Cumulative Mortality (%)
10
ST ACS
8
STEMI with
6
fibrinolytics
4
T-wave
inversion
2
0
0
30
60
90
120
150
180
Days From Randomization
GUSTO, Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes; ECG, electrocardiogram; ACS, acute coronary syndrome; STEMI, ST-segment elevation myocardial infarction. Savonitto S, et al. JAMA. 1999;281:707-713. (with permission)
• ST deviation
• Elevated cardiac markers (CK-MB or troponin)
TIMI, thrombosis in myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation myocardial infarction; CAD, coronary artery disease. Antman EM, et al. JAMA. 2000;284:835-842.
30-Day Mortality Relative Risk
OPUS-TIMI 16
6
TACTICS-TIMI 18
6
P=.014
14
P<.001
13
5
12
4
3
2
1 1
0
67
3.5 1.8
150
155
10
8 5.7
6
4 2.1
2
1
78
0
504
717
324
90
0
1
2
3
No. of Elevated Biomarkers
Acute Coronary Syndromes Evaluation and Risk Stratification
New Terminology in ACS
Old term
Stable Angina
Unstable Angina
Plaque Rupture
Non–
Q-wave
Q-wave MI
Population (%): 4.3 17.3 32.0 29.3 13.0 3.4
Antman EM, et al. JAMA. 2000;284:835-442. (with permission)
TIMI Risk Score vs Prognosis in Unselected Patients (TIMI 3 Registry)
TIMI Risk Score for UA/NSTEMI: 7 Independent Predictors
• Aged ≥65 years
• ≥3 CAD risk factors
• Prior CAD (stenosis >50%)
• Aspirin in last 7 days
• >2 anginal events in ≤24 hours
MI
New term Atherothrombosis
Daysweeks
UA/NSTEMI
STEMI
Minuteshours
Antithrombotic Therapy
Thrombolysis Primary PCI
ACS, acute coronary syndrome; MI, myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation myocardial infarction; STEMI, ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention. Cannon CP. J Thromb Thrombolysis. 1995;2:205-218.
TIMI Risk Score For UA/NSTEMI
• Age >65 years • >3CAD Risk Factors
C Statistic=0.65 c2 trend P<.001
D/MI/Urg Revasc (%)
• Prior Stenosis >50 %
• ST deviation
• >2 Anginal events <24 hours
• ASA in last 7 days
50 40 30 20 10 4.7
40.9
26.2 19.9 13.2 8.3
• Elev Cardiac Markers (CK-MB or troponin)
0 0/1
2
3
4
5
6/7
Number of Risk Factors
Progressive mechanical obstruction
Dynamic obstruction
Secondary UA (b MVO2)
Inflammation/ infection
Braunwald E. Circulation. 1998;98:2219-2222.
GUSTO IIb: Correlation of 6-Month Mortality With Baseline ECG Findings in Patients Wiof Elevated Biomarkers
Sabatine M, et al. Circulation. 2002;105:1760-1763. (with permission)
Braunwald Etiologic Classification of UA
Nonocclusive thrombus on pre-existing plaque
Troponin I (TnI), C-Reactive Protein (CRP), and B-type Natriuretic Peptide (BNP) as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia: A Multimarker Approach