Risk Stratification of UA/NSTEMI

Mohammad Atef Ebada, Msc

And just long enough to cover what you need to cover

•A good presentation should be like a miniskirt…

As short as possible to catch everyone's attention

Risk Stratification• Definition: Medical decision-making The constellation of activities –e.g., lab

and clinical testing used to determine a person's risk for suffering a particular condition and need–or lack thereof–for preventive intervention

(McGraw-Hill Concise Dictionary of Modern Medicine © 2002 by The McGraw-Hill Companies, Inc.)

Risk Stratification• Definition: Formation of layers (strata) in which subjects are arranged according to their exposure to risk.

Benefits• Assessment of risk guides initial

evaluation, selection of the site of care (i.e. coronary care unit, intermediate care unit, inpatient monitored unit or regular unit) and therapy, including antithrombotic treatment and timing of coronary angiography

• Initiation of preventive strategies

(Roffi et Al. Eur Heart J 2015;eurheartj.ehv320)

UA/NSTMI Risk stratification

UA/NSTMI ischemic risk scores1. TIMI risk score2. PURSUIT score3. FRISC score4. GUSTO score5. GRACE score

UA/NSTMI bleeding risk scores

1. CRUSADE score2. ACUITY risk score3. HAS-BLED score

Ischemic risk stratification

TIMI risk score 7 possible risk factors:• Age ≥ 65 years• Documented coronary stenosis ≥ 50 % by angio.• ≥ 3 coronary risk factors ( Age > 45 (M) > 55 (F),

FH [CAD in first degree relatives, <55 (M) <65 (F)], HTN, High cholesterol, DM, current smoker)

• Aspirin use within 7 days• ST segment deviation ≥ 0.5 mm.• ≥ 2 episodes of angina within 24 hours• Elevated cardiac markers (MB or T)

(Antman EM et al: JAMA 2000;284:835-42)

Mnemonic AMERICAAge ≥ 65Markers

ECGRisk factors

Ischemia )≥ 2 episodes of angina within 24 hours( CAD )≥ 50 % stenosis(

Aspirin

Low risk = 1-2 risk factors Intermediate risk = 3-4 risk factors

High risk = 5-7 risk factors

PURSUIT score)Platelet glycoprotein IIb/IIIa in unstable agina: Receptor Suppression Using Integrilin(

(1) Age, separate points for enrolment diagnosisDecade [UA (MI)]

50 8 (11) 60 9 (12) 70 11 (13) 80 12 (14)(2) Sex Male 1 Female 0(3) Worst CCS-class in previous 6 weeks No angina or CCS I/II 0 CCS III/IV 2(4) Signs of heart failure 2(5) ST-depression on presenting ECG 1

Eur Heart J (May 2005) 26 (9):865-872.

FRISC score)Fast Revascularisation in Instability in Coronary disease(

(1) Age ≥ 70 years01

(2) Male sex 

01

(3) Diabetes 

01

(4) Previous MI 

01

(5) ST depression on ECG 01

(6) Elevated Troponin levels 01

(7) Elevated Interleukin 6 or CRP 01Heart 2005; 91: 1074-52.

GUSTO score)Global Utilization of Streptokinase and tissue Plasminogen Activator for Occluded Coronary Arteries(

(1) Age

 

50 - 59 260 - 69 470 - 79 6

≥ 80 8

(2) Clinical Hx 

Prior HF 2Prior stroke/TIA 2

Prior MI 1

(3) Vitals & Labs

HR ≥ 90 3Elevated markers 3Creatinine > 1.4 2

CRP > 20 2CRP = 10-20 1

Anaemia 1Circulation 1998; 98: 1860-8.

GRACE score)Global Registry of Acute Coronary Events(

Age (years)<40 0

 40–49 18 50–59 36 60–69 55 70–79 73

≥ 80 91

Heart rate (bpm)

<70 0 70–89 7 90–109 13 110–149 23 150–199 36

> 200 46

Systolic BP (mmHg)<80 63

 80–99 58 100–119 47 120–139 37 140–159 26 160–199 11

> 200 0Creatinine

(mg/dL)0.0- 0.39 2

 0.4–0.79 5 0.8–1.19 8 1.2–1.59 11 1.6–1.99 14 0.2–3.99 23

 <4 31

Killip classClass I 0Class II 21Class III 43Class IV 64

Cardiac arrest at admission 43Elevated cardiac markers 15ST-segment deviation 30

Eur Heart J 2005; 26 (9):865-872.

TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value

and interaction with revascularization in NSTE‐ACS

Pedro de Araújo Gonçalves ,Jorge Ferreira ,

Carlos Aguiar andRicardo Seabra-Gomes

Eur Heart J (May 2005) 26 (9):865-872.

Conclusion The GRACE score was the

best for predicting the risk of death or MI at 1 year after admission.

Bleeding risk stratification

ACUITY risk score)The Acute Catheterization and Urgent Intervention Triage strategy(

Six independent baseline predictors (i.e. female gender, advanced age, elevated serum creatinine, white blood cell count, anaemia and presentation as NSTEMI or STEMI) and one treatment- related variable [use of unfractionated heparin (UFH) and a glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitor rather than bivalirudin alone]

J Am Coll Cardiol 2010;55:2556–2566.

www.escardio.org/guidelines European Heart Journal (2010) 31, 2369-2429

The HAS-BLED bleeding risk score

*Hypertension is defined as systolic blood pressure > 160 mmHg.INR = international normalized ratio.

Cleveland clinic journal of medicine (June 2011), volume 78, no.6

ST-segment and T-wave morphologies Suggestive of ischemic abnormalities

Cleveland clinic journal of medicine (June 2011), volume 78, no.6

Normal pattern of T-wave inversions in a 2-year old boy

Persistent juvenile T-wave pattern

•T-wave inversion in V1–V3•Asymmetric T wave inversion•Young female )< 40 years old(•No other electrocardiographic or clinical abnormality

Secondary repolarization abnormalities

LVH

RVH

LBBB

RBBB•ST segment and T wave move in the same direction•Discordant to QRS•Asymmetric T wave inversion

Cleveland clinic journal of medicine (June 2011), volume 78, no.6

Cleveland clinic journal of medicine (June 2011), volume 78, no.6

Posterior MI

V7 V8 V9

• NSTEMI• Hypertrophic cardiomyopathy (apical HCM)• Takotsubo cardiomyopathy (+ long QT)• Intracranial hemorrhage• Normal variant in Blacks

Global T-wave inversion

(Roffi et Al. Eur Heart J 2015;eurheartj.ehv320)

(Roffi et Al. Eur Heart J 2015;eurheartj.ehv320)

Take Home Messages1. Every cardiologist should know how to risk stratify his patients.2. Simple bed side score like TIMI score can

stratify patients in low, intermediate and high risk patients

3. Further risk scoring with GRACE score identifies in-hospital and post discharge mortality.

4. Assessment of bleeding with CRUSADE score is a must before initiation of therapy.

Thanks For You Attention.…