ACS - risk stratification

HEART Score

• The score has been derived and validated in an ED population and predicts 6 week adverse cardiac events

HEART Score

HEART Score Calculator

Criteria	Select One
History	Slightly suspicious (0)	Moderately suspicious (+1)	Highly suspicious (+2)
EKG	Normal (0)	Non-specific repolarization disturbance (+1)	Significant ST deviation (+2)
Age	<45 (0)	45–64 (+1)	≥65 (+2)
Risk Factors HTN, hypercholesterolemia, DM, obesity (BMI >30), smoking, family hx CVD, or hx atherosclerotic disease	No known risk factors (0)	1–2 risk factors (+1)	≥3 risk factors or hx atherosclerotic disease (+2)
Initial Troponin	≤normal limit (0)	1–3× normal limit (+1)	>3× normal limit (+2)
HEART Score	/ 10

Interpretation

0–3	Low Risk — 0.9–1.7% risk of MACE. Consider discharge with outpatient follow-up.
4–6	Moderate Risk — 12–16.6% risk of MACE. Consider admission for observation and further workup.
7–10	High Risk — 50–65% risk of MACE. Consider early invasive measures (cardiology consult, catheterization).

References

Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196. PMID 18665203. Backus BE, Six AJ, Kelder JC, et al. Prospective validation of the HEART score for chest pain patients. Int J Cardiol. 2013;168(3):2153-2158. PMID 23465250. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203. PMID 25737484.

New Vancouver Chest Pain Rule

• Useful for screening patient with low risk for ACS
• The old Vancouver chest pain rule was not properly validated
• The new rule was validated in 2014 on 1635 patients and published in 2014
• With high sensitivity troponins the sensitivity is 99.1% (95% CI 97.4-99.7), & specificity is 16.1 (95% CI 14.2-18.2)
• With sensitive troponin-I the sensitivity was 98.8% (97.0-99.5), & specificity of 15.8 (13.9-17.9)

Algorithm

• Is the same for c-TnI assay and hs-TnI assay but sensitivity differences by a percentage point

1. Is there an abnormal ECG, positive troponin at 2 hrs or prior ACS nitrate use?
   • If Yes to any then no early discharge
2. Does palpation reproduce the pain?
   • If Yes then early discharge
3. Age ≥50, or does pain radiate to neck, jaw, or left arm?
   • If Yes then no early discharge

• If answer is No to all of the above stepwise questions then the patient can have early discharge with close follow-up for further provocative testing

Likelihood That Signs/Symptoms Represent ACS due to CAD

Feature	High Likelihood (any of the following)	Intermediate Likelihood (absence of high-likelihood features and presence of any of the following)	Low Likelihood (absence of high- or intermediate-likelihood features but may have)
History	Chest or left arm pain or discomfort as chief symptom reproducing prior documented angina	Chest or left arm pain or discomfort as chief symptom	Probable ischemic symptoms in absence of any of the intermediate-likelihood characteristics
	Known history of coronary artery disease, including myocardial infarction	Age >70 y old	Recent cocaine use
		Male sex
		Diabetes mellitus
Examination	Transient mitral regurgitation murmur, hypotension, diaphoresis, pulmonary edema, or rales	Extracardiac vascular disease	Chest discomfort reproduced by palpation
ECG	New, or presumably new, transient ST-segment deviation (1 mm or greater) or T-wave inversion in multiple precordial leads	Fixed Q waves	T-wave flattening or inversion <1 mm in leads with dominant R waves
		ST depression 0.5–1.0 mm or T-wave inversion >1 mm
			Normal ECG
Cardiac markers	Elevated cardiac troponin I, troponin T, or MB fraction of creatine kinase	Normal	Normal

Short-Term Risk of Composite Outcome

Composite Outcome: Death or Nonfatal Myocardial Infarction by Risk Stratification in Patients with Unstable Angina

Feature	High Likelihood (at least one of the following features must be present)	Intermediate Likelihood (no high-risk feature, but must have one of the following)	Low Likelihood (no high- or intermediate-risk feature, but may have any of the following)
History	Accelerating tempo of ischemic symptoms in preceding 48 h	Prior myocardial infarction, peripheral or cerebrovascular disease, or coronary artery bypass grafting; prior aspirin use	—
Character of the pain	Prolonged ongoing (>20 min) rest pain	Prolonged (>20 min) rest angina, now resolved, with moderate or high likelihood of CAD	Increased angina frequency, severity, or duration
		Rest angina (>20 min) or relieved with rest or sublingual nitroglycerin	Angina provoked at a lower threshold
			New-onset angina with onset 2 wk to 2 mo before presentation
		Nocturnal angina
		New-onset or progressive Canadian Cardiology Society Class III or IV angina in the past 2 wk without prolonged (>20 min) rest pain but with intermediate or high likelihood of CAD;
Clinical findings	Pulmonary edema, most likely due to ischemia	Age >70 y old	Chest discomfort reproduced by palpation
	New or worsening mitral regurgitation murmur
	S3 or new/worsening rales
	Hypotension, bradycardia, tachycardia
	Age >75 y old
ECG	Angina at rest with transient ST-segment changes >0.5 mm	T-wave changes, pathologic Q waves, or resting ST depression <1 mm in multiple lead groups (anterior, inferior, lateral)	Normal or unchanged ECG
	Bundle-branch block, new or presumed new
	Sustained ventricular tachycardia
Cardiac markers	Elevated cardiac TnT, TnI, or CK-MB (e.g., TnT or TnI >0.1 nanogram/mL)	Slightly elevated cardiac TnT, TnI, or CK-MB (e.g., TnT >0.01 but <0.1 nanogram/mL)	Normal

TIMI Risk Stratification Score

NSTEMI TIMI Score

Used to estimate percent risk of all-cause mortality, new/recurrent MI, or need for revascularization at 14 days

• Age >65 yrs (1 point)
• Three or more risk factors for coronary artery disease: (1 point)
  • family history of coronary artery disease
  • hypertension
  • hypercholesterolaemia
  • diabetes
  • current smoker
• Use of aspirin in the past 7 days (1 point)
• Significant coronary stenosis (stenosis >50%) (1 point)
• Severe angina (e.g., >2 angina events in past 24 h or persisting discomfort) (1 point)
• ST-segment deviation of ≥0.05 mV on first ECG (1 point)
• Increased troponin and/or creatine kinase-MB blood tests (1 point)

TIMI Risks

points	% risk of mortality, MI, or need for revascularization
0	5%
1	5%
2	8%
3	13%
4	20%
5	26%
6	41%

See Also

• Acute Coronary Syndrome (Main)
• ADAPT Trial