Prognostic Significance of the TIMI Risk Score:

A Retrospective Analysis of Acute Coronary Syndrome

Queeni Sharon Melam¹, Ramya Kumari N¹, Ravi Shankar C², Shanu D¹, Eshwari Bai V¹,

Kavya Sree K¹, Uma Maheswar Rao⁴, Pathan Amanulla Khan³, Manoj Kumar Mudigubba^1*

¹Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, Anantapur, Andhra Pradesh- 515721, India.

²Department of Anaesthesia, Critical Care and Emergency, KIMS Hospital, Anantapur, Andhra Pradesh-515001.

³Department of Pharmacy Practice, Anwarul Uloom College of Pharmacy, Hyderabad, Telangana, India-500016.

⁴CMR College of Pharmacy, Kandlakoya, Hyderabad-501401.

*Corresponding Author E-mail: manojkumar.health@gmail.com

ABSTRACT:

Background: Patients with acute coronary syndrome without ST-segment elevation are diagnosed with unstable angina or non-ST elevation myocardial infarction, both associated with varied mortality and ischemic risks. Effective management requires individual risk stratification; the validated TIMI (Thrombolysis in Myocardial Infarction) risk score categorizes patients by risk and predicts major adverse cardiac events (MACE). This facilitates timely clinical interventions, potentially mitigating complications and healthcare costs. In resource-limited settings, such as India, the TIMI score can identify high-risk patients early, thereby enhancing the efficacy of interventions and reducing strain on the healthcare system. Methods: This retrospective observational study included 520 patients diagnosed with NSTEMI/UA. Data were collected from medical records, and the TIMI risk score was calculated. The 14-day outcomes were recorded, and the relationship between the TIMI score and patient outcomes was analyzed. Descriptive statistics and chi-square analysis were employed for comparison, and regression analyses were conducted to determine the influence of individual parameters on the increasing TIMI risk score. Results: The study revealed that 34.4% of the participants were female and 65.6% were male. Additionally, 71.3% were under 65 years old. The mortality rate was 6.3%, which was higher in diabetic patients (p = 0.041). Elevated TIMI risk scores correlated with an increased mortality risk. Men experienced more adverse events than women. Conclusion: An elevated TIMI risk score is correlated with an increased probability of major adverse cardiovascular events. The TIMI score functions as a straightforward, validated instrument for risk evaluation in patients with acute coronary syndrome.

KEYWORDS: Acute Coronary Syndrome, Major Adverse Cardiac Events, Non-ST Elevated Myocardial Infarction, Unstable Angina, Risk Assessment.

INTRODUCTION:

Cardiovascular diseases are the most common causes of increased hospitalisations and death rates globally, accounting for one-third of deaths worldwide. Among the cardiovascular diseases, Acute Coronary Syndrome (ACS) ranks as the most prevalent as Myocardial infarction.^1,2,3,4 ACS affects around 126 million individuals worldwide, accounting for 38% of fatalities among females and 44% in males.⁵In the United States of America, 53% of cardiovascular deaths occurred due to coronary heart disease, and approximately 782000 cases of MI are identified annually.³ Whereas in developing countries like India, 68% of morbidity is due to non-communicable disease, in which ACS was the major cause.⁶ The prevalence of ACS in urban areas ranges from 2.5-12.6%, and in comparison to the rural regions, it was 1.4%-4.6%.⁷Patients presenting with acute coronary syndrome (ACS) that does not show ST-segment elevation are classified as having either non-ST-segment elevation myocardial infarction or unstable angina.^8,9 NSTEMI and unstable angina are interrelated conditions; their pathophysiologic mechanisms and clinical manifestations are similar but vary in severity.⁵ Clinically, NSTEMI differs from unstable angina (UA) with cardiac-specific biomarkers (Troponin T or I or Creatinine kinase).⁹ Most of the elderly patients diagnosed with NSTEMI/UA are at enhanced risk of cardiovascular complications. Notwithstanding the advancements in therapeutic interventions over the past decade, NSTEMI continues to represent a significant burden in terms of morbidity and mortality.¹⁰ Risk factors for acute coronary syndrome include low physical activity, alcohol consumption, age over 65 years, high LDL cholesterol, hypertension, diabetes mellitus, chronic kidney disease, excessive COVID-19 infection, and atherosclerosis.^2,4 The Thrombolysis in Myocardial Infarction risk assessment tool is a straightforward and validated instrument designed to categorize patients diagnosed with UA and NSTEMI into different risk categories for experiencing major adverse cardiac events (MACE). The TIMI risk score was originally designed to be used in individuals experiencing unstable angina and non-ST elevation myocardial infarction (NSTEMI).^11,13

It has been extensively validated in emergency departments treating cardiac chest pain, thereby representing the highest level of evidence available.^15,16,17 It is an effective tool of risk stratification for forecasting the 14-day hospital-mortality among patients with NSTEMI.¹⁷ This tool includes seven prognostic parameters: age greater than sixty-five years, ³3 risk factors for CAD (smoking, hypertension, diabetes mellitus), known CAD stenosis, severe angina, Aspirin use within the past seven days, elevated cardiac biomarkers, and ST deviation segment.^12,13 The necessity for stratification is twofold: it aids in making clinical decisions regarding patient management and predicting major adverse cardiac events.^11,13,18 Nonetheless, the validation of the TIMI score has predominantly been developed in developed nations, and the literature from developing countries remains limited despite the higher burden of disease.¹⁹Therefore, our study evaluated the prognostic relevance of the TIMI risk score in acute coronary syndrome.

MATERIALS AND METHODS:

The study was a retrospective observational study carried out over the course of one year at an urban tertiary care hospital in Anantapur City, Andhra Pradesh, India. A total of 520 patients >18 years of age, diagnosed with coronary artery disease and exhibiting symptoms of non-ST-elevation myocardial infarction (NSTEMI) or Unstable Angina (UA), were hospitalized in the cardiology department. Patients who had previously undergone cardiac surgeries or interventions were excluded from the study. The study has prior approval of the IEC Committee of the Raghavendra Institute of Pharmaceutical Education and Research under reference number IRB/PP/2023/008. Data was collected from patient medical records and the electronic health record database, which included demographics, baseline investigations, and defined TIMI risk score parameters. After gathering all the required data, the TIMI score was calculated by assigning 1 point for each parameter present and 0 for each absent. This Tool functions based on the following seven clinical factors: . Age: 1 point for individuals aged 65 years or older; ii. Three or more risk factors – 1 point; iii. Known coronary artery disease with stenosis – 1 point; iv. Aspirin intake in the preceding 7 days – 1 point; v. Angina occurring more than two episodes within 24 hours – 1 point; vi. EKG ST-segment changes exceeding 0.5 mm – 1 point; vii. Positive cardiac biomarkers (troponin or CK-MB) – 1 point. The total TIMI risk score is computed as the sum of the points assigned to each of the seven factors. A higher TIMI Risk Score indicates an increased risk of adverse events.

Patients were monitored for 14 days following their hospital stay, and outcomes during this period were recorded. The TIMI score was then compared with patient outcomes. The relative differences were determined by comparing event rates against increasing TIMI scores and assessing the effectiveness of the TIMI risk score in predicting major adverse cardiac events in patients experiencing acute coronary syndrome. Major adverse cardiac events include death, recurrent myocardial infarction, and urgent revascularization.

RESULTS:

The study comprised 520 patients who fulfilled the established inclusion criteria. Among these participants, 34.4% were identified as females (180 n), whereas 65.6% were identified as males (340 n). Additionally, 71.3% of the subjects were classified as being under 65 years of age (371n), with the remaining 28.7% being aged 65 years or older (149n). The Body Mass Index (BMI) analysis of the study population indicated that 56.3% were categorized within the range of 18.5-24.9 (293n), followed by 22.7% within the range of 25-29.9 (118n) and 20.6% (107n) classified as obese (>30).

Furthermore, the following symptoms were documented in the study population upon hospital admission: chest pain (90.8%), hypertension (57.1%), diabetes mellitus (37.9%), smoking (27.1%), shortness of breath (19.6%), and obesity (20.6%). Observations from our study indicated that men experienced a greater incidence of adverse events compared to women. The reported mortality rate was 6.3%. Notably, patients with diabetes exhibited a significantly higher mortality rate (p = 0.041). Moreover, an elevated TIMI risk score was strongly correlated with an increased mortality risk.

Table 1: Relationship between TIMI score and Adverse events

TIMI Score T	Total in Score Group n (%)	No. of patients with events n (%)
0	0	-
1	8 (1.5%)	0
2	151 (29%)	3 (1.98%)
3	226 (43.4%)	3 (1.32%
4	130 (25%)	23 (17.69%)
5	5 (0.9%)	4 (80%)

Table 2: Classification of patients by using TIMI risk score

Category	TIMI Risk Score	Percentage (%)
Low Risk	0-2	159 (30.6%)
Intermittent Risk	3-4	356(68.5%)
High Risk	5-7	5(1%)

Table 3: Baseline characteristics and 14-day outcomes in the study population

Characteristic

Survived

n=487 (93.7%)

Expired

n=33 (6.3%)

P value

Gender

Male

Female

313 (60.1%)

174 (33.4%)

27 (5.1%)

06 (1.1)

0.042

Age

>65 Years

<65 Years

137 (26.3%)

350 (67.3%)

12 (2.3%)

21 (4.0%)

0.311

Risk Factors

Hypertension

Diabetes

Obesity

Smoking

274(92.3%)

179(90.9%)

103 (96%)

130(92.2%)

23(7.7%)

18(9.1%)

04 (4%)

11(7.8%)

0.131

0.041

0.406

The study subjects were categorized into three distinct categories based on the TIMI risk score: low risk (30.6%), intermediate risk (68.5%), and high risk (1%). In our investigation, 43.5% of patients underwent urgent revascularization, whereas 5% were readmitted due to recurrent myocardial infarction (MI). The survival rate was considerably reduced in patients aged 65 years or above. Incidence of adverse events increased with higher risk scores for individuals. Among the 520 patients, 43.4% had a TIMI risk score of 3, and 25% had a TIMI score of 4. Among patients (130n) with a TIMI score of 4, 17.69% patients experienced adverse events.

Regression analysis was used to estimate the unadjusted regression coefficients (independent parameters) effect on the TIMI score of the study, such as age, hypertension, diabetes, presence of coronary artery disease, smoking, and BMI. These unadjusted coefficients estimate the individual effect of the study factors on TIMI score in the absence of other study factors. The multivariate logistic regression analysis demonstrates that several clinical variables are significantly associated with an enhanced risk of adverse outcomes, with all predictors showing statistical significance (p < 0.05).

Age greater than 65 years was one of the strongest predictors, indicating that older individuals were more than twice as likely to experience adverse outcomes. Similarly, coronary artery disease and diabetes mellitus were also strongly associated with higher risk. Although the effects of smoking and obesity were relatively modest, they were still statistically significant. These results indicate that age, comorbidities such as diabetes, CAD, hypertension, smoking, and obesity are significant independent predictors of adverse outcomes when assessed in relation to the TIMI score.

DISCUSSION:

This study evaluates the effectiveness of the TIMI risk score tool to predict MACE among patients experiencing acute coronary syndrome. Our findings indicate that an elevated TIMI score is significantly correlated with an increased likelihood of adverse cardiac events, recurrent myocardial infarction, morbidity, revascularization, and, in the most severe cases, mortality. Furthermore, the study emphasizes the widespread application of the TIMI score in emergency settings for the prompt risk stratification in patients presenting with suspected acute coronary syndrome.

The calculation of the TIMI score takes into account individuals aged 65 years or older. In our study, this demographic constitutes 26.3% of the total population, signifying that elderly individuals face a heightened risk and encounter more adverse events, accompanied by a lower survival rate. Similarly, the research conducted by ALIQ et al.^19,20 indicates a lower survival rate in older groups. Patients diagnosed with NSTEMI tend to be older and have a higher risk of experiencing cardiovascular complications.¹⁰ Numerous risk factors can augment the likelihood of MACE in patients experiencing acute coronary syndrome, including hypertension, diabetes mellitus, obesity, smoking, and alcohol consumption. A study conducted by Jacqueline Locks and colleagues found that 61.8% of participants had elevated blood pressure, which notably increased the TIMI risk score ³. Similarly, our evaluation revealed that 58.8% of patients reported a history of hypertension, further raising the TIMI risk score. Additionally, diabetes was linked to a statistically significant rise in the MACE.

Additionally, the smoking habit demonstrated a significant correlation with an enhanced risk of cardiovascular events. However, BMI does not significantly affect the TIMI risk score. Moreover, factors such as aspirin usage in the past week, ST-segment changes on the ECG, known CAD, elevated cardiac biomarkers, and more than one angina episode within 24 hours can influence the TIMI score ^21,22. The TIMI risk score represents a validated instrument utilized for patients diagnosed with coronary artery disease. It serves to classify these patients according to their risk levels and aids physicians in making informed clinical decisions ^11,13. Patients who attain low scores, thereby classified as low risk, are recommended to undergo treatment with aspirin, clopidogrel, and nitrates. Conversely, patients identified as high risk for major adverse cardiac events necessitate hospitalization and may require invasive interventions. Our study has revealed that patients within high-risk categories demonstrate a significantly elevated incidence of major adverse cardiac events in comparison to those classified as low risk ^3,20.

Our analysis demonstrates that the patients with a past history of diabetes mellitus are significantly correlated with an enhanced risk of 14-day mortality, which aligns with the findings from the study proposed by Ryu et al. Diabetes mellitus is primarily correlated with cardiovascular events. Therefore, effectively managing diabetes is a crucial concern for reducing the risk of major adverse cardiac events ^{19, 23, 24}. Our study indicates that advanced age is the most significant predictor of MACE. Increasing age is strongly correlated with the risk of adverse cardiac events, as similarly reported by the study conducted by Kumar D et al. (10). The presence of cardiac-related issues and diabetes mellitus actively contributes to an elevated TIMI risk score. Hypertension doubles the risk of developing adverse cardiac events. The influence of BMI on increasing the TIMI risk score is statistically modest. The validation and integration of this risk score into clinical practice hold significant potential for developing nations such as India, where the incidence of ischemic heart disease is remarkably elevated among middle-aged populations, coupled with a scarcity of relevant literature.

CONCLUSION:

Our study substantiates the correlation between elevated TIMI scores and an increased risk of adverse cardiovascular events, such as morbidity, myocardial infarction, revascularization, and mortality. This highlights the crucial importance of the TIMI risk score in identifying high-risk patients who require immediate medical intervention. In developing nations, particularly India, where the prevalence of ischemic heart disease is markedly high, the implementation of this tool has potential to enhance patient outcomes and alleviate the financial burden associated with treatment. Risk stratification with the TIMI risk score is essential for patients with Diabetes and hypertension for early preventive management. Furthermore, additional research is warranted to investigate how the calculation of the TIMI risk score during the preliminary assessment of risk for adverse cardiovascular events may contribute to the reduction of the financial burden experienced by patients.

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Received on 03.05.2025 Revised on 25.09.2025

Accepted on 28.11.2025 Published on 01.07.2026

Available online from July 04, 2026

Research J. Pharmacy and Technology. 2026;19(7):3176-3180.

DOI: 10.52711/0974-360X.2026.00451

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Coefficients	Odds Ratio	95.0% Confidence Interval for Beta		p-value
Coefficients	Beta	Lower Bound	Upper Bound	p-value
Age >65	2.302	1.767	2.998	0.000
Hypertension	1.920	1.519	2.426	0.000
Diabetes mellitus	2.057	1.616	2.619	0.000
CAD	2.761	1.668	4.570	0.000
Smoking	1.305	1.022	1.667	0.033
Obesity	1.308	1.050	1.630	0.017
Dependent Variable: TIMI score,