ACS - Risk Stratification

Likelihood That Signs/Symptoms represent ACS 2/2 CAD 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 L arm pain/discomfort as chief symptom reproducing prior documented angina/MI

• Known history of CAD, including MI

• Chest or left arm pain/discomfort as chief symptom

• Age > 70yrs
• Male sex
• DM

Probable ischemic symptoms in absence of any of the intermediate likelihood characteristics

Recent cocaine use

Exam Transient MR murmur, hypotension, diaphoresis, pulm edema, or rales Extracardiac vascular disease Chest discomfort reproduced by palpation ECG New transient ST-segment deviation (1mm or greater) or T-wave inversion in multiple precordial leads Fixed Q waves

ST depression 0.5 to 1mm or TWI > 1mm

T-wave flattening or inversio n less than 1mm in leads with dominant R waves

Biomarkers Elevated troponin or CK-MB Normal Normal

Short-Term Risk of 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 (Table 53-0.1) in the past 2 wk without prolonged (>20 min) rest pain but with intermediate or high likelihood of CAD (Table 53-2)
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

Source:

2007 ACC/AHA Guidelines for the Management of Patients with UA/NSTEMI