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AcuteCoronarySyndromesEvaluationandRiskStratificationNewTerminologyinACSACS,acutecoronarysyndrome;MI,myocardialinfarction;UA,unstableangina;NSTEMI,non–ST-segmentelevationmyocardialinfarction;STEMI,ST-segmentelevationmyocardialinfarction;PCI,percutaneouscoronaryintervention.CannonCP.JThrombThrombolysis.1995;2:205-218.AntithromboticTherapyStableAnginaUnstableAnginaNon–Q-waveMIThrombolysisPrimaryPCIQ-waveMIMinutes-hoursDays-weeksSTEMIUA/NSTEMIAtherothrombosisNewtermOldtermPlaqueRuptureTroponinI(TnI),C-ReactiveProtein(CRP),andB-typeNatriureticPeptide(BNP)asDeterminantsof30-DayMortalityRisksinAcuteCoronaryIschemia:AMultimarkerApproachOPUS-TIMI1611.83.5601234560123No.ofElevatedBiomarkers30-DayMortalityRelativeRiskP=.014P<.001671501557850471732490SabatineM,etal.Circulation.2002;105:1760-1763.(withpermission)ProgressivemechanicalobstructionSecondaryUA(MVO2)Inflammation/infectionDynamicobstructionNonocclusivethrombusonpre-existingplaqueBraunwaldE.Circulation.1998;98:2219-2222.BraunwaldEtiologicClassificationofUAGUSTOIIb:Correlationof6-MonthMortalityWithBaselineECGFindingsinPatientsWithACSCumulativeMortality(%)02468100306090120150180DaysFromRandomizationT-waveinversionSTACSSTEMIwithfibrinolyticsGUSTO,GlobalUseofStrategiesToOpenOccludedArteriesinAcuteCoronarySyndromes;ECG,electrocardiogram;ACS,acutecoronarysyndrome;STEMI,ST-segmentelevationmyocardialinfarction.SavonittoS,etal.JAMA.1999;281:707-713.(withpermission)TIMI,thrombosisinmyocardialinfarction;UA,unstableangina;NSTEMI,non–ST-segmentelevationmyocardialinfarction;CAD,coronaryarterydisease.AntmanEM,etal.JAMA.2000;284:835-842.TIMIRiskScoreforUA/NSTEMI:7IndependentPredictors•Aged≥65years•≥3CADriskfactors•PriorCAD(stenosis>50%)•Aspirininlast7days•>2anginaleventsin≤24hours•STdeviation•Elevatedcardiacmarkers(CK-MBortroponin)TIMIRiskScoreForUA/NSTEMIAntmanEM,etal.JAMA.2000;284:835-442.(withpermission)•Age>65years•>3CADRiskFactors•PriorStenosis>50%•STdeviation•>2Anginalevents<24hours•ASAinlast7days•ElevCardiacMarkers(CK-MBortroponin)4.78.313.219.926.240.9010203040500/123456/7D/MI/UrgRevasc(%)NumberofRiskFactorsPopulation(%):4.317.332.029.313.03.4CStatistic=0.652trendP<.001P<.001P=.004P<.001P<.001SciricaBM,etal.AmJCardiol.2002;90:303-305.(withpermission)TIMIRiskScorevsPrognosisinUnselectedPatients(TIMI3Registry)TRS0-2TRS3-4TRS5-70%10%20%30%40%50%DeathMIDeath/MIDeath/MI/RIEventRateat1year(%)PrognosticValueofTroponinTorIinACS:AMeta-analysis1.96.76.420.80510152025DeathDeath/MI%RR3.9(2.9-5.3)RR3.8(2.6-5.5)No.Studies:136NegPos(TropI+T)36341849737322HeidenreichPA,JAmCollCardiol.2001;38:478-485.TIMIIIIB:TroponinILevelsPredictMortalityInUA/NSTEMI1.01.73.43.76.07.5024680to<0.40.4to<1.01.0to<2.02.0to<5.05.0to<9.0>9.08311741481346750RiskCardiacTroponinI(ng/ml)Ratio1.01.83.53.96.27.8Mortalityat42Days(%ofPatients)AntmanEA,etal.NEnglJMed.1996;335:1342-1349.(withpermission)LindahlB,etal.NEnglJMed.2000;343:1139-1147.(withpermission)PredictiveValueofTroponinTandhs-CRPforMortalityfromACSinFRISCSubstudy201000612182430364248CumulativeProbabilityofDeath(%)MonthsTroponinT>0.60µg/l(n=377)TroponinT0.60-0.59µg/l(n=367)TroponinT<0.60µg/l(n=173)P=.007P=.001CRP2-10mg/l(n=294)201000612182430364248CRP>10mg/l(n=309)CRP<2mg/l(n=314)P=.001P=.29CRPTroponinMonthsRiskStratificationWithCRPandTroponinTChiSquare:P=.00079.1%4.7%0.4%012345678910R...