Improved in-hospital outcomes in acute coronary syndromes (unstable angina/non-ST segment elevation myocardial infarction) despite similar TIMI risk scores.
BACKGROUND
The Thrombolysis In Myocardial Infarction (TIMI) Risk Score has been shown to predict prognosis in acute coronary syndromes (ACS) comprised of unstable angina (UA) and non-ST segment elevation myocardial infarction (STEMI). We sought to evaluate the impact of newer antiplatelet and antithrombotic therapies for ACS, such as glycoprotein IIb/IIIa inhibitors (GPI) and low molecular weight heparin (LMWH), on in-hospital outcomes over time in patients (pts) with similar TIMI risk scores.


METHODS
The baseline demographics and clinical outcomes of pts with ACS (UA and non-STEMI) in 1998 (Group 1998) and 2000 (Group 2000) at a single large university medical center were compared using a prospectively collected database. In-hospital major adverse cardiac events (MACE) included death, MI, or recurrent angina that resulted in urgent revascularization. Risk was estimated by utilizing the TIMI Risk Score, which uses 7 predictor variables: age > 65 years, at least 3 risk factors for coronary artery disease, prior coronary stenosis of   50%, ST segment deviation on EKG, severe angina, prior aspirin use, and elevated cardiac biomarkers.


RESULTS
Comparing Group 1998 (n = 563) and Group 2000 (n = 604), there was no difference between the mean TIMI Risk Score (2.90   1.52 vs. 2.91   1.52; p = 0.97), demonstrating a similar risk profile. Nevertheless, significant improvement in in-hospital MACE (9.1% vs. 2.8%; p < 0.001) was noted. The improvement in MACE was due to differences in rates of recurrent angina, without significant differences in death and myocardial infarction. This occurred temporally in association with a significant increase in GPI (1.0% vs. 8.3%; p < 0.01) and LMWH (0.0% vs. 15.6%; p < 0.001) use within 24 hours of presentation, and the increased utilization of intracoronary stenting (46.6% vs. 64.6%; p = 0.005), findings which were confirmed with multivariate analysis.


CONCLUSIONS
Despite similar TIMI Risk Scores, the in-hospital outcomes of pts with ACS have improved over time. This temporal change is associated with the greater use of newer antiplatelet and antithrombotic therapies and increased utilization of intracoronary stenting.
Almeda
Francis Q
FQ
Rush-Presbyterian-St. Luke's Medical Center, Rush Heart Institute, Chicago, IL, USA.
Hendel
Robert C
RC
Nathan
Sandeep
S
Meyer
Peter M
PM
Calvin
James E
JE
Klein
Lloyd W
LW
D000368:Aged; D000789:Angina, Unstable / Q000188:drug therapy* / Q000401:mortality* / Q000628:therapy; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use*; D017052:Hospital Mortality; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality* / Q000628:therapy; D009204:Myocardial Revascularization / Q000379:methods; D017063:Outcome Assessment, Health Care; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors
D005343:Fibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex