Acute coronary syndrome risk stratification

Acute Coronary Syndrome Chapters
Heart Attack Patient Information
Unstable Angina Patient Information
Overview
Classification Unstable Angina Non-ST Elevation Myocardial Infarction ST Elevation Myocardial Infarction
Causes
Differential Diagnosis
Treatment
AHA/ACC Guidelines for Acute Coronary Syndrome
Guideline for Risk Stratification in ACS
Guideline for Pre-Hospital Evaluation and Care
Guidelines for Initial Management of ACS
Guidelines for Patients with Atrial Fibrillation Complicating ACS

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

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)

Early Risk Stratification (DO NOT EDIT)

Class I

"1. A rapid clinical determination of the likelihood risk of obstructive CAD (i.e., high, intermediate, or low) should be made in all patients with chest discomfort or other symptoms suggestive of an ACS and considered in patient management. (Level of Evidence: C)"

"2. Patients who present with chest discomfort or other ischemic symptoms should undergo early risk stratification for the risk of cardiovascular events (e.g., death or [re]MI) that focuses on history, including anginal symptoms, physical findings, ECG findings, and biomarkers of cardiac injury and results should be considered in patient management. (Level of Evidence: C)"

"3. A 12-lead ECG should be performed and shown to an experienced emergency physician as soon as possible after ED arrival, with a goal of within 10 min of ED arrival for all patients with chest discomfort (or anginal equivalent) or other symptoms suggestive of ACS. (Level of Evidence: B)"

"4. If the initial ECG is not diagnostic but the patient remains symptomatic and there is high clinical suspicion for ACS, serial ECGs, initially at 15- to 30-min intervals, should be performed to detect the potential for development of ST-segment elevation or depression. (Level of Evidence: B)"

"5. Cardiac biomarkers should be measured in all patients who present with chest discomfort consistent with ACS. (Level of Evidence: B)"

"6. A cardiac-specific troponin is the preferred marker, and if available, it should be measured in all patients who present with chest discomfort consistent with ACS. (Level of Evidence: B)"

"7. Patients with negative cardiac biomarkers within 6 h of the onset of symptoms consistent with ACS should have biomarkers remeasured in the time frame of 8 to 12 h after symptom onset. (The exact timing of serum marker measurement should take into account the uncertainties often present with the exact timing of onset of pain and the sensitivity, precision, and institutional norms of the assay being utilized as well as the release kinetics of the marker being measured.) (Level of Evidence: B)"

"8. The initial evaluation of the patient with suspected ACS should include the consideration of noncoronary causes for the development of unexplained symptoms. (Level of Evidence: C)"

Class III

"1. Total CK (without MB), aspartate aminotransferase (AST, SGOT), alanine transaminase, beta-hydroxybutyric dehydrogenase, and/or lactate dehydrogenase should not be utilized as primary tests for the detection of myocardial injury in patients with chest discomfort suggestive of ACS. (Level of Evidence: C)"

Class IIa

"1. Use of risk-stratification models, such as the Thrombolysis In Myocardial Infarction (TIMI) or Global Registry of Acute Coronary Events (GRACE) risk score or the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) risk model, can be useful to assist in decision making with regard to treatment options in patients with suspected ACS. (Level of Evidence: B)"

"2. It is reasonable to remeasure positive biomarkers at 6- to 8-h intervals 2 to 3 times or until levels have peaked, as an index of infarct size and dynamics of necrosis. (Level of Evidence: B)"

"3. It is reasonable to obtain supplemental ECG leads V7 through V9 in patients whose initial ECG is nondiagnostic to rule out MI due to left circumflex occlusion. (Level of Evidence: B)"

"4. Continuous 12-lead ECG monitoring is a reasonable alternative to serial 12-lead recordings in patients whose initial ECG is nondiagnostic. (Level of Evidence: B)"

Class IIb

"1. For patients who present within 6 h of the onset of symptoms consistent with ACS, assessment of an early marker of cardiac injury (e.g., myoglobin) in conjunction with a late marker (e.g., troponin) may be considered. (Level of Evidence: B)"

"2. For patients who present within 6 h of symptoms suggestive of ACS, a 2-h delta CK-MB mass in conjunction with 2-h delta troponin may be considered. (Level of Evidence: B)"

"3. For patients who present within 6 h of symptoms suggestive of ACS, myoglobin in conjunction with CK-MB mass or troponin when measured at baseline and 90 min may be considered. (Level of Evidence: B)"

"4. Measurement of B-type natriuretic peptide (BNP) or NT-pro-BNP may be considered to supplement assessment of global risk in patients with suspected ACS. (Level of Evidence: B)"

Risk Stratification Before Discharge (DO NOT EDIT)

Class I

"1. Noninvasive stress testing is recommended in low-risk patients who have been free of ischemia at rest or with low-level activity and of heart failure for a minimum of 12 to 24 h. (Level of Evidence: C)"

"2. Noninvasive stress testing is recommended in patients at intermediate risk who have been free of ischemia at rest or with low-level activity and of heart failure for a minimum of 12 to 24 h. (Level of Evidence: C)"

"3. Choice of stress test is based on the resting ECG, ability to perform exercise, local expertise, and technologies available. Treadmill exercise is useful in patients able to exercise in whom the ECG is free of baseline ST segment abnormalities, bundle branch block, left ventricular hypertrophy, intraventricular conduction defect, paced rhythm, pre-excitation, and digoxin effect. (Level of Evidence: C)"

"4. An imaging modality should be added in patients with resting ST segment depression (≥0.10 mV), left ventricular hypertrophy, bundle branch block, intraventricular conduction defect, pre-excitation, or on digoxin treatment who are able to exercise. In patients undergoing a low level exercise test, an imaging modality can add sensitivity. (Level of Evidence: B)"

"5. Pharmacological stress testing with imaging is recommended when physical limitations (e.g., arthritis, amputation, severe peripheral vascular disease, severe chronic obstructive pulmonary disease, or general debility) preclude adequate exercise stress. (Level of Evidence: B)"

"6. Prompt angiography without noninvasive risk stratification should be performed for failure of stabilization with intensive medical treatment. (Level of Evidence: B)"

"7. A non invasive test (echocardiogram or radionuclide angiogram) is recommended to evaluate left ventricular function in patients with definite acute coronary syndromes who are not scheduled for coronary angiography and left ventriculography. (Level of Evidence: B)"

Related Chapters

• The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines
• Unstable Angina/ Non ST Elevation Myocardial Infarction
• ST Elevation Myocardial Infarction

References

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