Unstable Angina / Non ST Elevation Myocardial Infarction: Risk Stratification and Prognosis
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There are several scoring systems which have been devised as methods of identifying high-risk patients presenting with acute coronary syndrome (ACS). These include, among others, the Braunwald classification system (Lee & Roe, 2004), the Rizik classification system,rizikref1 the TIMI risk score,antmanref1, pollackref1 the GRACE risk scoregrangerref1, eagleref1 and the PURSUIT risk score.boersmaref1
Braunwald Classification of UA (Lee & Roe, 2004)
The Braunwald Classification of Unstable Angina (UA) stratifies patients according to both the type of anginal pain and the underlying cause of the pain. Increasing class is associated with increasing risk of both recurrent ischemia and death at 6 months.
Characteristics
- Class I: Exertional angina (new onset, severe, or accelerated; angina of less than 2 months duration; more frequent angina; angina precipitated by less exertion; no rest angina in the last 2 months)
- Class II: Rest angina, subacute (rest angina within the last month but none within 48 hours of presentation)
- Class III: Rest angina, acute (rest angina within 48 hours of presentation)
Clinical Circumstances
- Class A: Secondary unstable angina (caused by a noncardiac condition such as anemia, infection, thyrotoxicosis or hypoxemia)
- Class B: Primary unstable angina
- Class C: Post-infarction unstable angina (within 2 weeks of documented myocardial infarction)
Rizik Classification Schemerizikref1
The Rizik classification scheme of UA has been shown to be predictive of in-hospital adverse cardiac events and as such could be used to make decisions regarding hospitalization and intensity of treatment.
- Class IA: Acceleration of previously existent chronic stable angina without new EKG changes
- Class IB: Acceleration of previously existent chronic stable angina with new EKG changes
- Class II: Exertional angina of new onset without respect to EKG morphology
- Class III: New onset resting angina (either with or without history of prior stable angina)
- Class IV: Patients with protracted chest pain of > 20 minutes with EKG changes
TIMI Risk Scoreantmanref1
The TIMI Risk Score for UA/non-ST-elevation myocardial infarction (NSTEMI) is based on the TIMI 11B and ESSENCE trials and has been shown to be predictive of all-cause mortality, myocardial infarction, and severe recurrent myocardial ischemia prompting urgent revascularization for the first 14 days after presentation. It has also been validated as a tool for 30-day risk stratification of patients presenting to the emergency room with chest pain.pollackref1 It is very likely the most commonly used tool for risk-stratification as it is the easiest to understand and use of those listed.
Scoring System (one point is given for each of the following risk factors, with a total of 7 points possible)
- age > 65 years
- presence of 3 or more risk factors for coronary artery disease (CAD) (family history of CAD, hypertension, hypercholesterolemia, diabetes, current smoker)
- prior coronary stenosis of at least 50%
- presence of ST-segment deviation on admission EKG
- at least 2 episodes of angina in the past 24 hours
- prior use of aspirin in the past 7 days
- elevated cardiac biomarkers (creatine kinase MB fraction or troponin)
Incidence of Adverse Events (all-cause mortality, myocardial infarction, and severe recurrent myocardial ischemia prompting urgent revascularization for the first 14 days after presentation)
- TIMI Risk Score 0/1: 4.7%
- TIMI Risk Score 2: 8.3%
- TIMI Risk Score 3: 13.2%
- TIMI Risk Score 4: 19.9%
- TIMI Risk Score 5: 26.2%
- TIMI Risk Score 6/7: 40.9%
The GRACE Prediction Modelgrangerref1
The GRACE model has been shown to be predictive of in-hospital mortality for patients presenting with ACS. The 8 risk factors listed below were shown to be the most strongly predictive. A probability of in-hospital death can be assigned by adding up the points allocated for each risk factor (range from <0.2% for less than 61 points to > 51% for more than 249 points). This model was validated as a tool to predict 6-month mortality in patients who survived hospital admission for ACS as well.eagleref1
- increasing age (0-100 points)
- increasing Killip class (0-59 points)
- decreasing systolic blood pressure (0-58 points)
- ST-segment deviation (28 points)
- cardiac arrest during presentation (39 points)
- increasing serum creatinine level (1-28 points)
- elevated initial cardiac enzymes (14 points)
- increasing heart rate (0-46 points)
The PURSUIT Risk Scoreboersmaref1
The PURSUIT Risk score has been shown to be predictive of the 30-day incidence of death and the composite of death or myocardial (re)infarction in patients presenting with UA/NSTEMI (patients with ACS but without ST-elevation myocardial infarction). Points are given for each of the 7 below risk factors. The points are then summed to provide a risk score which can then be converted to a probability of either death or a composite of death or MI (from 0% to 50% depending on total points).
- Age (increased probability for age above 60 and above)
- Gender (increased probability for men, no increased probability for women)
- Worst Canadian Cardiovascular Society Classification for angina pectoris in the previous 6 weeks (from angina only during very strenuous activity (Class I) to angina at rest (Class IV), increased probability for Class III or IV)
- Heart rate (increased probability for heart rate 100 and above)
- Systolic blood pressure (increased probability for systolic blood pressure 100 and below)
- Signs of heart failure (i.e., rales)
- ST-segment depression on presenting EKG
References
<biblio>
- rizikref1 pmid=7747701
- pollackref1 pmid=16365321
- grangerref1 pmid=14581255
- eagleref1 pmid=15187054
- boersmaref1 pmid=10840005
- antmanref1 pmid=10938172
</biblio> Lee, DS & Roe, MT (2004). Unstable angina and non-ST-elevation myocardial infarction, In Griffin & Topol Eds, Manual of Cardiovascular Medicine, 2nd ed. Lippincott Williams & Williams: Philadelphia, PA, pp 27-44.
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
