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ACUTE MYOCARDIAL INFARCTION

Performance of the thrombolysis in myocardial infarction risk index in the National Registry of Myocardial Infarction-3 and -4

A simple index that predicts mortality in ST-segment elevation myocardial infarction

Stephen D. Wiviott, MD^*,,*, David A. Morrow, MD, MPH^*,, Paul D. Frederick, MPH, MBA, Robert P. Giugliano, SM, MD^*,, C.Michael Gibson, MS, MD^*,, Carolyn H. McCabe, BS^*,, Christopher P. Cannon, MD^*,, Elliott M. Antman, MD^*, and Eugene Braunwald, MD^*,

^* TIMI Study Group
Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
Ovation Research, Seattle, Washington, USA
Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

Manuscript received October 22, 2003; revised manuscript received May 12, 2004, accepted May 18, 2004.

^* Reprint requests and correspondence: Dr. Stephen D. Wiviott, TIMI Study Group, Brigham and Women's Hospital, Cardiovascular Division, 75 Francis Street, Boston, Massachusetts 02115 (Email: swiviott{at}partners.org).

OBJECTIVES: We sought to evaluate a simple risk index based on age and vital signs in a community sample of patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND: A simple risk index based on age and vital signs (heart rate x [age/10]²/systolic blood pressure) developed from patients with STEMI accurately predicts mortality in clinical trials of fibrinolysis. The application of such a tool in an unselected population is necessary to evaluate its utility in clinical practice.

METHODS: To evaluate the Thrombolysis In Myocardial Infarction (TIMI) risk index for routine practice, we tested it in the National Registry of Myocardial Infarction (NRMI)-3 and -4. The risk index was evaluated as a continuous variable in patients with STEMI from NRMI and in subgroups based on age and reperfusion status.

RESULTS: A total of 153,486 patients with STEMI were eligible. As anticipated, STEMI patients in NRMI had a higher risk index profile, as compared with those in the clinical trial (median 26.9 vs. 20, p < 0.0001). Classification of NRMI patients with STEMI into risk groups revealed a significant graded relationship with mortality (0.9% to53.2%, p_trend < 0.0001, c statistic 0.79). The discriminatory capacity of the risk index was particularly strong in the 81,679 patients receiving reperfusion therapy (0.6% to60%, p_trend < 0.0001, c statistic 0.81). For the 71,807 patients not receiving reperfusion therapy, a strong graded relationship remained (1.9% to 52.2%, p_trend < 0.0001, c statistic 0.71). Among the elderly, although the distribution of scores was shifted toward higher risk, the performance remained (0% to 53.1%, p_trend< 0.0001, c statistic 0.71).

CONCLUSIONS: A simple risk index from baseline clinical variables routinely obtained at the first patient encounter predicted mortality in a large unselected heterogeneous group of patients with STEMI.

Abbreviations and Acronyms   CCP = Cardiovascular Cooperative Project   HR = heart rate   InTIME-II = Intravenous nPA for Treatment of Infarcting Myocardium Early trial   IQR = interquartile range   MI = myocardial infarction   NRMI = National Registry of Myocardial Infarction   PCI = percutaneous coronary intervention   RT = reperfusion therapy   SBP = systolic blood pressure   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction

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