CHADS2 + TIMI

1. What is CHADS2 score?

2. What is TIMI score?

3. A male patient presents to you with pyrexia 39'C, nausea/vomiting/diarrhea/abdominal cramp, drowsy. When you assess him, you notice his BP is lowish and pulse rate is irregular, 160/min. CXR showed cardiomegaly. ECG shows atrial fibrillation. He has lid lag sign and proptosis. What is the first line to manage this disease? (hint: this condition is life-threatening).

1. CHADS₂ Score [points]

• C - Congestive heart failure [1]
• H - Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) [1]
• A - Age ≥75 years [1]
• D - Diabetes mellitus [1]
• S₂ - Pior Stroke or TIA [2]    

CHADS₂ score estimating the risk of stroke in patients with non-rheumatic AF, and it indicates the need of starting anticoagulant therapy with ASA or warfarin.

• Score 0: None or ASA daily
• Score 1: ASA daily or raise INR with warfarin till 2.0-3.0
• Score 2: Raise INR with warfarin till 2.0-3.0 unless contraindicated.

CHA₂DS₂-VASc Score [points]

• C - Congestive heart failure [1]
• H - Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) [1]
  
• A₂ - Age ≥75 years [2]
  
• D - Diabetes mellitus [1]
  
• S₂ - Pior Stroke or TIA [2]
• V - Vascular disease (eg. peripheral artery disease, MI, aortic plaque) [1]
• A - Age 65-74 years [1]
• Sc - Sex category (i.e. female gender) [1]

CHA₂DS₂-VASc score is a refinement of CHADS₂ score.

2. TIMI (Thrombolysis in MI) Risk Score

History

• Age ≥ 65
• At least 3 risk factors for CAD: HPT or on anti-HPT, smoking, low HDL or high cholesterol, DM, FHx of premature CAD (CAD in male first-degree relative, or father less than 55, or female first-degree relative or mother less than 65).
• Known CAD (stenosis ≥ 50%)
• ASA use in the last 7/7 (patient experiences chest pain despite ASA use in past 7days)

Clinical pictures

• At least 2 angina episodes within the last 24hrs
• ST changes ≥ 0.5mm on admission ECG
• Elevated serum cardiac biomarkers

TIMI risk Score is used in patients with UA/NSTEMI. Every criterion carries 1 point. TIMI score estimates risk at 14 days of all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.

Total Score = 7 points

• Low Risk : < 2 point 
• Moderate Risk: 3-4 points 
• High Risk : > 5 points

It is less accurate in predicting events, but is simple and widely accepted. Another scoring system is GRACE prediction score, which estimates all cause mortality from discharge to 6 months, but is a much more extensive scoring system. 

3. Lid lag and proptosis point the diagnosis to hyperthyroid crisis / thyrotoxic storm. The acute abdomen is a bit misleading, at first sight I though is cardiogenic shock or GIT infection.

• Since patient is hypotensive, we should prevent shock by giving IVI NS 500ml/h. Insert a CVL to monitor hydration status to prevent dehydration but at the same time we need to prevent overhydration since patient might have heart failure indicated by cardiomegaly.
• NGT to prevent aspiration since patient is vomiting. 
• Propanolol 1-2mg/6h IV or 40-80mg/6h PO. Contraindication: Pulmonary or peripheral edema, asthma. In these case use atropine 0.4-1mg IV (edema) or diltiazem 60-120mg/6h PO (in asthma)
• Antithyroid: carbimazole 15-25mg/6h PO or via NGT, or propylthiouracil (PTU)  600mg state + 900-1200mg/d in 4-6 divided dose PO or via NGT.
• Block T3/T4 release by: Sodium iodide 1g/d slow IVI or potassium iodide 100mg/6h PO (given 1-4h after antithyroid)
• Hydrocortisone 100mg/6h IV or Dexamethasone 2mg/6h IV (block T3/T4 release and inhibit peripheral conversion of T4 to T3).
• Treat heart failure with diuretic and O2. Treat AF with digoxin.
• Heparin 5000U BD SC to prevent thromboembolism due to AF.
• Infection is the usual cause of thyrotoxic storm. Find source of infection, take blood C+S. Treatment with cephalosporin 3rd-4th generation.
• Treatment fever with fanning, tepid sponging, PCM. Avoid ASA.
• Consider sedation with chlorpromazine in sever agitated patient. 

--- UPDATE ---

There is no doubt that the patient comes with thyroid storm as well as unstable fast atrial fibrillation. First step > emergent cardioversion. AF can be acute or chronic. If AF is prolonged, usually more than 48 hours, then it is chronic. An AF with low BP, low consciousness level should be treated as unstable AF. Unstable AF should be reverted with cardioversion.