Risk Stratification

Patient symptoms, past medical history, ECG, and biomarkers, particularly troponins, are utilized to stratify patients into low, medium, or high risk of death, MI, or likelihood of failing pharmacotherapy and needing urgent coronary angiography and percutaneous coronary intervention (PCI). Initial treatment according to risk stratification is depicted in Figure 8—1. Patients with STE are at the highest risk of death. Initial treatment of STE ACS should proceed without evaluation of the troponins, as these patients have a greater than 97% chance of having an MI subsequently diagnosed with biochemical markers. The ACC/AHA define a target time to initiate reperfusion treatment as within 30 minutes of hospital presentation for fibrinolytics (e.g., streptokinase, alteplase, reteplase, and tenecteplase) and within 90 minutes or less from presentation for primary PCI. The sooner the infarct-related coronary artery is opened for these patients, the lower their mortality and the greater the amount of

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myocardium that is preserved. ' While all patients should be evaluated for reperfusion therapy, not all patients may be eligible. Indications and contraindications for fibrinolytic therapy are described in the treatment section of this chapter. Less than 25% of hospitals in the United States are equipped to perform primary PCI. If patients are not eligible for reperfusion therapy, additional pharmacotherapy for STE patients should be initiated in the emergency department and the patient transferred to a coronary intensive care unit. The typical length of stay for a patient with uncomplicated STE MI is less than 4 days.

Risk-stratification of the patient with NSTE ACS is more complex, as in-hospital outcomes for this group of patients varies with reported rates of death of 0% to 12%,

reinfarction rates of 0% to 3%, and recurrent severe ischemia rates of 5% to 20%. Not all patients presenting with suspected NSTE ACS will even have CAD. Some

will eventually be diagnosed with nonischemic chest discomfort. In general, among NSTE patients, those with ST-segment depression (Fig. 8—1) and/or elevated biomarkers are at higher risk of death or recurrent infarction.

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