American Journal of Emergency Medicine (2013) 31, 185189

www.elsevier.com/locate/ajem

Original Contribution

Prospective evaluation of the use of the thrombolysis in

myocardial infarction score as a risk stratification tool for
chest pain patients admitted to an ED observation unit
Jessica Holly MD, Matthew Fuller MD , David Hamilton BS, Michael Mallin MD,
Kathryn Black BS, Riann Robbins BS, Virgil Davis MD, Troy Madsen MD
University of Utah School of Medicine, Department of Surgery, Division of Emergency Medicine, Salt Lake City,
UT 84132, USA
Received 13 April 2012; revised 4 July 2012; accepted 7 July 2012

Abstract
Background: The Thrombolysis in Myocardial Infarction (TIMI) score has shown use in predicting 30day and 1-year outcomes in emergency department (ED) patients with potential acute coronary
syndrome. Few studies have evaluated the TIMI score in risk stratifying patients selected for the ED
observation Unit (EDOU). Risk stratification of patients in this group could identify those at risk for
significant cardiac events. Our goal was to evaluate TIMI use for risk stratification in this population and
compare outcomes among differing scores.
Methods: A prospective observational study with 30-day telephone follow-up for a 12 month period.
Baseline data, outcomes related to EDOU stay, admission, and 30-day outcomes were recorded. TIMI
scores were calculated for each patient placed in EDOU. TIMI score was not utilized in the decision to
place patients in observation.
Results: N = 552. Composite outcomes recorded were myocardial infarction, revascularization, or
death either during the EDOU stay, inpatient admission, or the 30-day follow-up. Eighteen
composite outcomes were recorded: stent (12 patients), coronary artery bypass graft (3 patients),
myocardial infarction and stent (2 patients), and myocardial infarction, and coronary artery bypass
graft (1 patient). Distribution by TIMI score was: 0 (102 patients), 1 (196), 2 (142), 3 (72), 4 (27),
and 5 (5). Risk of composite outcome increased by score: 0 (1%), 1 (2.6%), 2 (2.1%), 3 (6.9%), 4
(11.1%), and 5 (20%). Those with an intermediate risk score (3-5) were also more likely to require
admission (15.4% vs 9.8%, P = .048).
Conclusion: The TIMI risk score may serve as an effective risk stratification tool among chest pain
patients selected for EDOU placement. Patients with intermediate-risk by TIMI may be considered
for inpatient admission and/or more aggressive evaluation and therapy.
2013 Elsevier Inc. All rights reserved.

1. Introduction

Funding Sources: University of Utah Medical Group Quality

Assessment Grant.
Corresponding author. Tel.: +1 801 581 2272; fax: +1 801 585 0603.
E-mail address: matthew.fuller@hsc.utah.edu (M. Fuller).

0735-6757/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajem.2012.07.006

Chest pain is a common presenting complaint among

emergency department (ED) patients. Accurate and timely
risk stratication is necessary to initiate appropriate

186

J. Holly et al.

treatment and patient disposition. Electrocardiograms

(ECG) and cardiac biomarkers can be helpful; however,
risk stratication of nonST-segment elevation (NSTE)
acute coronary syndrome (ACS) remains a challenge.
Among chest pain patients with nondiagnostic ECGs and
normal cardiac biomarkers, 2% to 4% of patients with
acute myocardial infarction (MI) are inadvertently discharged home from the emergency department [1-3].
Several scoring systems have been developed to aid in
the risk stratication of patients with unstable angina and
NSTE MI. The Thrombolysis In Myocardial Infarction
(TIMI) score is a widely validated tool initially developed to
predict the patient's risk of death or cardiac ischemic events
at 14 days [4]. The TIMI score is a simple summation of 7
variables that can be easily calculated in an emergency
department setting (Table 1). Multiple studies have
demonstrated the utility of the TIMI score in predicting
both 30-day and 1-year outcomes among emergency
department patients with potential ACS. [5-12]; however,
few studies have evaluated the utility of the TIMI score as a
risk stratication tool among patients selected for placement
in an emergency department observation unit (EDOU) [13].
Conti and colleagues [13] demonstrated that EDOUs were
equally as safe and more cost effective than conventional
inpatient units for care of intermediate- (TIMI 3-4) to highrisk (TIMI N4) chest pain patients. This cost effective
advantage, however, was lost in patients with TIMI score
N4, suggesting these patients should be admitted to
traditional inpatient units.
Accurate risk stratication in this group could potentially
identify patients at higher risk for signicant cardiac events
who may be more appropriate for inpatient admission, rather
than EDOU admission. Our goal was to evaluate the use of
the TIMI score as a risk stratication tool for chest pain
patients admitted to an EDOU and to compare outcomes
and inpatient admission rates for patients stratied by the
TIMI score.

Table 1

The TIMI risk score for unstable angina and NSTE MI

Historical
Age N65
3 or more CAD risk factors (FHx, HTN,
hyperlipidemia, DM, smoker)
Known CAD (stenosis N50%)
Aspirin use in past 7 days
PRESENTATION
2 or more angina events in the past 24 hours
ST-elevation or depression N1 mm
Elevated cardiac biomarkers
RISK SCORE = total points (0-7)

Points
1
1
1
1

1
1
1

2. Methods
The study design was a prospective observational study
of all chest pain patients admitted to our observation unit
with 30-day follow up. The University of Utah Emergency
Department is an urban emergency department with 39000
patient visits per year. The observation unit is a 10-bed
unit, which opened in April 2006. The observation unit is
under the direction of ED physicians and physician
assistants and cares for over 2500 patients per year. The
unit is designed to care for a variety of patients who are
admitted under different treatment protocols. Each protocol
has specic inclusion and exclusion criteria for the
observation unit and protocolized order sets for these
patients. The University of Utah EDOU has 21 different
treatment protocols for patient care, including chest pain,
abdominal pain, transient ischemic attack, and pulmonary
embolism, among others, with the chest pain protocol being
the most frequently used.
The chest pain protocol allows physicians to admit chest
pain patients to the observation unit if they have a nondiagnostic ECG, normal or indeterminate troponin I on initial
ED testing, are hemodynamically stable, and are chest pain
free. Patients requiring escalation of care for continued chest
pain require inpatient subsequent admission. Additional
exclusion criteria include age greater than 80 and signicant
comorbidities such as cancer, liver disease, congestive heart
failure, or renal disease. These were not included as they
have not been demonstrated as risk factors for heart disease,
given our primary outcomes identied. A history of coronary
artery disease is not an exclusion criterion and patients could
be admitted to the observation unit if the emergency
physician felt that the individual episode of chest pain had
low-risk features.
All chest pain patients admitted to the EDOU receive
serial troponin I measurements every six hours for a total of
three, and ECGs as needed for recurrent chest pain or as
deemed necessary by the EDOU midlevel provider.
Cardiology attending physicians evaluate chest pain patients
in the morning, if requested by the ED attending/midlevel
provider after their observation unit admission and make
further decisions on mode of evaluation (nuclear vs
treadmill stress test vs coronary computed tomography
angiography), cardiac catheterization, and inpatient admission. Cardiology consultations were available in the EDOU
seven days a week and on holidays. Stress testing is
available every day except Sunday before noon. Patients
discharged Sunday morning who were unable to complete
testing had prompt next day testing arranged. Patients placed
in the ECU in the early afternoon were kept overnight for a
period of up to 23 hours for additional testing and
cardiology consultation.
The ultimate decision to admit the patient to an inpatient
unit from the EDOU is made by the consulting cardiologist
in cooperation with the EDOU midlevel provider and the
attending emergency physician, as needed. Admission

TIMI as risk stratification tool for chest pain patients

decisions are based on results of the patient's testing in the
EDOU, determination for further inpatient evaluation based
on the patient's history and presentation, or additional
diagnoses or conditions which may have been identied
during the EDOU stay.
We performed a prospective evaluation of all patients
admitted to the observation unit under the chest pain
protocols for the 12-month period from June 1, 2009, to
May 31, 2010. The study received approval from the
hospital's institutional review board in October 2007, and all
participants provided informed written consent for participation and contact via phone at 30 days. Trained research
associates staffed the observation unit seven days a week to
obtain baseline data on all patients placed in the observation
unit under the chest pain protocols. Baseline data were
recorded at the time of the patient's observation unit
admission. TIMI scores were calculated based on baseline
risk factors and clinical characteristics as well as provider
interpretation of ECG. ECG interpretation for all patients
was reviewed by the principal investigator (TM). Any
discrepancies in ECG interpretation were claried by
another investigator (JH). TIMI score was not utilized in
the decision to admit to the ECU and was calculated with
blinding to the patient outcomes. Electronic medical records
were reviewed for patient outcomes related to the EDOU
stay, including positive troponin, provocative testing,
cardiac catheterization, stent placement, coronary artery
bypass graft (CABG) surgery, and inpatient admission from
the observation unit. Adverse events during observation unit
admission were recorded, including bleeding, clinically
signicant arrhythmia requiring medical intervention, unstable vital signs, and death. A positive troponin was dened
as a Troponin I greater than or equal to 0.50 ng/mL (ARUP
Mill, CPT code 84484), consistent with myocardial
ischemic injury.
Patient outcomes during 30-day follow-up were determined through telephone contact with patients and review of
the electronic medical record (EMR) at least 30 days after the
EDOU admission. We were able to contact 79.2% of patients
by phone, with follow up performed by EMR review for the
remaining 20.8% not contacted by phone. All patients were
included in the nal database. Outcomes measured at 30-day
follow up included myocardial infarction, stent placement,
CABG or other unplanned events including death. We
considered any patient to have experienced an unanticipated
adverse event during the 30-day follow up period if they
experienced MI or death, or if stent placement or CABG was
performed and was not part of their arranged outpatient
follow-up from the EDOU.
The principal investigator (TM) reviewed 20% of the
charts, selected randomly, as quality assessment of data
obtained from electronic medical record ( = .96). In
addition, the principal investigator reviewed the records of
all patients who had myocardial infarction, inpatient
admission, cardiac catheterization, positive stress test,
stent, or CABG to assure the accuracy of the chart review

187
and to conrm details as reported by patients in telephone
follow-up.
Data were entered into Research Electronic Data Capture
database and imported into a Microsoft Excel database for 2
statistical analysis (SPSS v 17.0). Categorical data are
presented as the percentage frequency occurrence. The
relationship between TIMI risk score and the composite
outcome was presented as percentage frequency occurrence.

3. Results
During the 12-month study period, a total of 552 patients
were admitted to the observation unit under the chest pain
protocol, 46% of whom were male with a mean age of 54.1
years (Table 2). Other gathered demographic data indicated
that approximately 20% were smokers, 20% were diabetic,
37% had family history of cardiac disease, 18% had prior
coronary artery disease, and another 36.6% had 3 or more
cardiac risk factors.
Of the 552 patients admitted for chest pain, 269 (48.7%)
patients had stress echocardiogram and 16 (2.9%) had
myocardial perfusion stress testing performed. Of the 275
patients who had stress testing performed, 7.4% had results
suggestive of ischemia.
Primary composite study outcomes included myocardial
infarction, revascularization (stent/CABG), or death either
during the EDOU stay, inpatient admission, or the 30-day
follow-up period were evaluated. Eighteen (3.2%) patients
experienced the composite outcome; 12 patients underwent
stent, 3 patients underwent CABG, 2 patients experienced
MI and stent, and 1 patient experienced MI and CABG. Risk
of the composite outcome generally increased by TIMI
score: 0 (1%), 1 (2.6%), 2 (2.1%), 3 (6.9%), 4 (11.1%), and 5
(20%) (Table 3).
Based on the rates of composite outcome, we established
a threshold score of 3 or higher as a potential predictor of
intermediate-risk EDOU chest pain patients; 104 (18.8%)
patients were intermediate-risk (TIMI score 3-5) vs 448
(81%) low-risk patients (TIMI score 0-2). Those who were
intermediate-risk were signicantly more likely to experience MI, stent, or CABG than the low-risk group (8.7% vs
2%, P = .002) (Fig.). Those intermediate-risk by TIMI score

Table 2

Baseline characteristics

Total
Age(y)
Male
Smoker
Diabetic
Fam Hx CAD
Hyperlipidemia
Prior CAD

552
54.1 (19-80)
46% (254)
19.6% (108)
19.9% (110)
37.1% (205)
36.6% (204)
18.1% (100)

188
Table 3

J. Holly et al.
Rates of myocardial infarction, revascularization, and death by TIMI risk score

TIMI Score

6-7

N
Composite outcome
0 (0%)

102
1 (1%)

201
5 (2.6%)

145
3 (2.1%)

72
5 (6.9%)

27
3(11.1%)

5
1 (20%)

were also more likely to require admission to an inpatient

unit from the EDOU (15.4% vs 9.8%, P = .048).

4. Discussion
This study demonstrated that the TIMI risk score may
serve as an effective risk stratication tool for ED patients
selected for EDOU placement. When a threshold TIMI
score of 3 or higher is used, intermediate-risk (TIMI score
3 or higher) patients are more likely to experience MI,
revascularization or death, and inpatient admission than
low-risk patients (TIMI score 0-2). The increased rates of
the composite outcome and inpatient admission suggests
that those who are intermediate-risk by TIMI may be
considered for either inpatient admission or more
aggressive evaluation, treatment, and consultation while
in observation.
The use of the EDOU for intermediate-risk chest pain
patients may decrease crowding in inpatient units and
reduce costs and resource utilization. Prior studies have
demonstrated that the use of the EDOU for chest pain
patients results in improved patient care, higher patient
satisfaction scores, and increased hospital revenue [13-17].
However, appropriate patient selection for EDOUs is
necessary to ensure patient safety, appropriate patient
care, and cost effectiveness. Several scoring systems have
been developed to aid in the risk stratication of patients
with chest pain, with the TIMI risk score being one of the

Fig. Rates of composite outcome and inpatient admission of

study population stratied by the TIMI risk score (TIMIb3 vs
TIMI3).

most widely used. Several studies have demonstrated the

utility of the TIMI risk score in predicting both 30-day and
1-year outcomes among emergency department patients
with potential ACS [5-12]. Our literature search found only
one prior study which evaluated the utility of the TIMI
score as a risk stratication tool among patients selected for
placement in an EDOU [13]. Our study reafrms that TIMI
is an appropriate tool for differentiation of chest pain
patients in an EDOU.
The TIMI score is a simple scoring system combining 7
variables that can be easily calculated shortly after patient
arrival, making it an ideal risk stratication tool for an
emergency department and EDOU setting. Further research
in this area may continue to improve the risk stratication of
chest pain patients in the EDOU, with the ultimate goal being
the development of simple risk stratication tool application
within this population, helping to identify patients at risk and
their appropriate disposition.

5. Limitations
There exist several potential limitations within this study.
The TIMI risk score was developed in high risk populations
and may not necessarily be applicable to lower-risk
populations. Despite this original design, several studies
have validated use of the TIMI score in undifferentiated chest
pain populations, suggesting it may be appropriate to use in
lower risk populations. The demographics of patients
presenting to our ED may represent a lower risk population
whose rates of the composite outcome or inpatient admission
are lower than other populations. Correspondingly, rates of
composite outcome in our study population in relation to
TIMI risk score were generally lower than those reported by
other studies [7,10,12].
Patients considered to be too high risk for the observation
unit were admitted directly to inpatient units from the ED
and, thus, not included in our analysis. This may subject our
results to selection or exclusion bias. In addition, the
inclusion of patients with pre-existing coronary disease in
our observation unit may represent a practice divergent from
that in other observation units and may also subject our
results to selection bias.
Our data are strictly observational; thus, conclusions
about the relative cost-effectiveness and safety of our
observation unit compared to hospital admission cannot be
drawn from our data pool. Admission to the observation
unit was at physician discretion and the generalizability of

TIMI as risk stratification tool for chest pain patients

this patient group to other settings and practice patterns
cannot be predicted.
We utilized telephone follow-up and EMR chart review
for outcomes related to the EDOU stay and inpatient
admission, as well as the 30-day follow-up evaluation. The
use of EMR chart review exposes us to inherent limitations
associated with chart reviews, and the use of telephone
follow up limits us by patient memory and recall of events. In
an effort to address these stated limitations, EMR data was
compared with telephone follow-up data and conrmed that
all events which patients reported by phone were also
documented in the EMR.
Finally, not all observation patients underwent stress
testing, as this practice was at the discretion of the ED
attending and the consulting cardiologist. This may introduce
a bias as to which patients were diagnosed with ACS during
their ED stay and may have eventually required stent
placement. Our study design aimed to utilize the 30-day
follow-up evaluation to capture any diagnoses or outcomes
which may have been missed due to possible selection and
testing bias. However, this potential for bias remains.

6. Conclusion
The data from our study would suggest that TIMI score is
not only applicable in an ED setting, but also in an EDOU
population. The risk stratication of chest pain patients in an
ED/EDOU setting continues to be an important and pressing
issue, both in terms of allocating appropriate care, but also in
terms of controlling cost. As such, use of the TIMI score in
patients admitted to an EDOU may serve as a simple and
effective evaluation strategy. Our study data suggests
intermediate-risk (TIMI score 3 or higher) patients were
more likely to experience MI, revascularization or death, and
inpatient admission than low-risk patients (TIMI score 0-2).
The use of this tool helps facilitate further delineation
between low and intermediate risk chest pain patients
admitted to the EDOU, with the end result being identication of those patients who would benet from a more
aggressive work up and intervention.

Acknowledgments
REDCap (Research Electronic Data Capture).

189

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