This document discusses guidelines for the assessment and management of acute coronary syndromes (ACS). It defines ACS and describes the risk of mortality. Guidelines recommend initial evaluation including electrocardiograms and serial troponin levels to determine risk. Risk scores can further assess prognosis and help determine appropriate treatment, such as an early invasive strategy for high-risk patients. Accurate risk stratification is important to avoid over or under treatment of ACS.

1. By
Essam Mahfouz, MD
Professor of Cardiology, Mansoura University

2. Agenda
Introduction
Risk scores
Guidelines
Value of risk stratification
 take home messages

3. Introduction
Definitions
ACS has evolved as a useful operational
term that refers to a spectrum of conditions
compatible with acute myocardial ischemia
and/or infarction due to an abrupt
reduction in coronary blood flow
ACS is leading cause of death allover
the world

4. Introduction
Anginal pain in NSTE-ACS patients may have
the following presentations:
Prolonged (>20 min) anginal pain at rest;
New onset (de novo) angina (class II or III)
Recent destabilization of previously stable angina
with at least Class III (crescendo angina); or
Post-MI angina.

5. Acute Coronary Syndromes (top half)

6. Acute Coronary Syndromes (bottom half)

9. Initial assessment of ACS
ESC Guidelines 2015

10. Value of hsTroponin in ACS
ESC Guidelines 2015

11. Vascular
Damage
Inflammation
Myocyte Necrosis
Accelerated
Atherosclerosis
Hemodynamic Stress
HbA1c
Blood
glucose
CrCl
Microalbuminuria
Troponin
BNP, NT-proBNPhs-CRP, CD40L
Morrow DA, et al. Circulation. 2003;108:250-252.
Multimarker Strategy in ACS

12. Multimarker Approach: Troponin I, CRP, and
BNP to Predict 30-Day Mortality in ACS
Sabatine M, et al. Circulation. 2002;105:1760-1763.
OPUS-TIMI 16
1
1.8
3.5
6
0
1
2
3
4
5
6
0 1 2 3
No. of Elevated Biomarkers
TACTICS-TIMI 18
1
2.1
5.7
13
0
2
4
6
8
10
12
14
0 1 2 3
No. of Elevated Biomarkers
P=.014 P=.001
67 150 155 78
504 717 324 90
30DayMortality(%)
30-DayMortalityRelRisk

13. TIMI Risk Score For UA/NSTEMI
Antman EM, et al. JAMA. 2000;284:835-442. (with permission)
• Age >65 years
• >3CAD Risk Factors
• Prior Stenosis >50 %
• ST deviation
• >2 Anginal
events <24 hours
• ASA in last 7 days
• Elev Cardiac
Markers (CK-MB or
troponin)
4.7
8.3
13.2
19.9
26.2
40.9
0
10
20
30
40
50
0/1 2 3 4 5 6/7
D/MI/UrgRevasc(%)
Number of Risk Factors
Population (%): 4.3 17.3 32.0 29.3 13.0 3.4
C Statistic=0.65
c2 trend P<.001

14. 4.13.9
7.1
19.5
6.5
4.9
10.8
35.1
21.0
10.7
49.6
24.4
P<.001 P=.004 P<.001 P<.001
Scirica BM, et al. Am J Cardiol. 2002;90:303-305.
(with permission)
TIMI Risk Score vs Prognosis
in Unselected Patients (TIMI 3 Registry)
TRS 0-2 TRS 3-4 TRS 5-7
0%
10%
20%
30%
40%
50%
Death MI Death/MI Death/MI/RI
EventRateat1year(%)

17. Risk Scores
TIMI GRACE
History
Age
Hypertension
Diabetes
Smoking
↑ Cholesterol
Family history
History of CAD
Age
Presentation
Severe angina
Aspirin within 7 days
Elevated markers
ST-segment deviation
Heart rate
Systolic BP
Elevated creatinine
Heart failure
Cardiac arrest
Elevated markers
ST-segment deviation

20. Clinical Assessment and Initial Evaluation
Recommendations COR LOE
Patients with suspected ACS should be risk stratified
based on the likelihood of ACS and adverse outcome(s) to
decide on the need for hospitalization and assist in the
selection of treatment options.
I B
Patients with suspected ACS and high-risk features such
as continuing chest pain, severe dyspnea,
syncope/presyncope, or palpitations should be referred
immediately to the ED and transported by emergency
medical services when available.
I C
Patients with less severe symptoms may be considered
for referral to the ED, a chest pain unit, or a facility
capable of performing adequate evaluation depending on
clinical circumstances.
IIb C

21. Prognosis: Early Risk Stratification
Recommendations COR LOE
In patients with chest pain or other symptoms
suggestive of ACS, a 12-lead ECG should be performed
and evaluated for ischemic changes within 10 minutes of
the patient’s arrival at an emergency facility.
I C
If the initial ECG is not diagnostic but the patient remains
symptomatic and there is a high clinical suspicion for
ACS, serial ECGs (e.g., 15- to 30-minute intervals during
the first hour) should be performed to detect ischemic
changes.
I C
Serial cardiac troponin I or T levels (when a
contemporary assay is used) should be obtained at
presentation and 3 to 6 hours after symptom onset (see
Section 3.4, Class I, #3 recommendation if time of
symptom onset is unclear) in all patients who present
with symptoms consistent with ACS to identify a rising
and/or falling pattern of values.
I A

22. Prognosis: Early Risk Stratification (cont’d)
Recommendations COR LOE
Additional troponin levels should be obtained
beyond 6 hours after symptom onset (see Section
3.4, Class I, #3 recommendation if time of symptom
onset is unclear) in patients with normal troponin
levels on serial examination when changes on ECG
and/or clinical presentation confer an intermediate
or high index of suspicion for ACS.
I A
Risk scores should be used to assess prognosis in
patients with NSTE-ACS. I A
Risk-stratification models can be useful in
management.
IIa B

23. Prognosis: Early Risk Stratification (cont’d)
Recommendations COR LOE
It is reasonable to obtain supplemental ECG leads V7
to V9 in patients whose initial ECG is nondiagnostic
and who are at intermediate/high risk of ACS.
IIa B
Continuous monitoring with 12-lead ECG may be a
reasonable alternative in patients whose initial ECG is
nondiagnostic and who are at intermediate/high risk of
ACS.
IIb B
Measurement of B-type natriuretic peptide or N-
terminal pro–B-type natriuretic peptide may be
considered to assess risk in patients with suspected
ACS.
IIb B

25. ESC Guidelines
2015

27. Factors Associated With Appropriate Selection of Early Invasive
Strategy or Ischemia-Guided Strategy in Patients With NSTE-ACS
Immediate
invasive
(within 2 h)
Refractory angina
Signs or symptoms of HF or new or worsening mitral regurgitation
Hemodynamic instability
Recurrent angina or ischemia at rest or with low-level activities despite
intensive medical therapy
Sustained VT or VF
Ischemia-
guided
strategy
Low-risk score (e.g., TIMI [0 or 1], GRACE [<109])
Low-risk Tn-negative female patients
Patient or clinician preference in the absence of high-risk features
Early
invasive
(within 24
h)
None of the above, but GRACE risk score >140
Temporal change in Tn (Section 3.4)
New or presumably new ST depression
Delayed
invasive
(within
2572 h)
None of the above but diabetes mellitus
Renal insufficiency (GFR <60 mL/min/1.73 m²)
Reduced LV systolic function (EF <0.40)
Early postinfarction angina
PCI within 6 mo
Prior CABG
GRACE risk score 109–140; TIMI score ≥2

29. Take home messages
ACS is very important health problem and is the leading
cause of death allover the world
The management of ACS had been improved markedly in
the last 3 decades by the use of antithrombotics and
improved PCI techniques and devices
Early diagnosis and risk stratification is the corner stone of
successful management of this disorder
The use of risk scores help the treating physician to select
the best line of treatment for those patients and in the
proper time

30. Take home messages
ACS is a dynamic process that need continuous
reevaluation and follow up
Predischarge risk assessment is important especially
in low and moderate risk patient treated by
conservative strategy
Accurate risk stratification is very important to avoid
over or under treatment