ST elevation myocardial infarction risk stratification and prognosis

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Risk calculators and risk factors for ST elevation myocardial infarction risk stratification and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Two main risk-stratification scores are used when assessing a patient with ST elevation MI and acute coronary syndromes; the TIMI Risk Score (for STEMI), and the GRACE risk score (for acute coronary syndrome.

The TIMI Risk Score

The TIMI risk score for STEMI was created from simple arithmetic sum of independent predictors of mortality weighted according to the adjusted odds ratios from logistic regression analysis. The risk score was derived from 14,114 patients enrolled in the Intravenous nPA for Treatment of Infarcting Myocardium Early II trial (TIME II). The TIMI risk score was subsequently validated in an unselected heterogeneous community population through the National Registry of Myocardial Infarction (NRMI) 3 & 4.

The TIMI risk score for TIMI is calculated by adding the numbers assigned to the different criteria shown below. The total possible score is 14.

Risk Factor	Points
Demographic data and medical history
Age ≥75 years	3
Age 65–74 years	2
History of diabetes mellitus or hypertension or angina	1
Physical examination
Systolic blood pressure <100	3
Heart rate >100	2
Killip class II–IV	2
Weight <67 kg	1
Evaluation at presentation
Anterior ST elevation or left bundle branch block	1
Time to therapy >4 hours	1

Interpretation of TIMI Risk Score for STEMI

Score	30 Day Mortality (%)
0	0.8%
1	1.6%
2	2.2%
3	4.4%
4	7.3%
5	12.4%
6	16.1%
7	23.4%
8	26.8%
>8	35.9%

GRACE Risk Score

• The Global Registry of Acute Coronary Events (GRACE) risk score for ACS:
  • The GRACE risk score was created from a multivariable logistic regression model using ACS patients enrolled in the GRACE registry (N=11389).
  • The GRACE risk score was validated using subsequent cohort of patients enrolled in GRACE (n=3972) and the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial (n=12142).

Calculation of Grace Risk Score for In-Hospital Mortality

The total GRACE risk score is calculated by adding the points assigned to the different variable shown below. The highest total possible score 363.

Variable	Points
Age (years)
<30	0
30–39	8
40–49	25
50–59	41
60–69	58
70–79	75
80–89	91
≥90	100
Heart rate (beats/minute)
<50	0
50–69	3
70–89	9
90–109	15
110–149	24
150–199	38
≥200	46
Systolic blood pressure (mmHg)
<80	58
80–99	53
100–119	43
120–139	34
140–159	24
160–199	10
≥200	0
Initial serum creatinine (mg/dL)
0.0–0.39	1
0.4–0.79	4
0.8–1.19	7
1.2–1.59	10
1.6–1.99	13
0.2–3.99	21
≥4	28
Killip class
I	0
II	20
III	39
IV	59
Cardiac arrest at admission	39
Elevated cardiac markers	14
ST segment deviation	28

Interpretation of Grace Risk Score for In-Hospital Mortality

A nomogram for the probability in-hospital mortality has been developed based on the GRACE score. Shown below is the probability of in-hospital mortality by the corresponding GRACE score value.

Score	Probability of in-hospital mortality (%)
≤60	≤0.2%
70	0.3%
80	0.4%
90	0.6%
100	0.8%
110	1.1%
120	1.6%
130	2.1%
140	2.9%
150	3.9%
160	5.4%
170	7.3%
180	9.8%
190	13%
200	18%
210	23%
220	29%
230	36%
240	44%
≥250	≥52%

Grace Risk Score for All-Cause Mortality From Discharge to 6 Months

Calculation of the GRACE Score for All-Cause Mortality From Discharge to 6 Months

The total GRACE risk score is calculated by adding the points assigned to the different variable shown below. The highest total possible score 263.

Variable	Points
Age (years)
<40	0
40–49	18
50–59	36
60–69	55
70–79	73
80–89	91
≥90	100
Heart rate (beats/minute)
≤49.9	0
50–69.9	3
70–89.9	9
90–109.9	14
110–149.9	23
150–199.9	35
≥200	43
Systolic blood pressure (mmHg)
<80	24
80–99.9	22
100–119.9	18
120–139.9	14
140–159.9	10
160–199.9	4
≥200	0
Initial serum creatinine (mg/dL)
0.0–0.39	1
0.4–0.79	3
0.8–1.19	5
1.2–1.59	7
1.6–1.99	9
0.2–3.99	15
≥4	20
History of congestive heart failure	24
History of myocardial infarction	12
Elevated cardiac markers	15
ST segment depression	11
No in-hospital PCI	14

The AHA/ACC Guidelines

The AHA/ACCA Guidelines for Unstable Angina/Non -ST-Elevation Myocardial Infarction provide guidelines for risk stratification for ACS.

References

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