The Living Guidelines: UA/NSTEMI Recommendations for Early Risk Stratification Suggest Revisions to the CLASS I Guidelines

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Class I Guidelines

 * 1) A rapid clinical determination of the likelihood risk (i.e., high, intermediate, or low) of obstructive coronary artery disease (CAD) should be made in all patients with chest discomfort or other symptoms suggestive of an ACS and considered in patient management. (Level of Evidence: C)
 * 2) Patients who present with chest discomfort or other ischemic symptoms should undergo early risk stratification for the risk of cardiovascular events (e.g., death, first or recurrent myocardial infarction) that focuses on history, including anginal symptoms, physical findings, ECG findings, and biomarkers of cardiac injury, and results should be considered in patient management. (Level of Evidence: C)
 * 3) A 12-lead ECG should be performed and shown to an experienced emergency physician as soon as possible after ED arrival, with a goal of within 10 min of ED arrival for all patients with chest discomfort (or anginal equivalent) or other symptoms suggestive of ACS. (Level of Evidence: B)
 * 4) If the initial ECG is not diagnostic but the patient remains symptomatic and there is high clinical suspicion for ACS, serial ECGs, initially at 15 to 30 min intervals, should be performed to detect the potential for development of ST segment elevation or depression. (Level of Evidence: B)
 * 5) Cardiac biomarkers should be measured in all patients who present with chest discomfort consistent with ACS. (Level of Evidence: B)
 * 6) A cardiac specific troponin is the preferred marker, and if available, it should be measured in all patients who present with chest discomfort consistent with ACS. (Level of Evidence: B)
 * 7) Patients with negative cardiac biomarkers within 6 h of the onset of symptoms consistent with ACS should have biomarkers remeasured in the time frame of 8 to 12 h after symptom onset. (The exact timing of serum marker measurement should take into account the uncertainties often present with the exact timing of onset of pain and the sensitivity, precision, and institutional norms of the assay being utilized as well as the release kinetics of the marker being measured.) (Level of Evidence: B)
 * 8) The initial evaluation of the patient with suspected ACS should include the consideration of non coronary causes for the development of unexplained symptoms. (Level of Evidence: C)