title: Combining Thrombolysis in Myocardial Infarction risk score and clear-cut alternative diagnosis for chest pain risk stratification.
abstract: 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, the use of a clear-cut alternative noncardiac diagnosis risk stratifies patients but does not identify a group safe for discharge. We hypothesized that the 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 an alternative noncardiac diagnosis. Investigators followed the patients through the hospital course, and 30-day follow-up was done. 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 an 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 an alternative noncardiac diagnosis still have a risk of 30-day adverse events that is not low enough to allow safe discharge from the ED.
authors.affiliation: Department of Emergency Medicine, Ground Ravdin, Hospital of the University of Pennsylvania, Philadelphia.
authors.forename: Caren F
authors.initials: CF
authors.lastname: Campbell
authors.affiliation: Department of Emergency Medicine, Ground Ravdin, Hospital of the University of Pennsylvania, Philadelphia. Electronic address: annamarie.chang@uphs.upenn.edu.
authors.forename: Anna Marie
authors.initials: AM
authors.lastname: Chang
authors.affiliation: Department of Emergency Medicine, Ground Ravdin, Hospital of the University of Pennsylvania, Philadelphia.
authors.forename: Keara L
authors.initials: KL
authors.lastname: Sease
authors.affiliation: Department of Emergency Medicine, Ground Ravdin, Hospital of the University of Pennsylvania, Philadelphia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Follansbee
authors.affiliation: Department of Emergency Medicine, Ground Ravdin, Hospital of the University of Pennsylvania, Philadelphia.
authors.forename: Christine M
authors.initials: CM
authors.lastname: McCusker
authors.affiliation: Department of Emergency Medicine, Ground Ravdin, Hospital of the University of Pennsylvania, Philadelphia.
authors.forename: Frances S
authors.initials: FS
authors.lastname: Shofer
authors.affiliation: Department of Emergency Medicine, Ground Ravdin, Hospital of the University of Pennsylvania, Philadelphia.
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis*; D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000175:diagnosis / Q000209:etiology; D002637:Chest Pain / Q000209:etiology*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis*; D010351:Patient Discharge; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors