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TIMI Risk Score for Secondary Prevention to Risk Stratify Chronic Coronary Syndrome Patients: External Validation
Henrique Trombini Pinesi1,2, Eduardo Martelli Moreira1, Marcelo Henrique Moreira Barbosa1
1Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.
Insights
The TIMI Risk Score for Secondary Prevention (TRS2P) identifies high-risk chronic coronary syndrome patients but underestimates cardiovascular events and shows poor discrimination in Brazil. Further validation is needed for this population.
Area of Science:
- Cardiology
- Clinical Risk Stratification
- Public Health
Background:
- Chronic coronary syndrome (CCS) patient risk stratification is complex.
- The TIMI Risk Score for Secondary Prevention (TRS2P) predicts major adverse cardiovascular events (MACE) in post-myocardial infarction (MI) patients.
- No prior studies validated TRS2P in the Brazilian CCS population.
Purpose of the Study:
- To validate the predictive accuracy of the TRS2P score in a Brazilian cohort of CCS patients.
- To assess the calibration and discrimination of the TRS2P score in this specific population.
Main Methods:
- A registry-based study included 515 CCS patients.
- The primary outcome was the three-year incidence of MACE (death, MI, or stroke).
- Calibration was assessed using a calibration plot and Hosmer-Lemeshow test; discrimination was evaluated with the C-statistic.
Main Results:
- The observed three-year MACE incidence was 24%, significantly higher than the predicted 15%.
- The TRS2P score underestimated MACE incidence across all risk strata (p < 0.01).
- The model demonstrated poor discrimination, with a C-statistic of 0.64.
Conclusions:
- The TRS2P score identifies higher-risk CCS patients but underestimates MACE in a Brazilian cohort.
- The score exhibits poor discrimination and requires recalibration for use in this population.
- This study highlights the need for population-specific risk models in cardiovascular medicine.
Background:
Risk stratification in chronic coronary syndrome (CCS) patients is challenging. TIMI Risk Score for Secondary Prevention (TRS2P) is a simple nine-point tool developed to predict cardiovascular death, myocardial infarction (MI), and ischemic stroke among post-MI patients. No studies have been conducted on it in the Brazilian population.
Objective:
Validate the TRS2P score among CCS patients at a tertiary center in Brazil.
Methods:
This is a registry-based study of patients with CCS, defined as having a previous revascularization procedure, previous MI, or ≥50% stenosis in at least one epicardial coronary artery. The primary outcome was the three-year incidence of MACE (death, MI or stroke). The predicted risk was as reported in the original derivation study. Calibration was assessed through a calibration plot and the Hosmer-Lemeshow test. Discrimination was evaluated through the concordance (C)-statistic. A significance level of 0.05 was adopted.
Results:
The study sample consisted of 515 patients. There were 173 (34%) women, 75 (15%) aged over 75 years, 298 (58%) had diabetes, and 156 (30%) had chronic kidney disease. During follow-up, 126 MACE were documented. The estimated three-year incidence was 24% (95% confidence interval [CI] 21%-28%), whereas the predicted incidence was 15%. Although higher TRS2P scores were associated with higher MACE incidence, the TRS2P risk score model underestimated MACE incidence at every strata (p < 0.01). The C-statistic was 0.64 (95% CI 0.58-0.69).
Conclusion:
The TRS2P score identifies patients with a higher risk of cardiovascular events but it underestimated MACE and presented poor discrimination in a Brazilian CCS cohort.
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