ACS - Risk Stratification: Difference between revisions

Revision as of 23:38, 1 March 2011

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 MI in Patients With UA/NSTEMI

	High Risk

At least 1 of the following must be present:

Intermediate Risk

No high-risk feature, but must have 1 of the following:

Low Risk

No high or intermediate-risk features but may have any of the following:

History Accelerating tempo of ischemic symptoms in preceding 48 h Prior MI, peripheral or cerebrovascular disease, or CABG; prior ASA use Character of Pain Prolonged ongoing (greater than 20 min)

Rest pain

* Prolonged (greater than 20 min) rest angina, now resolved, with moderate or high likelihood of CAD

Rest angina (greater than 20 min) or relieved with rest or sublingual NTG
Nocturnal angina
New-onset or progressive CCS class III or IV angina in the past 2 weeks without prolonged (greater than 20 min) rest pain but with intermediate or high likelihood of CAD

Increased angina frequency, severity, or duration

Angina provoked at a lower threshold

New onset angina with onset 2 weeks to 2 months prior to presentation

Clinical Findings Pulmonary edema, most likely due to ischemia

New or worsening MR murmur

S3 or new/worsening rales

Hypotension, bradycardia, tachycardia

Age > 75 yrs

Age > 70 yrs ECG Angina at rest with transient ST-segment changes greater than 0.5mm

New Bundle-branch block

Sustained ventricular tachycardia

T-wave changes

Pathological Q waves or resting ST-depression less than 1mm in multiple lead groups

Normal or unchanged ECG Biomarkers Elevated Troponin or CK-MB Slightly elevated troponin or CK-MB (e.g. trop > 0.01 but less than 0.1) Normal

Source:

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

Authors:

@@ Line 1: / Line 1: @@
-Likelihood Sx d/t CAD
+Likelihood That Signs/Symptoms represent ACS 2/2 CAD  	High Likelihood
-===HIGH===
+Any of the following:
+	Intermediate Likelihood
-History-chest or L arm pain or discomfort as chief symptom reproducing prior documented angina, known history of CAD, including MI
+Absence of high-likelihood features and presence of any of the following:
-Exam-transient MR, hypotension, diaphoresis, pulmonary edema or rales
+	Low Likelihood
-EKG-new or presumably new, transient ST segment deviation > 0.05mV or T wave inversion > 0.2mV with symptoms
+Absence of high or intermediate likelihood features but may have:
-Markers-Elevated cardiac troponin I troponin T or CK-MB
+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
-===INTERMEDIATE===
+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
-Any of the below-none of the above:
+	T-wave flattening or inversio n less than 1mm in leads with dominant R waves
-History-chest or L arm pain as chief symptom, age > 70, male, diabetes
+Biomarkers 	Elevated troponin or CK-MB 	Normal 	Normal
-Exam-extracardiac vascular disease
-EKG-fixed Q's, abnormal ST segments or T waves not documented to be new
-Markers-normal
+Short-Term Risk of Death or Nonfatal MI in Patients With UA/NSTEMI
+ 	High Risk
-===LOW===
+At least 1 of the following must be present:
+	Intermediate Risk
-None of above but may have:
+No high-risk feature, but must have 1 of the following:
-History- recent ischemic symptoms without any interm. or high risk features. Recent cocaine use
+	Low Risk
-Exam- reproducible chest discomfort on palpation.
+No high or intermediate-risk features but may have any of the following:
-EKG- T wave flattening or inversions in leads with dominant R waves. Normal EKG
+History 	Accelerating tempo of ischemic symptoms in preceding 48 h 	Prior MI, peripheral or cerebrovascular disease, or CABG; prior ASA use
+Character of Pain 	Prolonged ongoing (greater than 20 min)
-Markers-normal
+Rest pain
+	* Prolonged (greater than 20 min) rest angina, now resolved, with moderate or high likelihood of CAD
+* Rest angina (greater than 20 min) or relieved with rest or sublingual NTG
+* Nocturnal angina
+* New-onset or progressive CCS class III or IV angina in the past 2 weeks without prolonged (greater than 20 min) rest pain but with intermediate or high likelihood of CAD
-== ==
+	Increased angina frequency, severity, or duration
-Risk of Death or MI in pts with UA=== ===
-===HIGH===
-At least one feature:
-History- accel tempo of ischemic symptoms in preceding 48 hrs
-Character- prolonged (greater 20 min) rest pain
-Clinical findings-pulm edema -most likely related to ischemia
--New or worsening MR murmur
--S3 or new or worsening rales
--Hypotension,bradycardia, tachycardia
--Age greater 75
-ECG- angina at rest with transient ST changes greater than .05 mv
--Bundle branch new or presumed new
+Angina provoked at a lower threshold
--Sustained V-tach
+New onset angina with onset 2 weeks to 2 months prior to presentation
-Markers-markedly elevated (tnT or TnI ) 0.4ng/ml
+Clinical Findings 	Pulmonary edema, most likely due to ischemia
-===INTERMEDIATE===
+New or worsening MR murmur
+S3 or new/worsening rales
-No high risk features, at least one of the following:
+Hypotension, bradycardia, tachycardia
-History-prior MI, peripheral or cerebral vascular disease, prior CABG, prior ASA use
+Age > 75 yrs
-Character-prolonged (greater than 20 min) rest angina...now resolved, with moderate or high prob of CAD
+	Age > 70 yrs
+ECG 	Angina at rest with transient ST-segment changes greater than 0.5mm
--Rest angina (less than 20 min. Or relieved with rest or NTG
+New Bundle-branch block
-Clinical findings-Age greater 70
+Sustained ventricular tachycardia
-ECG findings-T wave inversions greater than 0.2Mv, pathological Q's
+	T-wave changes
-Markers-slightly elevated (tnt greater than 0.04 but less than 0.4 ng/ml
+Pathological Q waves or resting ST-depression less than 1mm in multiple lead groups
+	Normal or unchanged ECG
+Biomarkers 	Elevated Troponin or CK-MB 	Slightly elevated troponin or CK-MB (e.g. trop > 0.01 but less than 0.1) 	Normal
-===LOW===
+===Source:===
-No high risk or intermediate risk features but may have:
-History-New onset CCS class3 or 4 angina in the past 2 wks with mod or high likelihood of CAD
-ECG-normal or unchanged ECG during episode of chest discomfort
-Markers-normal
+ACC/AHA Guidelines for the Management of Patients with UA/NSTEMI