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Printed on 6/29/2026
For informational purposes only. This is not medical advice.
The TIMI risk score for NSTEMI/UA uses 7 variables to stratify patients with non-ST elevation ACS. Scores range 0–7 and predict the 14-day risk of death, MI, or need for urgent revascularization, guiding decisions about invasive versus conservative management strategy.
Formula: Each criterion = 1 point. Age ≥65, CAD ≥50%, ASA use 7d, ≥2 angina 24h, ST dev ≥0.5mm, elevated biomarkers, ≥3 RF. Total 0–7.
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At the time of suspected NSTEMI or unstable angina presentation, score seven binary items (1 point each): age ≥65 years, ≥3 CAD risk factors (family history of CAD, hypertension, hypercholesterolemia, diabetes, or active smoking), prior coronary stenosis ≥50% (known CAD), ST deviation ≥0.5 mm on presenting ECG, ≥2 anginal events in the prior 24 hours, aspirin use in the past 7 days, and elevated cardiac biomarkers (troponin or CK-MB above the upper limit of normal).
Sum all positive items to get a total score of 0-7. Stratification: low risk (0-2 points): 14-day MACE rate ~5-8%; moderate risk (3-4 points): ~13-20%; high risk (5-7 points): ~26-41%. The presence of elevated troponin and ST deviation are particularly important individual markers of myocardial injury and ongoing ischemia.
TIMI score ≥3 favors early invasive strategy — coronary angiography within 24-72 hours per ACC/AHA guidelines. Score 0-2 may support initial conservative management with medical therapy, serial troponins, and non-invasive stress testing. Note that the GRACE score is now the preferred tool per ACC/AHA 2014 guidelines for ACS risk stratification due to superior discrimination (C-statistic 0.77 vs. 0.65).
Emergency physicians, cardiologists
The TIMI NSTEMI score provides rapid, bedside risk stratification for patients presenting with suspected NSTEMI or unstable angina. It integrates readily available clinical data to estimate 14-day risk of major adverse cardiac events (MACE: death, MI, or urgent revascularization).
Interventional cardiologists, hospitalists
TIMI NSTEMI ≥3 is associated with a 14-day MACE rate ≥13%, favoring early invasive strategy with catheterization within 24-72 hours. Scores 0-2 (5-8% MACE rate) may support conservative initial management with medical therapy and staged risk assessment.
Cardiologists, interventionalists
High TIMI NSTEMI scores combined with high-sensitivity troponin elevation, ST changes, or hemodynamic instability identify patients who need emergent or urgent catheterization (<2 hours or <24 hours) rather than the standard early invasive approach within 24-72 hours.
All clinicians managing ACS
A TIMI score of 6-7 (26-41% 14-day MACE) provides a concrete probability estimate for prognosis discussions with patients and families, helping to contextualize the urgency of invasive evaluation and the importance of dual antiplatelet therapy compliance.
Emergency physicians, hospitalists
TIMI score contributes to emergency department disposition in chest pain presentations — whether the patient requires ICU monitoring, telemetry admission, or observation unit placement before stress testing. Higher scores support higher-level monitoring and earlier cardiology consultation.
The ACC/AHA 2014 NSTEMI Guidelines (Amsterdam et al., JACC 2014) and ESC 2020 NSTEMI Guidelines (Collet et al., Eur Heart J 2021) both recommend the GRACE score over TIMI NSTEMI for ACS risk stratification. GRACE achieves C-statistic 0.77 vs. TIMI NSTEMI at 0.65. Despite this, TIMI NSTEMI remains widely used clinically due to its simplicity and 7-item binary scoring system that can be calculated in seconds at the bedside.
One of the most counterintuitive features of the TIMI NSTEMI score: aspirin use in the past 7 days adds 1 point (increases risk). This is not because aspirin causes harm — it is because aspirin use in the prior 7 days is a marker of previously recognized cardiovascular disease or aspirin resistance. A patient already on aspirin who develops ACS despite it has a higher baseline cardiovascular risk.
The TIMI NSTEMI score was developed with standard cardiac troponin. Modern practice uses high-sensitivity troponin (hsTn) with 0h/1h or 0h/2h protocols for rapid rule-in/rule-out. A single hsTn value at presentation above the upper limit of normal (99th percentile) satisfies the elevated biomarker criterion. Very low hsTn at 0h and 3h with no other high-risk features supports early discharge in the HEART Pathway and ESC guidelines.
The combination of elevated troponin and new ST deviation is a very high-risk finding in NSTEMI. ACC/AHA and ESC guidelines recommend immediate invasive strategy (<2 hours) for NSTEMI patients with refractory ischemia, hemodynamic instability, sustained VT/VF, or signs of cardiogenic shock — regardless of TIMI score.
ACC/AHA and ESC guidelines recommend ticagrelor (PLATO trial, 16% relative risk reduction vs. clopidogrel) or prasugrel (TRITON-TIMI 38, 19% relative risk reduction) for P2Y12 inhibition in NSTEMI over clopidogrel. Prasugrel is contraindicated in prior stroke/TIA and used with caution in age >75 and weight <60 kg. Ticagrelor is preferred for most NSTEMI patients.
All NSTEMI/UA patients should receive anticoagulation in addition to antiplatelet therapy. Options: unfractionated heparin (UFH), enoxaparin (preferred for medical management), bivalirudin (particularly for PCI), or fondaparinux (lowest bleeding risk for conservative strategy). Anticoagulation duration: until PCI, for 48 hours, or for the duration of hospitalization depending on strategy.
Unlike the GRACE score, TIMI NSTEMI does not include creatinine or estimated GFR. CKD is an independent predictor of NSTEMI mortality and affects drug dosing (enoxaparin, bivalirudin, contrast nephropathy risk). Always assess renal function separately in NSTEMI patients, especially when choosing anticoagulation and contrast-based procedures.
ESC 2020 guidelines endorse 0h/2h hsTn protocols for rapid NSTEMI rule-in/rule-out. If hsTn is undetectable at 0h and negative at 2h with low clinical probability (HEART score ≤3, TIMI score 0), patients may be candidates for early discharge with outpatient follow-up. High-risk NSTEMI (hsTn rising, ST changes, TIMI ≥3) requires hospitalization and invasive evaluation.
Oral beta-blockers should be started within 24 hours of NSTEMI for all patients without contraindications (acute decompensated HF, cardiogenic shock, significant bradycardia, or high-degree AV block). Intravenous beta-blockers are reserved for patients with refractory hypertension or tachycardia in the absence of LV dysfunction.
TIMI Risk Score for UA/NSTEMI developed by Antman et al. (JAMA 2000) from 1,957 patients in TIMI 11B and validated in ESSENCE trial. C-statistic 0.65 for 14-day MACE. GRACE score (Eagle et al., Eur Heart J 2004) — C-statistic 0.77 — recommended as preferred tool in ACC/AHA 2014 NSTEMI Guidelines (Amsterdam et al., JACC 2014) and ESC 2020 NSTEMI Guidelines (Collet et al., Eur Heart J 2021). PLATO trial (Wallentin et al., NEJM 2009): ticagrelor superiority over clopidogrel. TRITON-TIMI 38 (Wiviott et al., NEJM 2007): prasugrel superiority over clopidogrel. ESC 0h/2h hsTn protocol validation: Shah et al. (Eur Heart J 2015).
Your TIMI NSTEMI/UA score predicts the 14-day risk of a composite endpoint: all-cause death, new or recurrent myocardial infarction, or severe recurrent ischemia requiring urgent revascularization. A score of 0-2 indicates low risk (approximately 5-8% event rate), where conservative management with medical therapy and non-invasive stress testing may be appropriate. A score of 3-4 represents moderate risk (13-20%), and a score of 5-7 indicates high risk (26-41%), both of which favor an early invasive strategy with coronary angiography within 24-72 hours.
Each point in the TIMI NSTEMI score carries equal weight, making it simple to calculate at the bedside. However, the presence of elevated cardiac biomarkers (troponin) and ST deviation are particularly strong markers of ongoing ischemia and myocardial necrosis, and their presence should heighten clinical concern regardless of the total score.
Use this score when evaluating patients presenting to the emergency department or chest pain unit with suspected non-ST elevation acute coronary syndrome (NSTEMI or unstable angina). It should be calculated after the initial ECG and troponin results are available. The score helps guide the critical decision of whether to pursue an early invasive strategy (catheterization within 24-72 hours) versus an initially conservative approach (medical management with possible later non-invasive testing).
The TIMI NSTEMI score is also useful for communicating risk to patients and families, for emergency department disposition decisions (admission to monitored bed vs. observation unit), and for identifying patients who may benefit from more aggressive antithrombotic therapy (glycoprotein IIb/IIIa inhibitors, early dual antiplatelet therapy).
The TIMI NSTEMI score was derived from clinical trial populations (TIMI 11B and ESSENCE trials), which may not fully represent real-world emergency department patients. Trial exclusion criteria may have eliminated very high-risk and very low-risk patients, potentially affecting the score's calibration at the extremes.
The score uses binary variables, which limits its discriminative power compared to the GRACE score, which incorporates continuous variables such as age, heart rate, and creatinine. The TIMI score does not account for renal function, hemodynamic status, or heart failure, all of which are important prognostic factors in ACS. For these reasons, the ESC guidelines recommend the GRACE score as the preferred risk stratification tool, though the TIMI score remains widely used due to its simplicity and ease of bedside calculation.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
April 21, 2026 · trust-baseline
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