS) but does not identify patients safe for discharge from the emergency department (ED). Likewise, tile use of a clear-cut alternative noncardiac diagnosis risk stratifies patients but does not identify a group safe for discharge. We hypothesized that tile presence of an alternative diagnosis in patients with a TIMI risk score less than 2 might identify a cohort of patients safe for ED discharge. Methods: In prospective cohort study, we enrolled ED patients with potential ACS, Data included demographics, medical history, components of the TIMI risk score, and whether the treating physician ascribed the condition to ail alternative noncardiac diagnosis. Investigators followed the patients through the hospital Course, and 30-day follow-up was clone. The main outcome was 30-day death, myocardial infarction, or revascularization. Results: A total of 3169 patients were enrolled (mean age, 53.6 +/- 14 years; 45% men; 67% black). There were 991 patients (31 %) with an alternative diagnosis, 980 patients with a TIMI risk score of 0, and 828 with a TIMI score of 1. At low levels of TIMI risk (<3), adding in a clinical impression of an alternative diagnosis did not reduce risk; at higher levels of TIMI risk, it did. The incidence of 30-day death, myocardial infarction, or revascularization for patients with a clinical impression of In alternative diagnosis and a TIMI score of 0 was 2.9% (95% confidence interval, 1.6%-5.0%). Conclusions: The TIMI risk score stratifies patients with and without an alternative diagnosis. Unfortunately, patients with both a low TIMI risk score and a clinical impression of ail alternative noncardiac diagnosis still have a risk of 30-day adverse events that is not low enough to allow safe discharge from the ED. (C) 2009 Elsevier Inc. All rights reserved.