TIMI bleeding criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria [1][2][3][4] is one of the most frequently used classifications in the cardiovascular trials. These criteria were developed during early TIMI trials to define minor and major hemorrhagic episodes in patients of ST segment elevation MI (STEMI) treated with a fibrinolytic drug and have been there for 30 years. It was mainly dependent on laboratory values like decrease in hemoglobin or hematocrit values. It has been modified over time and the most recent version is shown below.

TIMI Bleeding Criteria

Non-CABG Related Bleeding:

1. Major
  • Any intracranial bleeding (excluding microhemorrhages <10 mm evident only on gradient-echo MRI)
  • Clinically overt signs of hemorrhage associated with a drop in hemoglobin of ≥5 g/dL or a ≥15% absolute decrease in haematocrit
  • Fatal bleeding (bleeding that directly results in death within 7 d)
2. Minor
  • Clinically overt (including imaging), resulting in hemoglobin drop of 3 to <5 g/dL or ≥10% decrease in haematocrit
  • No observed blood loss: ≥4 g/dL decrease in the haemoglobin concentration or ≥12% decrease in haematocrit
  • Any overt sign of hemorrhage that meets one of the following criteria and does not meet criteria for a major or minor bleeding event, as defined above
  • Requiring intervention (medical practitioner-guided medical or surgical treatment to stop or treat bleeding, including temporarily or permanently discontinuing or changing the dose of a medication or study drug)
  • Leading to or prolonging hospitalization
  • Prompting evaluation (leading to an unscheduled visit to a healthcare professional and diagnostic testing, either laboratory or imaging)
3. Minimal
  • Any overt bleeding event that does not meet the criteria above
  • Any clinically overt sign of haemorrhage (including imaging) associated with a <3 g/dL decrease in haemoglobin concentration or <9% decrease in haematocrit

Bleeding in the Setting of CABG:

  • Fatal bleeding (bleeding that directly results in death)
  • Perioperative intracranial bleeding
  • Reoperation after closure of the sternotomy incision for the purpose of controlling bleeding
  • Transfusion of ≥5 U PRBCs or whole blood within a 48-h period; cell saver transfusion will not be counted in calculations of blood products.
  • Chest tube output >2 L within a 24-h period

References

  1. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J et al. (2011). "Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium.". Circulation 123 (23): 2736-47. doi:10.1161/CIRCULATIONAHA.110.009449. PMID 21670242.
  2. Rao SV, O'Grady K, Pieper KS, Granger CB, Newby LK, Van de Werf F et al. (2005). "Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes.". Am J Cardiol 96 (9): 1200-6. doi:10.1016/j.amjcard.2005.06.056. PMID 16253582.
  3. Bovill EG, Terrin ML, Stump DC, Berke AD, Frederick M, Collen D et al. (1991). "Hemorrhagic events during therapy with recombinant tissue-type plasminogen activator, heparin, and aspirin for acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI), Phase II Trial.". Ann Intern Med 115 (4): 256-65. PMID 1906692.
  4. Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S et al. (2007). "Prasugrel versus clopidogrel in patients with acute coronary syndromes.". N Engl J Med 357 (20): 2001-15. doi:10.1056/NEJMoa0706482. PMID 17982182.

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