I hate using the TIMI score to risk-stratify patients in the Emergency Department. It wasn’t derived from a question asked in the Emergency Department, but has been co-opted by hundreds of studies as it has some value as part of our common language with inpatient medicine and cardiology teams. We’re familiar enough with it’s shoehorning into our environment that we can use it to assist in some rough decisions about prognosis, but, clearly a better tool must exist.
A couple years back, the HEART score came out of the Netherlands. In a small derivation and validation cohort, it did a reasonable job of predicting outcomes, using language and variables more relevant to the Emergency Department. However, these authors from Ehrlanger in Chattanooga recognized one of the limitations of the HEART score was the somewhat arbitrary “expert” weighting of the various elements. They therefore undertook a study with the goal of using logistic regression and likelihood ratios of the various included elements to expand the score and modify the weighting.
The good news: they improved the AUC of the scoring system from 0.827 and 0.816 for acute MI and 30-day ACS, respectively, to 0.959 and 0.902. At the reasonable cut-off, the HEARTS3 score gets up close to ~98% sensitivity with ~60% specificity for 30-day ACS.
The bad news: a complex clinical situation requires a complex clinical decision instrument. No one will be able to hold this in their head like the NEXUS criteria, the TIMI score, or Wells criteria – if we were even bothering to hold all these hundreds of decision instruments in our heads to start. Luckily, smartphones, the Internet, and decision-support built-in to electronic health records is making progress towards readily available peripheral brains with which to quickly reference risk-stratification instruments such as this.
It still needs external validation, but this is one of the tools seeming to have the greatest potential I’ve recently seen
“Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score”
http://www.ncbi.nlm.nih.gov/pubmed/22626816