Unstable angina non ST elevation myocardial infarction risk stratification and prognosis
| Unstable angina pectoris | |
 | |
|---|---|
| Plaque rupture in a coronary artery at arrows yielding obstructive thrombus in red. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology | |
| ICD-10 | I20 |
| ICD-9 | 413 |
| DiseasesDB | 8695 |
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| MeSH | D000787 |
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Synonyms and related keywords: progressive angina, crescendo angina, accelerating angina, new-onset angina, pre-infaction angina, unstable angina pectoris, UAP, UA
Prognosis of Unstable Angina Pectoris
The incidence of ischemic complications and the risk of death in unstable angina pectoris is lower than that of patients with either non ST elevation myocardial infarction (NSTEMI) or that or patients with ST segment elevation myocardial infarction (STEMI) but higher than that of patients with chronic stable angina pectoris. The presence of congestive heart failure, new or worsening mitral regurgitation and hypotension (especially during episodes of ischemia) are important determinants of prognosis. The greater the magnitude and duration of EKG changes, the poorer the prognosis.
Risk Stratification of the Patient with Unstable Angina Pectoris
There are several scoring systems which have been devised as methods of identifying high-risk patients presenting with acute coronary syndrome (ACS). These include, among others, the Braunwald classification system [1], the Rizik classification system,[2] the TIMI risk score,[3] [4] the GRACE risk score [5] [6] and the PURSUIT risk score.[7] [8] [9] [10] [11]
TIMI Risk Score
The TIMI Risk Score for UA/non-ST-elevation myocardial infarction (NSTEMI) is based on the TIMI 11B and ESSENCE trials and has been shown to be predictive of all-cause mortality, myocardial infarction, and severe recurrent myocardial ischemia prompting urgent revascularization for the first 14 days after presentation. It has also been validated as a tool for 30-day risk stratification of patients presenting to the emergency room with chest pain. [4] It is very likely the most commonly used tool for risk-stratification as it is the easiest to understand and use of those listed.
The TIMI risk score is determined by the sum of the presence of 7 variables at admission; 1 point is given for each of the following variables:[12]
- Age 65 years or older
- At least 3 risk factors for coronary artery disease
- Prior coronary artery stenosis of 50% or more
- ST segment deviation on EKG presentation
- At least 2 anginal events in prior 24 h
- Use of aspirin in prior 7 days
- Elevated serum levels of cardiac biomarkers
In TIMI risk scoring, prior coronary stenosis of 50% or more remained relatively insensitive to missing information and remained a significant predictor of events. [13] [14]
Incidence of Adverse Events (all-cause mortality, myocardial infarction, and severe recurrent myocardial ischemia prompting urgent revascularization for the first 14 days after presentation)
- TIMI Risk Score 0/1: 4.7%
- TIMI Risk Score 2: 8.3%
- TIMI Risk Score 3: 13.2%
- TIMI Risk Score 4: 19.9%
- TIMI Risk Score 5: 26.2%
- TIMI Risk Score 6/7: 40.9%
Braunwald Classification
The Braunwald Classification of unstable angina pectoris (UAP) stratifies patients according to both the type of anginal pain and the underlying cause of the pain. Increasing class is associated with increasing risk of both recurrent ischemia and death at 6 months.
Characteristics
- Class I: Exertional angina (new onset, severe, or accelerated; angina of less than 2 months duration; more frequent angina; angina precipitated by less exertion; no rest angina in the last 2 months)
- Class II: Rest angina, subacute (rest angina within the last month but none within 48 hours of presentation)
- Class III: Rest angina, acute (rest angina within 48 hours of presentation)
Clinical Circumstances
- Class A: Secondary unstable angina (caused by a noncardiac condition such as anemia, infection, thyrotoxicosis or hypoxemia)
- Class B: Primary unstable angina
- Class C: Post-infarction unstable angina (within 2 weeks of documented myocardial infarction)
Rizik Classification Scheme
The Rizik classification scheme of UAP has been shown to be predictive of in-hospital adverse cardiac events and as such could be used to make decisions regarding hospitalization and intensity of treatment.[2]
- Class IA: Acceleration of previously existent chronic stable angina without new EKG changes
- Class IB: Acceleration of previously existent chronic stable angina with new EKG changes
- Class II: Exertional angina of new onset without respect to EKG morphology
- Class III: New onset resting angina (either with or without history of prior stable angina)
- Class IV: Patients with protracted chest pain of > 20 minutes with EKG changes
The PURSUIT Risk Score
The PURSUIT Risk score has been shown to be predictive of the 30-day incidence of death and the composite of death or myocardial (re)infarction in patients presenting with UA/NSTEMI (patients with ACS but without ST-elevation myocardial infarction). Points are given for each of the 7 below risk factors. The points are then summed to provide a risk score which can then be converted to a probability of either death or a composite of death or MI (from 0% to 50% depending on total points). [7]
- Age (increased probability for age above 60 and above)
- Gender (increased probability for men, no increased probability for women)
- Worst Canadian Cardiovascular Society Classification for angina pectoris in the previous 6 weeks (from angina only during very strenuous activity (Class I) to angina at rest (Class IV), increased probability for Class III or IV)
- Heart rate (increased probability for heart rate 100 and above)
- Systolic blood pressure (increased probability for systolic blood pressure 100 and below)
- Signs of heart failure (i.e., rales)
- ST-segment depression on presenting EKG
GRACE risk models
The GRACE model has been shown to be predictive of in-hospital mortality for patients presenting with ACS. The 8 risk factors listed below were shown to be the most strongly predictive. A probability of in-hospital death can be assigned by adding up the points allocated for each risk factor (range from <0.2% for less than 61 points to > 51% for more than 249 points). This model was validated as a tool to predict 6-month mortality in patients who survived hospital admission for ACS as well.[15]
- Increasing age (0-100 points)
- Increasing Killip class (0-59 points)
- Decreasing systolic blood pressure (0-58 points)
- ST-segment deviation (28 points)
- Cardiac arrest during presentation (39 points)
- Increasing serum creatinine level (1-28 points)
- Elevated initial cardiac enzymes (14 points)
- Increasing heart rate (0-46 points)
References
- ↑ Lee, DS & Roe, MT (2004). Unstable angina and non-ST-elevation myocardial infarction, In Griffin & Topol Eds, Manual of Cardiovascular Medicine, 2nd ed. Lippincott Williams & Williams: Philadelphia, PA, pp 27-44. ISBN 9780781759984
- ↑ 2.0 2.1 Rizik DG, Healy S, Margulis A, Vandam D, Bakalyar D, Timmis G, Grines C, O'Neill WW, Schreiber TL. A new clinical classification for hospital prognosis of unstable angina pectoris. Am J Cardiol. 1995 May 15;75(15):993-7. PMID 7747701
- ↑ Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000; 284: 835–42. PMID 10938172
- ↑ 4.0 4.1 Pollack CV Jr, Sites FD, Shofer FS, Sease KL, Hollander JE. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med. 2006 Jan;13(1):13-8. Epub 2005 Dec 19. PMID 16365321
- ↑ Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, Van De Werf F, Avezum A, Goodman SG, Flather MD, Fox KA; Global Registry of Acute Coronary Events Investigators. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003 Oct 27;163(19):2345-53. PMID 14581255
- ↑ Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, Goodman SG, Granger CB, Steg PG, Gore JM, Budaj A, Avezum A, Flather MD, Fox KA; GRACE Investigators. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. JAMA. 2004 Jun 9;291(22):2727-33. PMID 15187054
- ↑ 7.0 7.1 Boersma E, Pieper KS, Steyerberg EW, Wilcox RG, Chang WC, Lee KL, Akkerhuis KM, Harrington RA, Deckers JW, Armstrong PW, Lincoff AM, Califf RM, Topol EJ, Simoons ML. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation. 2000 Jun 6;101(22):2557-67. PMID 10840005
- ↑ Lindahl B, Diderholm E, Lagerqvist B, et al: Mechanisms behind the prognostic value of troponin T in unstable coronary artery disease: A FRISC II substudy. J Am Coll Cardiol 2001; 38:979-986.* Lenderink T, Boersma E, Heeschen C, et al: Elevated troponin T and C-reactive protein predict impaired outcome for 4 years in patients with refractory unstable angina, and troponin T predicts benefit of treatment with abciximab in combination with PTCA. Eur Heart J 2003; 24:77-85. PMID 11583868
- ↑ Heeschen C, Hamm CW, Bruemmer J, Simoons ML, for the Chimeric c7E3 AntiPlatelet Therapy in Unstable angina REfractory to standard treatment trial (CAPTURE) Investigators: Predictive value of C-reactive protein and troponin T in patients with unstable angina: A comparative analysis. J Am Coll Cardiol 2000; 35:1535-1542. PMID 10807457
- ↑ Gibson CM, Pinto DS, Murphy SA, et al: Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality. J Am Coll Cardiol 2003; 42:1535-1543. PMID 14607434
- ↑ The RISC Group: Risk of myocardial infarction and death during treatment with low-dose aspirin and intravenous heparin in men with unstable coronary artery disease. Lancet 1990; 336:827-830. PMID 1976875
- ↑ Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000; 284: 835–42. PMID 10938172
- ↑ Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). Circulation 2007 116: e148 – e304. PMID 17679616
- ↑ Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738
- ↑ Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, Goodman SG, Granger CB, Steg PG, Gore JM, Budaj A, Avezum A, Flather MD, Fox KA; GRACE Investigators. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. JAMA. 2004 Jun 9;291(22):2727-33. PMID 15187054