By

Essam Mahfouz, MDProfessor of Cardiology, Mansoura University

ACS: Risk Stratification

Agenda

Introduction Risk scores Guidelines Value of risk stratification take home messages

Introduction Definitions

ACS has evolved as a useful operational term that refers to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction due to an abrupt reduction in coronary blood flow

ACS is leading cause of death allover the world

Introduction Anginal pain in NSTE-ACS patients may

have the following presentations: Prolonged (>20 min) anginal pain at rest; New onset (de novo) angina (class II or III) Recent destabilization of previously stable

angina with at least Class III (crescendo angina); or

Post-MI angina.

Acute Coronary Syndromes (top half)

Acute Coronary Syndromes (bottom half)

Initial assessment of ACS

ESC Guidelines 2015

Value of hsTroponin in ACS

ESC Guidelines 2015

Vascular Damage

Inflammation

Myocyte Necrosis

Accelerated Atherosclerosis

Hemodynamic Stress

HbA1cBlood

glucoseCrClMicroalbuminuria

Troponin

BNP, NT-proBNPhs-CRP, CD40L

Morrow DA, et al. Circulation. 2003;108:250-252.

Multimarker Strategy in ACS

Multimarker Approach: Troponin I, CRP, and BNP to Predict 30-Day Mortality in ACS

Sabatine M, et al. Circulation. 2002;105:1760-1763.

OPUS-TIMI 16

1

1.8

3.5

6

0

1

2

3

4

5

6

0 1 2 3No. of Elevated Biomarkers

TACTICS-TIMI 18

12.1

5.7

13

0

2

4

6

8

10

12

14

0 1 2 3No. of Elevated Biomarkers

P=.014 P=.001

67 150 155 78 504 717 324 90

30

Day

Mor

talit

y (%

)

30-D

ay M

orta

lity

Rel

Ris

k

TIMI Risk Score For UA/NSTEMI

Antman EM, et al. JAMA. 2000;284:835-442. (with permission)

• Age >65 years

• >3CAD Risk Factors

• Prior Stenosis >50 %

• ST deviation

• >2 Anginal events <24 hours

• ASA in last 7 days

• Elev Cardiac Markers (CK-MB or troponin)

4.78.3

13.219.9

26.2

40.9

0

10

20

30

40

50

0/1 2 3 4 5 6/7D

/MI/U

rg R

evas

c (%

)

Number of Risk Factors

Population (%): 4.3 17.3 32.0 29.3 13.0 3.4

C Statistic=0.65c2 trend P<.001

4.13.97.1

19.5

6.54.9

10.8

35.1

21.0

10.7

49.6

24.4

P<.001 P=.004 P<.001 P<.001

Scirica BM, et al. Am J Cardiol. 2002;90:303-305. (with permission)

TIMI Risk Score vs Prognosis in Unselected Patients (TIMI 3 Registry)

TRS 0-2 TRS 3-4 TRS 5-7

0%

10%

20%

30%

40%

50%

Death MI Death/MI Death/MI/RI

Even

t Rat

e at

1 y

ear (

%)

Risk ScoresTIMI GRACE

History

AgeHypertensionDiabetesSmoking↑ CholesterolFamily historyHistory of CAD

Age

Presentatio

n

Severe anginaAspirin within 7 daysElevated markersST-segment deviation

Heart rateSystolic BPElevated creatinineHeart failureCardiac arrestElevated markersST-segment deviation

Clinical Assessment and Initial Evaluation

Recommendations COR LOEPatients with suspected ACS should be risk stratified based on the likelihood of ACS and adverse outcome(s) to decide on the need for hospitalization and assist in the selection of treatment options.

I B

Patients with suspected ACS and high-risk features such as continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations should be referred immediately to the ED and transported by emergency medical services when available.

I C

Patients with less severe symptoms may be considered for referral to the ED, a chest pain unit, or a facility capable of performing adequate evaluation depending on clinical circumstances.

IIb C

Prognosis: Early Risk StratificationRecommendations COR LOE

In patients with chest pain or other symptoms suggestive of ACS, a 12-lead ECG should be performed and evaluated for ischemic changes within 10 minutes of the patient’s arrival at an emergency facility.

I C

If the initial ECG is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for ACS, serial ECGs (e.g., 15- to 30-minute intervals during the first hour) should be performed to detect ischemic changes.

I C

Serial cardiac troponin I or T levels (when a contemporary assay is used) should be obtained at presentation and 3 to 6 hours after symptom onset (see Section 3.4, Class I, #3 recommendation if time of symptom onset is unclear) in all patients who present with symptoms consistent with ACS to identify a rising and/or falling pattern of values.

I A

Prognosis: Early Risk Stratification (cont’d)

Recommendations COR LOEAdditional troponin levels should be obtained beyond 6 hours after symptom onset (see Section 3.4, Class I, #3 recommendation if time of symptom onset is unclear) in patients with normal troponin levels on serial examination when changes on ECG and/or clinical presentation confer an intermediate or high index of suspicion for ACS.

I A

Risk scores should be used to assess prognosis in patients with NSTE-ACS. I A

Risk-stratification models can be useful in management. IIa B

Prognosis: Early Risk Stratification (cont’d)

Recommendations COR LOEIt is reasonable to obtain supplemental ECG leads V7 to V9 in patients whose initial ECG is nondiagnostic and who are at intermediate/high risk of ACS.

IIa B

Continuous monitoring with 12-lead ECG may be a reasonable alternative in patients whose initial ECG is nondiagnostic and who are at intermediate/high risk of ACS.

IIb B

Measurement of B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide may be considered to assess risk in patients with suspected ACS.

IIb B

ESC Guidelines 2015

Factors Associated With Appropriate Selection of Early Invasive Strategy or Ischemia-Guided

Strategy in Patients With NSTE-ACSImmediate invasive (within 2 h)

Refractory anginaSigns or symptoms of HF or new or worsening mitral regurgitationHemodynamic instabilityRecurrent angina or ischemia at rest or with low-level activities despite intensive medical therapySustained VT or VF

Ischemia-guided strategy

Low-risk score (e.g., TIMI [0 or 1], GRACE [<109])Low-risk Tn-negative female patientsPatient or clinician preference in the absence of high-risk features

Early invasive (within 24 h)

None of the above, but GRACE risk score >140Temporal change in Tn (Section 3.4)New or presumably new ST depression

Delayed invasive (within 2572 h)

None of the above but diabetes mellitus Renal insufficiency (GFR <60 mL/min/1.73 m²)Reduced LV systolic function (EF <0.40)Early postinfarction anginaPCI within 6 moPrior CABGGRACE risk score 109–140; TIMI score ≥2

Take home messages ACS is very important health problem and is

the leading cause of death allover the world The management of ACS had been improved

markedly in the last 3 decades by the use of antithrombotics and improved PCI techniques and devices

Early diagnosis and risk stratification is the corner stone of successful management of this disorder

The use of risk scores help the treating physician to select the best line of treatment for those patients and in the proper time

Take home messages ACS is a dynamic process that need

continuous reevaluation and follow up Predischarge risk assessment is important

especially in low and moderate risk patient treated by conservative strategy

Accurate risk stratification is very important to avoid over or under treatment

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