The Uselessness of the TIMI Risk Score

Supposedly one of the measures which is evaluated during the process of "Chest Pain Center Accreditation" is the use of the TIMI Risk Score in the Emergency Department:

• Age over 65 years

• More than 3 risk factors for CAD

• Known CAD (stenosis ≥ 50%)

• ASA Use in Past 7 days

• Severe angina (≥ 2 episodes within 24 hrs)

• ST changes ≥ 0.5mm

• Positive Cardiac Marker

Add one point for each factor, total up the points, and you now have an estimate of the likelihood in the next 14 days of all-cause mortality, myocardial infarction, or severe recurrent ischemia requiring urgent revascularization.

In theory this sounds like a neat way to streamline and validate our medical decision-making, but in practice this system is totally worthless to us in the Emergency Department. Consider these examples:

1) The 64 year old with known coronary artery disease status post stenting of his proximal LAD, who has neglected to take his aspirin or plavix for the past week, who presents with a single severe episode of unstable angina that woke him from sleep 2 hours ago, who has significant ST depression, but his first set of cardiac enzymes is negative. He has only a TIMI risk score of 2, so he supposedly has only an 8% risk of death. I guess we should send him home.

2) The 44 year old hypertensive Marlboro man with chest pain and a positive troponin but no ECG changes gets only a TIMI score of 1, so his risk of death is even lower, only 5%. He can follow up next week, I suppose. Be sure to tell him to come back if he gets worse.

In practice, we aren't sending anyone home with ischemic ECG changes or elevated cardiac enzymes, so I find that this scoring system is completely useless to my practice. Protocol-driven medical decision-making is always going to be inferior to expert clinical judgment. This is also one of the reasons you should be suspicious of the current fad of the various "accreditation" merit badges hospitals proudly display. They are equally worthless.