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Usefulness of the TIMI risk score in predicting both short- and long-term outcomes in the Veterans Affairs Non–Q-Wave Myocardial Infarction Strategies In-Hospital (VANQWISH) Trial

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Abstract

We sought to test the validity and clinical utility of the Thrombolysis In Myocardial Infarction (TIMI) risk score for patients who have non–Q-wave myocardial infarction. A post hoc analysis of the Veterans Affairs Non–Q-Wave Infarction Strategies In-Hospital (VANQWISH) Trial was performed, wherein patients were assigned a TIMI risk score from which both 30-day and 12-month outcomes (death, nonfatal myocardial infarction, or urgent revascularization) were assessed. At 30 days, the TIMI risk score showed a close match between observed and predicted probabilities of events after adjustment for overall event rates. The event rate at 30 days was 6% for a score of 0 to 2, 10% for a score of 3, 13% for a score of 4, and 14% for a score of 5 to 7 (p = 0.003 and c statistic 0.59). Discriminative ability of the score was greater in the conservative group at 30 days (p = 0.0004, c statistic 0.67). The score remained modestly predictive of events at 1 year (c statistic 0.60). Conservative strategy patients had better 30-day outcomes than the invasive strategy patients if their score was 0 to 2 (odds ratio 0.24, 95% confidence interval 0.08 to 0.76). No significant difference in outcomes between strategies was detected for a score ≥3. The TIMI risk score provides moderate incremental prognostic information in high-risk patients, during both short- and long-term follow-up.

Section snippets

Patient selection:

Details of the VANQWISH Trial design and methods have been previously published.2 VANQWISH was a multicenter, Veterans Affairs Cooperative study in which patients with non–Q-wave myocardial infarction were randomized to an invasive versus a conservative strategy for the use of cardiac catheterization. The primary end point was death or nonfatal myocardial infarction over a mean of 23 months.

Assignment of TIMI risk score for patients in VANQWISH:

A TIMI risk score was assigned to the patients in VANQWISH, based on the following variables: (1) age >65

Discrimination of TIMI risk score for combined end point:

The 4 TIMI risk groups were, by design, comparably sized: TIMI risk score 0 to 2 (n = 280; 30%); TIMI risk score 3 (n = 264; 29%); TIMI risk score 4 (n = 210; 23%); and TIMI risk score 5 to 7 (n = 165; 18%). The event rate for all patients in VANQWISH for the combined end points (death, nonfatal myocardial infarction, or urgent revascularization) was 10.3% at 30 days, 19.5% at 6 months, and 26.5% at 1 year. There was a modest, but statistically significant increase in events from the lowest to

discrimination of the TIMI risk score in VANQWISH:

We found that the TIMI risk score was modestly predictive of the 30-day composite end point of all-cause mortality, nonfatal myocardial infarction, and urgent revascularization in patients with a non–Q-wave myocardial infarction enrolled in the VANQWISH trial. We did not expect a significantly higher degree of discrimination, given that the TIMI risk score was only moderately predictive in the original development sample and the similarly modest discrimination of other risk scores for acute

Acknowledgements

The VANQWISH participating medical centers and their principal investigators have been previously described.2

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