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 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: