Risk stratification of UA & NSTEMI

1. Risk Stratification of
UA/NSTEMI
Mohammad Atef Ebada, Msc

2. 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

3. 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.)

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

5. 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(

6. UA/NSTMI
Risk stratification

7. UA/NSTMI ischemic risk scores
1. TIMI risk score
2. PURSUIT score
3. FRISC score
4. GUSTO score
5. GRACE score

8. UA/NSTMI bleeding risk scores
1. CRUSADE score
2. ACUITY risk score
3. HAS-BLED score

9. Ischemic risk stratification

10. 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)

11. Mnemonic AMERICA
Age ≥ 65
Markers
ECG
Risk 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

12. PURSUIT score
(Platelet glycoprotein IIb/IIIa in unstable agina: Receptor Suppression Using Integrilin)
(1) Age, separate points for enrolment diagnosis
Decade [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.

13. FRISC score
(Fast Revascularisation in Instability in Coronary disease)
(1) Age ≥ 70 years
0
1
(2) Male sex
0
1
(3) Diabetes
0
1
(4) Previous MI
0
1
(5) ST depression on ECG 0
1
(6) Elevated Troponin levels 0
1
(7) Elevated Interleukin 6 or CRP 0
1Heart 2005; 91: 1074-52.

14. GUSTO score
(Global Utilization of Streptokinase and tissue Plasminogen Activator for Occluded Coronary Arteries)
(1) Age
50 - 59 2
60 - 69 4
70 - 79 6
≥ 80 8
(2) Clinical Hx
Prior HF 2
Prior stroke/TIA 2
Prior MI 1
(3) Vitals & Labs
HR ≥ 90 3
Elevated markers 3
Creatinine > 1.4 2
CRP > 20 2
CRP = 10-20 1
Anaemia 1Circulation 1998; 98: 1860-8.

15. 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 0
Creatinine
(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
Killip class
Class I 0
Class II 21
Class III 43
Class IV 64
Cardiac arrest at
admission 43
Elevated cardiac
markers 15
ST-segment
deviation 30
Eur Heart J 2005; 26 (9):865-872.

17. TIMI, PURSUIT, and GRACE risk
scores: sustained prognostic value and
interaction with revascularization in
NSTE ACS‐
Pedro de Araújo Gonçalves,
Jorge Ferreira,
Carlos Aguiar and
Ricardo Seabra-Gomes
Eur Heart J (May 2005) 26 (9):865-872.

18. Conclusion
The GRACE score was the best
for predicting the risk of death
or MI at 1 year after admission.

19. Bleeding risk stratification

21. 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.

22. 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.

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

30. ST-segment and T-wave morphologies
Suggestive of ischemic abnormalities
Cleveland clinic journal of medicine (June 2011), volume 78, no.6

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

32. 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

33. Secondary repolarization abnormalities
LVH
RVH
LBBB
RBBB
•ST segment and T wave move in the same direction
•Discordant to QRS
•Asymmetric T wave inversion

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

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

36. Posterior MI
V7 V8 V9

37. • NSTEMI
• Hypertrophic cardiomyopathy (apical HCM)
• Takotsubo cardiomyopathy (+ long QT)
• Intracranial hemorrhage
• Normal variant in Blacks
Global T-wave inversion

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

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

43. Take Home Messages
1. 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.

44. Thanks For You Attention….