We limited our analysis to patients ≥65 years of age who presented with an ST elevation or a left bundle-branch block MI. 15 These patients’ records were centrally abstracted for detailed clinical data including medical history, presentation, inhospital treatment, and outcomes. The CCP included fee-for-service Medicare beneficiaries discharged from an acute care nongovernmental hospital in the United States with a primary discharge diagnosis of acute MI ( International Classification of Diseases, Ninth Revision, Clinical Modification code 410) between January 1994 and February 1996, with the exception of readmissions (code 410. Our objective was to determine how effective this well-known risk score derived from an RCT population, widely distributed via a public-access web site ( accessed November 27, 2002), performs when applied to a community-based cohort of elderly patients hospitalized with STEMI. Using data from the Cooperative Cardiovascular Project (CCP), a Centers for Medicare & Medicaid Services initiative to improve quality of myocardial infarction (MI) care, we evaluated the prognostic calibration and discrimination of the TIMI score and the accuracy of its reported 30-day mortality rate estimates. To address this issue, we sought to determine the prognostic value of the TIMI score among a nationally representative cohort of elderly patients hospitalized with STEMI. Thus, an additional assessment of the TIMI score’s performance in more contemporary, generalizable community-based populations, using a standardized end point, is needed. 14 Because these studies have different limitations, it is difficult to reconcile their findings. 13 This study, however, was based upon patients drawn from a selected group of hospitals and limited by the evaluation of inhospital mortality, a nonstandardized end point susceptible to hospital differences in length of stay, discharge patterns, and interhospital transfer practices. 12 In contrast, an evaluation of the TIMI risk score in the NRMI 3 cohort found the score performed sufficiently well and recommended the score be used for the triage of patients with STEMI. 6, 12 An evaluation of the TIMI score in patients hospitalized in Olmsted County, Minnesota, found its performance to be poorer compared with another risk score, but this analysis was limited by the use of a homogenous, geographically restricted population and included patients treated in the pre-reperfusion therapy era. The 2 studies to date that have evaluated the performance of the TIMI score in nonrandomized trial cohorts have provided conflicting findings. 11 Because the simple risk score we evaluated was based on 3 variables, 3 it is unknown how the more clinically detailed TIMI score may perform when assessed in an elderly community-based population. Our recent evaluation of a simple risk score for patients with STEMI found significant limitations in the use of risk indices derived in RCTs in community-based populations. 10 It is unclear whether prognostic data derived from InTIME II, a cohort in which all patients underwent fibrinolytic therapy, are applicable to elderly patients who did not receive any reperfusion therapy. 9 Of particular concern are the > 60% of community-based elderly patients with STEMI who do not receive fibrinolytic therapy. 8 Community-based elderly patients are generally older, have a substantially higher comorbidity burden, and are treated at a more diverse spectrum of hospitals, with a variety of treatment strategies, compared with patients enrolled in RCTs. Although the TIMI score performed well in the randomized controlled trial (RCT) population in which it was developed and the TIMI 9A/B clinical trial cohort in which it was validated, 6 it is unclear how accurate the TIMI score is when applied to elderly patients, a group that is not well represented in RCT populations. Generalizability and validity are the sine qua non of prognostic models. 6 Developed as part of the InTIME II trial, 7 the TIMI score is a simple integer score that stratifies patients’ prognosis and provides specific short-term mortality estimates. 4, 5 One of the best known risk scores for patients hospitalized with ST-elevation myocardial infarction (STEMI) is the TIMI ST-elevation risk score (hereafter referred to as the TIMI score). 1 Effective management of these patients requires an accurate estimation of their prognosis, and current risk-assessment tools span the spectrum from simple risk scores 2, 3 to complex multivariable models. Elderly patients constitute the majority of patients hospitalized with acute coronary syndromes.
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