www.acc.org What's New? October 4 , 2001 Practice Guidelines: Atherosclerotic Cardiovascular Disease September 1 , 2001 Practice Guidelines: Atrial Fibrillation April 27 , 2001 Practice Guidelines: Percutaneous Coronary Intervention April 27 , 2001 Expert Consensus Document: Catheterization Laboratory Standard April 3 , 2001 Consensus Conference Report: Care of the Patient with Adult Congenital Heart Disease April 2 , 2001 Expert Consensus Document: Standards for Acquisition, Measurement and Reporting of Intravascular Ultrasound Studies March 1, 2001 Teaching Slides: ACC/AHA Guidelines for the Management of Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction January 1, 2001 Consensus Conference Report: Mechanical Cardiac Support 2000: Current Applications and Future Trial Design November 1, 2000 Clinical Competence Statement: Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion October 1, 2000 Clinical Competence Statement: Stress Testing September 1, 2000 Practice Guidelines: Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction September 1, 2000 Consensus Conference Report: Myocardial Infarction Redefined—A Consensus Document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction July 1, 2000 Expert Consensus Document: Electron-Beam Computed Tomography for the Diagnosis and Prognosis of Coronary Artery Disease June 1, 2000 Training Statement: Adult Cardiovascular Medicine (COCATS) Revised 6/00 Task Force #5: Training in Nuclear Cardiology
ACUTE CORONARY SYNDROME No ST Elevation ST Elevation Unstable Angina NQMI QwMI Myocardial In farction NSTEMI
The simplified criteria for Wellens' syndrome are as follows:
Prior history of chest pain
Little or no cardiac enzyme elevation
No pathologic precordial Q waves
Little or no ST-segment elevation
No loss of precordial R waves
Biphasic T waves in leads V 2 and V 3 or symmetric, often deeply inverted T waves in leads V 2 and V 3 .
Wellens' criteria are quite specific for left anterior descending artery disease. All of the patients (n=180) in his 1988 study had more than 50% narrowing of the left anterior descending artery (mean=85% narrowing) with complete or near-complete occlusion in 59%.
Clin Chem 1999: National Academy of Clinical Biochemistry Standards of Laboratory Practice: Recommendations for the Use of Cardiac Markers in Coronary Artery Diseases
Troponin I can be falsely elevated due to fibrin clot, heterophilic antibodies.
Use of 2 cut-offs point would require too much physician education…
AHA needs to better define NSTEMI due to important implication of being diagnosed with MI.
Figure 1. Plot of the appearance of cardiac markers in blood vs time after onset of symptoms. Peak A , early release of myoglobin or CK-MB isoforms after AMI; peak B , cardiac troponin after AMI; peak C , CK-MB after AMI; peak D , cardiac troponin after unstable angina. Data are plotted on a relative scale, where 1.0 is set at the AMI cutoff concentration.
Figure 1. TIMI Risk Score Rates of all-cause mortality, myocardial infarction, and severe recurrent ischemia prompting urgent revascularization through 14 days after randomization were calculated for various patient subgroups based on the number of risk factors present in the test cohort (the unfractionated heparin group in the Thrombolysis in Myocardial Infarction [TIMI] 11B trial; n = 1957) (see Table 1). Event rates increased significantly as the TIMI risk score increased ( P <.001 by 2 for trend).
Figure 2. Validation of TIMI Risk Score and Assessment of Treatment Effect According to Score Rates of all-cause mortality, myocardial infarction, and severe recurrent ischemia prompting urgent revascularization through 14 days after randomization were calculated for the enoxaparin and unfractionated heparin groups in the Thrombolysis in Myocardial Infarction (TIMI) 11B trial and the Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q-Wave MI trial (ESSENCE), based on the TIMI risk score. The pattern of increasing event rates with increasing TIMI risk score was confirmed in all 3 validation cohorts ( P <.001 by 2 for trend). C statistics were 0.65 for the unfractionated heparin group and 0.61 for the enoxaparin group in TIMI 11B; and 0.65 for the unfractionated heparin group and 0.59 for the enoxaparin group in ESSENCE. The rate of increase in events as more risk factors were present was significantly lower in the enoxaparin group in both studies (for TIMI 11B, P = .01; for ESSENCE, P = .03). Positive values for absolute risk difference (ARD) and number needed to treat to prevent 1 event (NNT) indicate calculations favoring enoxaparin, while negative values indicate calculations favoring unfractionated heparin.
That would make it a level…4 if we want to use it as a Clinical decision rule to know whether or not to use GP IIb/IIIa inhibitors.
TIMI Risk Calculator For Unstable Angina In the blue column, please enter the patient's age, and then answer each clinical question with a Y (for yes) or an N (for no). The patient's risk appears at the bottom of the blue column.