TIMI UA NSTEMI Calculator - 14-Day ACS Event Risk

The TIMI UA NSTEMI score is a seven-item bedside checklist that estimates the 14-day risk of death, new or recurrent MI, and severe recurrent ischemia requiring urgent revascularization in unstable angina or NSTEMI. Each item is worth 1 point, the total is 0 to 7, and the 14-day event rate climbs from 4.7% at 0 or 1 to 40.9% at 6 or 7. The score turns the first 30 minutes of a chest pain workup into one number the resident and the attending can both quote in the chart note.

• • Emergency department triage of suspected NSTEMI: A clinician deciding whether to admit for serial troponins, stress imaging, or an early invasive strategy.
• • Risk review on a chest pain unit or hospitalist admission: A bedside team using a structured score to set the level of monitoring and the timing of cardiology consult.
• • Documentation at sign-out and chart review: A structured note the resident and the attending can both quote at handoff.

TIMI stands for Thrombolysis In Myocardial Infarction. The score was derived in two phase 3 international randomized trials (TIMI 11B and ESSENCE) and published in JAMA in 2000, with independent validation in the TIMI III registry in 2002.

When the NSTEMI or UA admission is also being reviewed with an in-hospital mortality score, GRACE Score Calculator turns the eight GRACE variables into the published in-hospital probability of death that the ACC and AHA pathways list alongside the TIMI total.

The calculator takes each of the seven TIMI variables, scores it 0 or 1, adds the seven scores into a 0 to 7 total, and maps the total to the 14-day event rate from Antman 2000. The TIMI UA NSTEMI score is unweighted, so the integer total is the simple sum of the seven yes/no answers.

• Age 65 or older: 1 point if the patient is 65 years or older.
• Three or more CAD risk factors: 1 point if three or more of family history of CAD, hypertension, hypercholesterolemia, diabetes, or current smoker are present.
• Known CAD (stenosis 50% or more): 1 point for prior angiography with 50% or more stenosis, prior MI, prior PCI, or prior CABG.
• Aspirin use in the past 7 days: 1 point for aspirin of any dose, including over-the-counter 81 mg, in the seven days before presentation.
• Severe angina: 1 point if the patient has had at least two anginal episodes in 24 hours.
• ST-segment deviation on the admission ECG: 1 point for ST depression of 0.5 mm or more, transient ST elevation, or new T-wave inversion. Persistent ST elevation meeting STEMI criteria uses the STEMI pathway instead.
• Positive cardiac marker: 1 point if troponin I or T, CK-MB, or myoglobin is above the local upper reference limit.

The 14-day composite event rate is from the Antman 2000 test cohort of 1957 patients in TIMI 11B and 1564 patients in the ESSENCE heparin arm.

According to Antman et al. 2000 TIMI risk score (JAMA), the 14-day composite was 4.7% for 0/1, 8.3% for 2, 13.2% for 3, 19.9% for 4, 26.2% for 5, and 40.9% for 6/7.

When the chest pain workup also includes an ED triage score, Heart Score Calculator adds the History, ECG, Age, Risk factors, and Troponin total that pairs with the TIMI review for the disposition conversation.

Three ideas carry most of the clinical meaning: the 14-day composite endpoint, the yes/no scoring, and the band cut-offs.

The score is a triage aid, not a rule-out. A low TIMI total with recurrent rest pain, dynamic ECG changes, or rising troponin still needs the full NSTEMI workup.

When the ST-deviation factor in the TIMI total comes from an ECG strip that the team also wants to read for rate, ECG Heart Rate Calculator supports the 1500 or 300 method check that often runs alongside the TIMI ECG review.

Use the calculator after the initial ABCDE workup, the 12-lead ECG, and the first troponin.

1. 1 Score the history and risk factors: Add 1 point if the patient is 65 or older, and 1 point if three or more CAD risk factors (family history, hypertension, hypercholesterolemia, diabetes, current smoker) are present.
2. 2 Score treatment and known CAD: Add 1 point for prior angiography with 50% or more stenosis (or prior MI, PCI, or CABG), and 1 point for aspirin of any dose in the past 7 days.
3. 3 Score the symptom and ECG factors: Add 1 point for at least two anginal episodes in 24 hours, and 1 point for ST depression of 0.5 mm or more, transient ST elevation, or new T-wave inversion.
4. 4 Score the biomarker factor: Add 1 point if troponin I or T, CK-MB, or myoglobin is above the local upper reference limit. High-sensitivity troponin above the 99th percentile qualifies.
5. 5 Read the total and the band: Add the seven answers to get the 0 to 7 total. The calculator maps the total to the 14-day event rate and a Low, Intermediate, or High band. Persistent ST elevation meeting STEMI criteria should bypass this score.

A 68-year-old with hypertension, hypercholesterolemia, diabetes, prior PCI on aspirin, recurrent rest pain, ST depression, and elevated troponin has all seven factors. The total is 7, the 14-day event rate is 40.9%, and the band is High. The team activates the early invasive strategy.

When the next decision is an early invasive strategy that depends on renal function, GFR Calculator gives the estimated GFR that often runs alongside the TIMI review on the same chart.

The TIMI UA NSTEMI score is a bedside score that turns the first 30 minutes of an NSTEMI or UA workup into one defensible number for the chart and the disposition conversation.

• • Faster NSTEMI disposition: Gives the resident and the attending one number for the early invasive strategy decision and the level of monitoring.
• • Anchored to a published 14-day event rate: Each total is paired with a 14-day composite event rate from the Antman 2000 derivation.
• • Uses the data the team already has: Age, CAD risk factors, prior CAD, aspirin use, anginal history, the admission ECG, and the first troponin are all already collected.
• • Defensible at sign-out: A single integer (0 to 7) plus a 14-day percentage and a band is easier to defend in a chart note than a paragraph of impression.
• • Pairs with GRACE and HEART for a more complete picture: The score is one of three bedside tools (TIMI, GRACE, and HEART) that most ED and cardiology pathways use together.

When the bedside team wants to confirm a borderline blood pressure reading, Blood Pressure Calculator supports a manual cuff check and the mean arterial pressure that often sits next to the TIMI total.

Several things can move the TIMI UA NSTEMI score up or down, and the result is only as good as the inputs that go in.

• • The TIMI UA/NSTEMI score is a triage aid for suspected UA or NSTEMI, not a diagnostic test. A low score does not rule out ACS, and a high score does not replace a cardiology consult and serial troponins.
• • The score is not validated in pregnancy, in children, in patients with chronic troponin elevation from end-stage kidney disease, or after recent PCI or CABG.
• • The 14-day window is short. A low score is reassurance for the next two weeks, not an assurance of no future event. The score predicts relative benefit from enoxaparin in the high-risk band, not absolute benefit at the bedside.

According to Scirica et al. 2002 TIMI III registry validation (Am J Cardiol), the score was independently validated in 3,498 patients, with 14-day events from 4.6% in the lowest band to 33.5% in the highest.

According to Amsterdam et al. 2014 ACC/AHA NSTE-ACS guideline (Circulation), the seven TIMI UA/NSTEMI variables should be reviewed alongside the GRACE in-hospital mortality score when triaging a patient with a suspected acute coronary syndrome.