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A simple, readily available method for risk stratification of patients with unstable angina and non-ST elevation myocardial infarction

      The rationale for risk stratification of patients with unstable angina and non-ST elevation myocardial infarction (MI) includes the identification of patients at higher risk of recurrent events after index presentation to enable clinicians to triage patients to the most appropriate level of care in the inpatient or outpatient setting, and optimize the use of medications, revascularization options, and length of stay. Prior studies have shown that a variety of variables predict risk of clinical events, including the following: clinical criteria such as age and history of coronary artery disease
      • Braunwald E.
      Unstable angina a classification.
      ,
      • Rizik D.G.
      • Healy S.
      • Margulis A.
      • Vandam D.
      • Bakalyar D.
      • Timmis G.
      • Grines C.
      • O’Neill W.W.
      • Schreiber T.L.
      A new clinical classification for hospital prognosis of unstable angina pectoris.
      ; ST-segment changes on admission electrocardiogram or Holter monitor
      • Bugiardini R.
      • Borghi A.
      • Pozzati A.
      • Ruggeri A.
      • Puddu P.
      • Maseri A.
      Relation of severity of symptoms to transient myocardial ischemia and prognosis in unstable angina.
      ,
      • Cannon C.P.
      • McCabe C.H.
      • Stone P.H.
      • Rogers W.J.
      • Schactman M.
      • Thompson B.W.
      • Pearce D.J.
      • Diver D.J.
      • Kells C.
      • Feldman T.
      • Williams M.
      • Gibson R.S.
      • Kronenberg M.W.
      • Ganz L.I.
      • Anderson H.V.
      • Braunwald E.
      The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction results of the TIMI III registry ECG ancillary study.
      ; detection of serum cardiac markers such as creatine kinase, creatine kinase- MB fraction, myoglobin, or cardiac-specific troponins
      • Hamm C.W.
      • Ravkilde J.
      • Gerhardt W.
      • Jørgensen P.
      • Peheim E.
      • Ljungdahl L.
      • Goldman B.
      • Katus H.
      The prognostic value of serum troponin T in unstable angina.
      ,
      • Lindahl B.
      • Venge P.
      • Wallentin L.
      FRISC Study Group
      Relation between troponin T and the risk of subsequent cardiac events in unstable coronary artery disease.
      ,

      Antman EM, Tanasijevic MJ, Thompson B, Schactman M, McCabe CH, Cannon CP, Fischer GA, Fung AY, Thompson C, Wybenga D, Braunwald E. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996;335:18:1342–1349.

      ,
      • Ohman E.M.
      • Armstrong P.W.
      • Christenson R.H.
      • Granger C.B.
      • Katus H.A.
      • Hamm C.W.
      • O’Hanesian M.A.
      • Wagner G.S.
      • Kleiman N.S.
      • Harrell F.E.
      • Califf R.M.
      • Topol E.J.
      GUSTO-IIa Investigators
      Cardiac troponin T levels for risk stratification in acute myocardial ischemia.
      ,
      • Galvani M.
      • Ottani F.
      • Ferrini D.
      • Ladenson J.H.
      • Destro A.
      • Baccos D.
      • Rusticali F.
      • Jaffe A.S.
      Prognostic influence of elevated values of cardiac troponin I in patients with unstable angina.
      ,
      • Lüscher M.S.
      • Thygesen K.
      • Ravkilde J.
      • Heickendorff L.
      TRIM Study Group
      Applicability of cardiac troponin T and I for early risk stratification in unstable coronary artery disease.
      ,
      • Morrow D.A.
      • Antman E.M.
      • Tanasijevic J.
      • Rifai N.
      • de Lemos J.A.
      • McCabe C.H.
      • Cannon C.P.
      • Braunwald E.
      Cardiac troponin I for stratification of early outcomes and the efficacy of enoxaparin in unstable angina a TIMI 11B sub-study.
      ; detection in the serum of other biochemical markers such as fibrinogen and C-reactive protein,
      • Liuzzo G.
      • Biasucci L.M.
      • Gallimore J.R.
      • Grillo R.L.
      • Rebuzzi A.G.
      • Pepys M.B.
      • Maseri A.
      The prognostic value of C-reactive protein and serum amyloid A protein in severe unstable angina.
      ,
      • Toss H.
      • Lindahl B.
      • Siegbahn A.
      • Wallentin L.
      FRISC Study Group
      Prognostic influence of increased fibrinogen and c-reactive protein levels in unstable coronary artery disease.
      and nuclear imaging modalities.
      • Hilton T.C.
      • Thompson R.C.
      • Williams H.J.
      • Saylors R.
      • Fulmer H.
      • Stowers S.A.
      Technetium-99m sestamibi myocardial perfusion imaging in the emergency room evaluation of chest pain.
      Detailed statistical models have been created that integrate these variables noted above in a number of trials.
      • Cannon C.P.
      • Thompson B.
      • McCabe C.H.
      • Mueller H.S.
      • Kirshenbaum J.M.
      Predictors of non-Q-wave acute myocardial infarction in patients with acute ischemic syndromes an analysis from the Thrombolysis in Myocardial Ischemia (TIMI) III trial.
      ,
      • Van Miltenburg-van Zijl A.J.M.
      • Simoons M.L.
      • Veerhoek R.J.
      • Bossuyt P.M.M.
      Incidence and follow-up of Braunwald subgroups in unstable angina pectoris.
      A more detailed risk score for the Thrombolysis In Myocardial Infarction (TIMI) 11B cohort has been developed.
      • Antman E.M.
      • Cohen M.
      • Bernink P.J.L.M.
      • McCabe C.H.
      • Horacek T.
      • Papuchis G.
      • Mautner B.
      • Corbalan R.
      • Radley D.
      • Braunwald E.
      The TIMI risk score for unstable angina/non ST elevation MI a new, simple, bedside scheme for prognostication and therapeutic decision-making at patient presentation.
      This risk score requires 7 predictor variables, several of which may not be known at patient presentation, and is subject to patient recall and may require time to obtain. We tested a simple risk stratification scheme using age, ST deviation on the admission electrocardiogram, and the detection of elevated levels of serum cardiac markers, and evaluated its clinical usefulness in TIMI 11B, a large contemporary trial of patients presenting with unstable angina and non-ST elevation MI.
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