The initial evaluation of patients with acute coronary syndromes should focus on an assessment of the risk of a cardiac ischemic event (death, myocardial infarction, or recurrent ischemia) in the ensuing days, weeks, and months, as well as the risk of a bleeding complication from intensive medical therapy or an invasive cardiac procedure. During the past 10 years, two risk-assessment algorithms have been developed for determining whether a patient is at high risk or at relatively low risk for having an ischemic event. With this information in hand, a treatment strategy can be individually tailored, thereby reducing the occurrence of such an event. The first of these algorithms, the Thrombolysis in Myocardial Infarction (TIMI) risk score,5 uses seven easily assessed variables to identify patients with acute coronary syndromes who are at risk for death, myocardial infarction, or recurrent ischemia within 14 days after hospitalization. These variables are an age of more than 65 years, three or more risk factors for atherosclerosis, known coronary artery disease, two or more episodes of anginal chest pain in the 24 hours before hospitalization, the use of aspirin in the 7 days before hospitalization, ST-segment deviation of 0.05 mV or more, and elevated serum markers for myocardial necrosis (troponin or creatine kinase MB). Patients with three or more of the seven variables are considered to be at high risk, whereas those with no more than two of the variables are considered to be at low risk.6 The second algorithm, the Global Registry of Acute Coronary Events (GRACE) risk model,7 uses eight variables to predict whether a patient will die or have a myocardial infarction in the hospital or in the next 6 months. These variables are age, Killip class (a classification of the severity of heart failure with myocardial infarction), systolic arterial pressure, ST-segment deviation, cardiac arrest during presentation, serum creatinine concentration, elevated serum markers for myocardial necrosis, and heart rate. Each variable is assigned a numerical score on the basis of its specific value, and the eight scores are added to yield a total score, which is applied to a reference nomogram to determine the patients risk. The GRACE application tool is available at outcomes-umassmed.org/grace. A comparison of the TIMI and GRACE risk algorithms concluded that either can be used effectively to predict the rates of death or myocardial infarction for a year after hospitalization for acute coronary syndromes
Posted on: Mon, 13 Oct 2014 10:40:21 +0000
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