Cardiovascular Intervention and Therapeutics

, Volume 28, Issue 3, pp 242–249

Use of Thrombolysis in Myocardial Infarction Risk Score to predict bleeding complications in patients with unstable angina and non-ST elevation myocardial infarction undergoing percutaneous coronary intervention

  • Yohei Numasawa
  • Shun Kohsaka
  • Hiroaki Miyata
  • Akio Kawamura
  • Shigetaka Noma
  • Masahiro Suzuki
  • Susumu Nakagawa
  • Yukihiko Momiyama
  • Toshiyuki Takahashi
  • Yuji Sato
  • Keiichi Fukuda
Original Article


Thrombolysis in myocardial infarction (TIMI) is a prognostic score developed for managing the high risk of cardiac events immediately after unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI). In Asian populations that have a higher rate of bleeding complications, data about TIMI score are lacking. Using a Japanese multicenter registry, we investigated the impact of utilizing TIMI score in UA/NSTEMI patients, focusing on bleeding complications. The TIMI score was calculated for 587 patients who underwent percutaneous coronary intervention (PCI) for UA/NSTEMI (2008–2010). They were classified into low-risk (TIMI score 0–2, N = 268, 45.6 %), intermediate-risk (TIMI score 3–4, N = 264, 45.0 %) and high-risk (TIMI score 5–7, N = 55, 9.4 %) groups; patient characteristics for each group were statistically analyzed. The patients in the higher TIMI score group were older (p < 0.001), had lower GFR (p = 0.021) and hemoglobin level after PCI (p < 0.001), and severe coronary disease pattern (p = 0.014 and p = 0.023, respectively, for left main and three-vessel disease). The TIMI score was significantly associated with requirement of blood transfusion (low-risk, moderate-risk, and high-risk groups: 1.1, 4.2, and 7.3 %, respectively; p = 0.021), and the incidence of access site bleeding (1.1, 2.7, and 5.5 %, p = 0.112). The TIMI score might aid in subjectively quantifying the risk of in-hospital complication rates such as access site bleeding.


TIMI score Percutaneous coronary intervention Coronary artery disease 


  1. 1.
    Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007;28:1598–660.PubMedCrossRefGoogle Scholar
  2. 2.
    Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007;116:e148–304.PubMedCrossRefGoogle Scholar
  3. 3.
    Antman EM, McCabe CH, Gurfinkel EP, et al. Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation. 1999;100:1593–601.PubMedCrossRefGoogle Scholar
  4. 4.
    Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997;337:447–52.PubMedCrossRefGoogle Scholar
  5. 5.
    Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284:835–42.PubMedCrossRefGoogle Scholar
  6. 6.
    van der Zee PM, Verberne HJ, Cornel JH, et al. GRACE and TIMI risk scores but not stress imaging predict long-term cardiovascular follow-up in patients with chest pain after a rule-out protocol. Neth Heart J. 2011;19:324–30.PubMedCrossRefGoogle Scholar
  7. 7.
    Filipiak KJ, Koltowski L, Grabowski M, et al. Prospective comparison of the 5 most popular risk scores in clinical use for unselected patients with acute coronary syndrome. Circ J. 2010;75:167–73.PubMedCrossRefGoogle Scholar
  8. 8.
    Yan AT, Yan RT, Tan M, et al. Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better. Eur Heart J. 2007;28:1072–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Morrow DA, Antman EM, Snapinn SM, McCabe CH, Theroux P, Braunwald E. An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes. Application of the TIMI Risk Score for UA/NSTEMI in PRISM-PLUS. Eur Heart J. 2002;23:223–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Scirica BM, Cannon CP, Antman EM, et al. Validation of the thrombolysis in myocardial infarction (TIMI) risk score for unstable angina pectoris and non-ST-elevation myocardial infarction in the TIMI III registry. Am J Cardiol. 2002;90:303–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Soiza RL, Leslie SJ, Williamson P, et al. Risk stratification in acute coronary syndromes—does the TIMI risk score work in unselected cases? QJM. 2006;99:81–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Kohsaka S, Kimura T, Goto M, et al. Difference in patient profiles and outcomes in Japanese versus American patients undergoing coronary revascularization (collaborative study by CREDO-Kyoto and the Texas Heart Institute Research Database). Am J Cardiol. 2010;105:1698–704.PubMedCrossRefGoogle Scholar
  13. 13.
    Wang TY, Chen AY, Roe MT, et al. Comparison of baseline characteristics, treatment patterns, and in-hospital outcomes of Asian versus non-Asian white Americans with non-ST-segment elevation acute coronary syndromes from the CRUSADE quality improvement initiative. Am J Cardiol. 2007;100:391–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial. J Am Coll Cardiol. 2007;49:1362–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Manoukian SV. Predictors and impact of bleeding complications in percutaneous coronary intervention, acute coronary syndromes, and ST-segment elevation myocardial infarction. Am J Cardiol. 2009;104:9C–15C.PubMedCrossRefGoogle Scholar
  16. 16.
    Yatskar L, Selzer F, Feit F, et al. Access site hematoma requiring blood transfusion predicts mortality in patients undergoing percutaneous coronary intervention: data from the National Heart, Lung, and Blood Institute Dynamic Registry. Catheter Cardiovasc Interv. 2007;69:961–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Ko DT, Yun L, Wijeysundera HC, et al. Incidence, predictors, and prognostic implications of hospitalization for late bleeding after percutaneous coronary intervention for patients older than 65 years. Circ Cardiovasc Interv. 2010;3:140–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Lindsey JB, Marso SP, Pencina M, et al. Prognostic impact of periprocedural bleeding and myocardial infarction after percutaneous coronary intervention in unselected patients: results from the EVENT (evaluation of drug-eluting stents and ischemic events) registry. JACC Cardiovasc Interv. 2009;2:1074–82.PubMedCrossRefGoogle Scholar
  19. 19.
    Doyle BJ, Ting HH, Bell MR, et al. Major femoral bleeding complications after percutaneous coronary intervention: incidence, predictors, and impact on long-term survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005. JACC Cardiovasc Interv. 2008;1:202–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Numasawa Y, Kohsaka S, Miyata H, et al. Safety of transradial approach for percutaneous coronary intervention in relation to body mass index: a report from a Japanese multicenter registry. Cardiovasc Interv Ther 2012. doi:10.1007/s12928-012-0138-8.
  21. 21.
    Roe MT, Messenger JC, Weintraub WS, et al. Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. J Am Coll Cardiol. 2010;56:254–63.PubMedCrossRefGoogle Scholar
  22. 22.
    Anderson HV, Shaw RE, Brindis RG, et al. Risk-adjusted mortality analysis of percutaneous coronary interventions by American College of Cardiology/American Heart Association guidelines recommendations. Am J Cardiol. 2007;99:189–96.PubMedCrossRefGoogle Scholar
  23. 23.
    Stern S, Bayes de Luna A. Coronary artery spasm: a 2009 update. Circulation. 2009;2009(119):2531–4.CrossRefGoogle Scholar
  24. 24.
    Mehta SK, Frutkin AD, Lindsey JB, et al. Bleeding in patients undergoing percutaneous coronary intervention: the development of a clinical risk algorithm from the National Cardiovascular Data Registry. Circ Cardiovasc Interv. 2009;2:222–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879–87.PubMedCrossRefGoogle Scholar
  26. 26.
    Chase M, Robey JL, Zogby KE, Sease KL, Shofer FS, Hollander JE. Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population. Ann Emerg Med. 2006;48:252–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Pollack CV Jr, Sites FD, Shofer FS, Sease KL, Hollander JE. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med. 2006;13:13–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA. 2004;291:2727–33.PubMedCrossRefGoogle Scholar
  29. 29.
    Kinnaird TD, Stabile E, Mintz GS, et al. Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. Am J Cardiol. 2003;92:930–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Jani SM, Smith DE, Share D, et al. Blood transfusion and in-hospital outcomes in anemic patients with myocardial infarction undergoing percutaneous coronary intervention. Clin Cardiol. 2007;30:II49–56.PubMedCrossRefGoogle Scholar
  31. 31.
    Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA. 2004;292:1555–62.PubMedCrossRefGoogle Scholar
  32. 32.
    Robinson SD, Janssen C, Fretz EB, et al. Non-red blood cell transfusion as a risk factor for mortality following percutaneous coronary intervention. Int J Cardiol. 2012;157:169–73.PubMedCrossRefGoogle Scholar
  33. 33.
    Valente S, Lazzeri C, Chiostri M, et al. The impact of blood transfusion on short and long term prognosis in STEMI patients treated with primary percutaneous coronary intervention: a single center-experience. Int J Cardiol. 2012;157:281–3.PubMedCrossRefGoogle Scholar
  34. 34.
    Kaya E, Cuneo A, Hochadel M, et al. Impact of chronic kidney disease on the prognosis of patients undergoing percutaneous coronary interventions using drug-eluting stents. Clin Res Cardiol. 2011;100:1103–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Attallah N, Yassine L, Fisher K, Yee J. Risk of bleeding and restenosis among chronic kidney disease patients undergoing percutaneous coronary intervention. Clin Nephrol. 2005;64:412–8.PubMedGoogle Scholar
  36. 36.
    Latif F, Kleiman NS, Cohen DJ, et al. In-hospital and 1-year outcomes among percutaneous coronary intervention patients with chronic kidney disease in the era of drug-eluting stents: a report from the EVENT (Evaluation of Drug Eluting Stents and Ischemic Events) registry. JACC Cardiovasc Interv. 2009;2:37–45.PubMedCrossRefGoogle Scholar
  37. 37.
    Hanna EB, Chen AY, Roe MT, Wiviott SD, Fox CS, Saucedo JF. Characteristics and in-hospital outcomes of patients with non-ST-segment elevation myocardial infarction and chronic kidney disease undergoing percutaneous coronary intervention. JACC Cardiovasc Interv. 2011;4:1002–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Goodacre S, Locker T, Morris F, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med. 2002;9:203–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Ramsay G, Podogrodzka M, McClure C, Fox KA. Risk prediction in patients presenting with suspected cardiac pain: the GRACE and TIMI risk scores versus clinical evaluation. QJM. 2007;100:11–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Aragam KG, Tamhane UU, Kline-Rogers E, et al. Does simplicity compromise accuracy in ACS risk prediction? A retrospective analysis of the TIMI and GRACE risk scores. PLoS One. 2009;4:e7947.PubMedCrossRefGoogle Scholar
  41. 41.
    de Araujo Goncalves P, Ferreira J, Aguiar C, Seabra-Gomes R. TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. Eur Heart J. 2005;26:865–72.PubMedCrossRefGoogle Scholar

Copyright information

© Japanese Association of Cardiovascular Intervention and Therapeutics 2013

Authors and Affiliations

  • Yohei Numasawa
    • 1
  • Shun Kohsaka
    • 2
  • Hiroaki Miyata
    • 3
  • Akio Kawamura
    • 2
  • Shigetaka Noma
    • 4
  • Masahiro Suzuki
    • 5
  • Susumu Nakagawa
    • 6
  • Yukihiko Momiyama
    • 7
  • Toshiyuki Takahashi
    • 1
  • Yuji Sato
    • 8
  • Keiichi Fukuda
    • 2
  1. 1.Department of CardiologyAshikaga Red Cross HospitalAshikaga-shiJapan
  2. 2.Department of CardiologyKeio University School of MedicineTokyoJapan
  3. 3.University of Tokyo, Healthcare Quality AssessmentTokyoJapan
  4. 4.Department of CardiologySaiseikai Utsunomiya HospitalTochigiJapan
  5. 5.Department of CardiologyNational Hospital Organization, Saitama National HospitalSaitamaJapan
  6. 6.Department of CardiologySaiseikai Central HospitalTokyoJapan
  7. 7.Department of CardiologyNational Hospital Organization, Tokyo Medical CenterTokyoJapan
  8. 8.Center for Clinical ResearchKeio University School of MedicineTokyoJapan

Personalised recommendations