ACS - risk stratification

2014-10-01T21:41:12Z

Danbeam: n=1635 not 16305 as was previously listed in your summary

==New Vancouver Chest Pain Rule==
*Useful for screening patient with low risk for ACS
*The old Vancouver chest pain rule was not properly validated<ref name="Vancouver Validation">Jalili M. Validation of the Vancouver Chest Pain Rule: a prospective cohort study. Acad Emerg Med. 2012 Jul;19(7):837-42.</ref><ref name="Vancouver Original">Christenson J. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006 Jan;47(1):1-10. </ref> <ref name="Vancouver Original"></ref>
*The new rule was validated in 2014 on 1635 patients and published in 2014<ref>Cullen L et al. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. Am J Emerg Med. 2014 Feb;32(2):129-34</ref>
*With '''high sensitivity troponins''' the '''sensitivity is 99.1%''' (95% CI 97.4-99.7), & '''specificity is 16.1''' (95% CI 14.2-18.2)
*With '''sensitive troponin-I''' the sensitivity was 98.8% (97.0-99.5), & specificity of 15.8 (13.9-17.9)

===Algorithm===
*Is the same for c-TnI assay and hs-TnI assay but sensitivity differences by a percentage point
#'''Is there an abnormal ECG, positive troponin at 2 hrs or prior ACS nitrate use?'''
#*If ''Yes'' to any then no early discharge
#'''Does palpation reproduce the pain?'''
#*If ''Yes'' then early discharge
#'''Age ≥50, or does pain radiate to neck, jaw, or left arm?'''
#*If ''Yes'' then no early discharge

*If answer is ''No'' to all of the above stepwise questions then the patient can have early discharge with close followup for further provocative testing

== Likelihood That Signs/Symptoms Represent ACS due to CAD==
{| class="wikitable"
|-
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Feature
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | High Likelihood (any of the following)
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Intermediate Likelihood (absence of high-likelihood features and presence of any of the following)
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Low Likelihood (absence of high- or intermediate-likelihood features but may have)
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="4" class="font12" | History
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Chest or left arm pain or discomfort as chief symptom reproducing prior documented angina
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Chest or left arm pain or discomfort as chief symptom
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Probable ischemic symptoms in absence of any of the intermediate-likelihood characteristics
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="3" class="font12" | Known history of coronary artery disease, including myocardial infarction
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Age >70 y old
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="3" class="font12" | Recent cocaine use
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Male sex
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Diabetes mellitus
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Examination
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Transient mitral regurgitation murmur, hypotension, diaphoresis, pulmonary edema, or rales
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Extracardiac vascular disease
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Chest discomfort reproduced by palpation
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="3" class="font12" | ECG
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="3" class="font12" | New, or presumably new, transient ST-segment deviation (1 mm or greater) or T-wave inversion in multiple precordial leads
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Fixed Q waves
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | T-wave flattening or inversion <1 mm in leads with dominant R waves
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | ST depression 0.5–1.0 mm or T-wave inversion >1 mm
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Normal ECG
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Cardiac markers
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Elevated cardiac troponin I, troponin T, or MB fraction of creatine kinase
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Normal
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Normal
|}

== Short-Term Risk of Death or Nonfatal Myocardial Infarction by Risk Stratification in Patients with Unstable Angina ==

{| class="wikitable"
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Feature
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | High Likelihood (at least one of the following features must be present)
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Intermediate Likelihood (no high-risk feature, but must have one of the following)
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Low Likelihood (no high- or intermediate-risk feature, but may have any of the following)
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | History
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Accelerating tempo of ischemic symptoms in preceding 48 h
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Prior myocardial infarction, peripheral or cerebrovascular disease, or coronary artery bypass grafting; prior aspirin use
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | —
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Character of the pain
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Prolonged ongoing (>20 min) rest pain
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Prolonged (>20 min) rest angina, now resolved, with moderate or high likelihood of CAD
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Increased angina frequency, severity, or duration
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Rest angina (>20 min) or relieved with rest or sublingual nitroglycerin
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Angina provoked at a lower threshold
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | New-onset angina with onset 2 wk to 2 mo before presentation
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Nocturnal angina
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | New-onset or progressive Canadian Cardiology Society Class III or IV angina in the past 2 wk without prolonged (>20 min) rest pain but with intermediate or high likelihood of CAD;
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" |  
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Clinical findings
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Pulmonary edema, most likely due to ischemia
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Age >70 y old
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="5" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Chest discomfort reproduced by palpation
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | New or worsening mitral regurgitation murmur
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | S<sub>3</sub> or new/worsening rales<br> 
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Hypotension, bradycardia, tachycardia
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Age >75 y old
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | ECG
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Angina at rest with transient ST-segment changes >0.5 mm
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | T-wave changes, pathologic Q waves, or resting ST depression <1 mm in multiple lead groups (anterior, inferior, lateral)
| bgcolor="#ffffff" align="left" valign="top" class="font12" rowspan="3" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Normal or unchanged ECG
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Bundle-branch block, new or presumed new
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Sustained ventricular tachycardia
|- class="font12" style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;"
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Cardiac markers
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Elevated cardiac TnT, TnI, or CK-MB (e.g., TnT or TnI >0.1 nanogram/mL)
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Slightly elevated cardiac TnT, TnI, or CK-MB (e.g., TnT >0.01 but <0.1 nanogram/mL)
| bgcolor="#ffffff" align="left" valign="top" class="font12" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" | Normal
|}

== TIMI Risk Stratification Score ==
{{TIMI Score}}

== See Also ==
*[[Acute Coronary Syndrome (Main)]]
*[[EBQ:ADAPT_Trial_2-Hour_Troponin_Rule_Out|ADAPT Trial]]

== Source ==
*2007 ACC/AHA Guidelines for the Management of Patients with UA/NSTEMI
*Walker N. Characteristics and outcomes of young adults who present to the emergency department with chest pain. Acad Emerg Med. 2001 Jul;8(7):703-8.
<references/>

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ACS - risk stratification