Skip to main content
PMC home page
Annals of Noninvasive Electrocardiology logoLink to Annals of Noninvasive Electrocardiology
. 2006 Oct 27;6(1):64–75. doi: 10.1111/j.1542-474X.2001.tb00088.x

Clinical, Electrocardiographic, and Biochemical Data for Immediate Risk Stratification in Acute Coronary Syndromes

Stefano Savonitto 1,✉, Rossana Fusco 1, Christopher B Granger 2, Mauricio G Cohen 3, Trevor D Thompson 2, Diego Ardissino 4, Robert M Califf 2
PMCID: PMC7027624  PMID: 11174865

Abstract

The recent evolution in therapeutic options for acute coronary syndromes (ACS) mandates early risk stratification in order to select the appropriate treatment strategy for individual patients. Simple clinical data derived from the patient's medical history and physical examination, a standard twelve‐lead electrocardiogram (ECG), and determinations of biochemical markers of myocardial damage can be obtained in the emergency room and serve as a guide for deciding appropriate medical management and optimal use of available resources. Even the most important classification of the ACS is based upon a simple and dichotomous description of the ECG, where the presence of ST‐segment elevation mandates an immediate attempt to restore coronary perfusion (either pharmacologically or mechanically), whereas its absence suggests pharmacological stabilization before further evaluation. Across the whole spectrum of ACS, clinical history data (such as older age, previous coronary events, and diabetes) and clinical variables (such as higher heart rate, lower blood pressure, and higher Killip class) are the most powerful prognostic determinants at multivariate analyses derived from large databases. The ECG adds significant and independent prognostic information using the analysis of qualitative (direction of ST‐segment shift, associated T‐wave inversion, and presence of conduction disturbances) and quantitative (number of leads involved, amount of ST‐ segment shifts, duration of QRS) characteristics. Biochemical markers of myocardial damage have also been identified as independent predictors of events. In addition, retrospective analyses of clinical trials have suggested that biochemical markers might serve as a guide to select pharmacological therapy. However, how to best combine electrocardiographic and biochemical data for immediate risk stratification remains to be further elucidated. A.N.E. 2001;6(1):64–77

Keywords: acute coronary syndromes, prognosis, electrocardiogram, multivariate analysis

REFERENCES

  • 1. Volpi A, de Vita C, Franzosi MG, et al. Determinants of 6‐month mortality in survivors of MI after thrombolysis. Results of the GISSI‐2 data base. Circulation 1993;88: 416–429. [DOI] [PubMed] [Google Scholar]
  • 2. Lee KL, Woodlief LH, Topol EJ, et al, for the GUSTO‐I Investigators. Predictors of 30‐day mortality in the era of reperfusion for acute MI: Results from an international trial of 41021 patients. Circulation 1995;91: 1659–1668. [DOI] [PubMed] [Google Scholar]
  • 3. The Global Use of Strategies to Open Occluded Coronary arteries (GUSTO) lib Investigators. A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. N Engl J Med 1996;335: 775–782. [DOI] [PubMed] [Google Scholar]
  • 4. The PURSUIT Trial Investigators . Inhibition of platelet glycoprotein IIb/IIIa with eptinbatide in patients with acute coronary syndromes. N Engl J Med 1998;339:436–437. [DOI] [PubMed] [Google Scholar]
  • 5. OASIS‐2 Investigators. Effects of recombinant hirudin (lepirudin) compared with heparin on death, MI, refractory angina, and revascularization procedures in patients with acute myocardial ischemia without ST elevation: a randomized trial. Lancet 1999;353: 429–438. [PubMed] [Google Scholar]
  • 6. Fibrinolytic Therapy Trialists (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute Ml: Collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. Lancet 1994;343: 311–322. [PubMed] [Google Scholar]
  • 7. Califf RM, Mark DM. Clinical presentation and diagnostic techniques In Fuster V, Ross R, Topol EJ. (eds.): Atherosclerosis and Coronary Artery Disease. Philadelphia : Lippincott‐Raven, 1996, pp. 1299–1314. [Google Scholar]
  • 8. Klein LW, Helfant RH. The Q‐wave and non‐Q wave MI: Differences and similarities. Progr Cardiovasc Dis 1986;29:205–220. [DOI] [PubMed] [Google Scholar]
  • 9. Joint International Society and Federation of Cardiology/World Health Organization Task Force. Nomenclature and criteria for diagnosis of ischemic heart disease. Circulation 1979;59: 707–709. [DOI] [PubMed] [Google Scholar]
  • 10. Gillum R, Fortmann S, Prineas R, et al. International diagnostic criteria for acute MI and acute stroke. Am J Cardiol 1984;108:150–158. [DOI] [PubMed] [Google Scholar]
  • 11. Armstrong PW, Fu Y, Chang WC, et al. Acute coronary syndromes in the GUSTO‐IIb trial. Prognostic insights and impact of recurrent ischemia. Circulation 1998;98: 1860–1868. [DOI] [PubMed] [Google Scholar]
  • 12. Savonitto S, Granger CB, Ardissino D. Even minor elevations of creatine kinase predict increased risk of cardiac events in acute coronary syndromes without ST‐segment elevation. (abstract) J Am Coll Cardiol 1999;33 (Suppl A): 346A. [Google Scholar]
  • 13. Alexander JH, Sparapani RA, Mahaffey KW, et al. Association between minor elevations of creatine kinase‐MB level and mortality in patients with acute coronary syndromes without ST‐segment elevation. JAMA 2000;283:347–353. [DOI] [PubMed] [Google Scholar]
  • 14. Ravkilde J, Nissen H, Horder M, et al. Independent prognostic value of serum creatine kinase isoenzyme MB mass, cardiac troponin T and myosin light chain levels in suspected acute MI. Analysis of 28 months of follow‐up in 196 patients. J Am Coll Cardiol 1995;25: 574–581. [DOI] [PubMed] [Google Scholar]
  • 15. Savonitto S, Ardissino D, Granger CB, et al, on behalf of the GUSTO‐IIb investigators. Prognostic value of the admission ECG in acute coronary syndromes. Results from the GUSTO‐IIb trial. JAMA 1999;281: 707–713. [DOI] [PubMed] [Google Scholar]
  • 16. Liebson PR, Klein LW. The non Q wave MI revisited: 10 years later. Progr Cardiovasc Dis 1997;39:399–444. [DOI] [PubMed] [Google Scholar]
  • 17. Birnbaum Y, Herz I, Sclarovsky S, et al. Prognostic significance of the admission electrocardiogram in acute MI. J Am Coll Cardiol 1996;27:1128–1132. [DOI] [PubMed] [Google Scholar]
  • 18. ASSENT‐2 Investigators. Single bolus tenecteplase compared with front‐loaded alteplase in acute MI: the ASSENT‐2 double‐blind randomized trial. Lancet 1999;354: 716–722. [DOI] [PubMed] [Google Scholar]
  • 19. Rouan GW, Lee TH, Cook EF, et al. Clinical characteristics and outcome of acute MI in patients with initially normal or nonspecific ECGs (a report from the Multicenter Chest Pain Study). Am J Cardiol 1989;64:1087–1092. [DOI] [PubMed] [Google Scholar]
  • 20. Go AS, Barren HV, Rundle AC, et al. for the National Registry of MI 2 Investigators. Bundle‐branch block and in‐hospital mortality in acute MI. Ann Intern Med 1998;129: 690–697. [DOI] [PubMed] [Google Scholar]
  • 21. Sgarbossa EB, Pinski SL, Topol EJ, et al. for the GUSTO‐1 Investigators. Acute MI and complete bundle branch block at hospital admission. Clinical characteristics and outcome in the thrombolytic era. J Am Coll Cardiol 1998;31: 105–110. [DOI] [PubMed] [Google Scholar]
  • 22. Melgarejo‐Moreno A, Galcera‐Thomas J, Garcia‐Alberola A, et al. Incidence, clinical characteristics, and prognostic significance of right bundle‐branch block in acute MI. Circulation 1997;96:1139–1144. [DOI] [PubMed] [Google Scholar]
  • 23. Newby KH, Pisanò E, Krucoff MW, et al. Incidence and clinical relevance of the occurrence of bundle‐branch block in patients treated with thrombolytic therapy. Circulation 1996;94:2424–2428. [DOI] [PubMed] [Google Scholar]
  • 24. Hathaway WR, Peterson ED, Wagner GS, et al. Prognostic significance of the initial electrocardiogram in patients with acute MI. JAMA 1998;279:387–391. [DOI] [PubMed] [Google Scholar]
  • 25. Peterson ED, Hathaway WR, Zabel KM, et al. Prognostic significance of precordial ST segment depression during inferior MI in the thrombolytic era: Results in 16,521 patients. J Am Coll Cardiol 1996;28:305–312. [DOI] [PubMed] [Google Scholar]
  • 26. Birnbaum Y, Herz I, Sclarovsky S, et al. Prognostic significance of precordial ST segment depression on admission electrocardiogram on patients with inferior wall MI. J Am Coll Cardiol 1996;28:313–318. [DOI] [PubMed] [Google Scholar]
  • 27. Mauri F, Gasparini M, Barbonaglia L, et al. Prognostic significance of the extent of myocardial injury in acute MI treated by streptokinase (the GISSI trial). Am J Cardiol 1989;63:1291–1295. [DOI] [PubMed] [Google Scholar]
  • 28. Birnbaum Y, Herz I, Sclarowsky S, et al. Prognostic significance of the admission electrocardiogram in acute MI. J Am Coll Cardiol 1996;27:1128–1132. [DOI] [PubMed] [Google Scholar]
  • 29. Ohman EM, Armstrong PW, Christenson RH, et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. N Engl J Med 1996;335:1333–1341. [DOI] [PubMed] [Google Scholar]
  • 30. Ohman EM, Califf RM, Topol EJ, et al. Consequences of reocclusion after successful reperfusion therapy in acute MI. Circulation 1990;82:781–791. [DOI] [PubMed] [Google Scholar]
  • 31. Ohman EM, Armstrong PW, White HD, et al. Risk stratification with a bedside cardiac troponin T test in 12,000 patients with ST‐segment elevation MI: A GUSTO‐III substudy. Am J Cardiol 1999;84:1281–1286. [DOI] [PubMed] [Google Scholar]
  • 32. Braunwald E, Jones RH, Mark DB, et al. Diagnosing and managing unstable angina. Circulation 1994;90:613–623. [DOI] [PubMed] [Google Scholar]
  • 33. Roberts R, Fromm RE. Management of acute coronary syndromes based on risk stratification. An idea whose time has come. Circulation 1998;98: 1831–1833. [DOI] [PubMed] [Google Scholar]
  • 34. Holmvang L, Luescher MS. Clemmensen P, et al. Very early risk stratification using combined biochemical assessment in patients with unstable coronary artery disease (a thrombin inhibition in myocardial ischemia [TRIM] substudy). Circulation 1998;98:2004–2009. [DOI] [PubMed] [Google Scholar]
  • 35. Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation and outcome in unstable angina. JAMA 2000;283:646–652. [DOI] [PubMed] [Google Scholar]
  • 36. Hochman JS, McCabe CH, Stone PH, et al. Outcome and profile of women and men presenting with acute coronary syndromes: A report from TIMI IIIB. J Am Coll Cardiol 1997;30:141–148. [DOI] [PubMed] [Google Scholar]
  • 37. Hochman JS, Tamis JE, Thompson TD, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. N Engl J Med 1999;341:226–232. [DOI] [PubMed] [Google Scholar]
  • 38. Braunwald E. Unstable angina. A classification. Circulation 1989;80: 410–414. [DOI] [PubMed] [Google Scholar]
  • 39. Van Miltenburg‐van Zjil AJM. Simoons ML, Veerhoek RJ, et al. Incidence and follow‐up of Braunwald subgroups in unstable angina pectoris. J Am Coll Cardiol 1995;25:1286–1292. [DOI] [PubMed] [Google Scholar]
  • 40. Calvin JE, Klein LW, VandenBurg BJ, et al. Risk stratification in unstable angina: Prospective validation of the Braunwald classification. JAMA 1995;273:136–141. [PubMed] [Google Scholar]
  • 41. The FRISC II Investigators. Invasive compared with nonin‐vasive treatment in unstable coronary artery disease: FRISC II prospective randomized multicenter study. Lancet 1999;354: 708–715. [PubMed] [Google Scholar]
  • 42. Lee TH, Cook F, Weisberg M, et al. Acute chest pain in the emergency room. Identification and examination of low‐risk patients. Arch Intern Med 1985;145: 65–69. [PubMed] [Google Scholar]
  • 43. Nyman I, Areskog M, Areskog NH, et al. and the RISC Study Group. Very early risk stratification by electrocardiogram at rest in men with suspected unstable coronary heart disease. J Intern Med 1993;234: 293–301. [DOI] [PubMed] [Google Scholar]
  • 44. Goldman L, Cook EF, Johnson PA, et al. Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain. N Engl J Med 1996;334:1498–1504. [DOI] [PubMed] [Google Scholar]
  • 45. Lichtlen PR, Bargheer K, Wenzlaff P. Long‐term prognosis of patients with anginalike chest pain and normal coronary angiographic findings. J Am Coll Cardiol 1995;25:1013–1018. [DOI] [PubMed] [Google Scholar]
  • 46. Cannon CP, McCabe CH, Stone PH, et al. The electrocardiogram predicts one‐year outcome of patients with unstable angina and non‐Q‐wave MI: Results of the TIMI III registry ECG ancillary study. J Am Coll Cardiol 1997;30: 133–140. [DOI] [PubMed] [Google Scholar]
  • 47. Haines DE, Raabe DS, Gundel WD, et al. Anatomic and prognostic significance of new T‐wave inversion in unstable angina. Am J Cardiol 1983;52:14–18. [DOI] [PubMed] [Google Scholar]
  • 48. Granborg J, Grande P, Pedersen A. Diagnostic and prognostic implications of transient isolated negative T waves in suspected acute MI. Am J Cardiol 1986;57:203–207. [DOI] [PubMed] [Google Scholar]
  • 49. Lewin RF, Sclarowsky S, Rosenberg I, et al. Positivization of T wave with or without ST segment elevation in patients with unstable angina. Coronary angiographic findings and in‐hospital prognosis. Eur Heart J 1987;8: 31–37. [DOI] [PubMed] [Google Scholar]
  • 50. Califf RM, Mark DM. Clinical presentation and diagnostic techniques In Fuster V, Ross R, Topol EJ. (eds.): Atherosclerosis and Coronary Artery Disease. Philadelphia : Lippincott‐Raven, 1996, pp. 1299–1314. [Google Scholar]
  • 51. Nicod P, Gilpin E, Dittrich H, et al. Short‐ and long‐term clinical outcome after Q wave and non‐Q wave MI in a large patient population. Circulation 1989;79:528–536. [DOI] [PubMed] [Google Scholar]
  • 52. de Servi S, Ohio S, Ferrario S, et al. Clinical and angiographic findings in angina at rest. Am Heart J 1986;111:6–10. [DOI] [PubMed] [Google Scholar]
  • 53. Lee Shiang H, Cross SJ, Rawles JM et al. Patients with suspected MI who present with ST depression. Lancet 1993;345:1204–1207. [DOI] [PubMed] [Google Scholar]
  • 54. Sclarowsky S, Davidson E, Strasberg B, et al. Unstable angina: The significance of ST segment elevation or depression in patients without evidence of increased myocardial oxygen demand. Am Heart J 1986;112:463–469. [DOI] [PubMed] [Google Scholar]
  • 55. Cohen M, Hudson MP, Granger CB. Quantitative electro‐cardiographic variables predict adverse outcomes in non‐ST elevation acute coronary syndromes: Results from GUSTO lib. J Am Coll Cardiol 2000;35 (Suppl. A):410A. [Google Scholar]
  • 56. Hamm CW, Ravkilde J, Gerhardt W. et al. The prognostic value of serum troponin T in unstable angina. N Engl J Med 1992;327: 146–150. [DOI] [PubMed] [Google Scholar]
  • 57. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac‐specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996;335:1342–1349. [DOI] [PubMed] [Google Scholar]
  • 58. Newby LK, Christenson RH, Ohman EM, et al. Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. Circulation 1998;98:1853–1859. [DOI] [PubMed] [Google Scholar]
  • 59. Hamm CW, Goldman BU, Heeschen C, et al. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med 1997;337:1648–1653. [DOI] [PubMed] [Google Scholar]
  • 60. de Winter RJ, Bholasingh R, Nieuwenhujis AB, et al. Ruling out a MI early with two serial creatine kinase‐MB mass determinations. Eur Heart J 1999;20:967–972. [DOI] [PubMed] [Google Scholar]
  • 61. Jurlander B, Clemmensen P, Wagner GS, et al. Very early diagnosis and risk stratification of patients admitted with suspected acute MI by the combined evaluation of a single serum value of cardiac troponin‐T, myoglobin, and creatine kinase MBmass. Eur Heart J 2000;21:382–389. [DOI] [PubMed] [Google Scholar]
  • 62. Liuzzo G, Biasucci LM, Gallimore JR, et al. The prognostic value of C‐reactive protein and serum amyloid A protein in severe unstable angina. N Engl J Med 1994;331:417–424. [DOI] [PubMed] [Google Scholar]
  • 63. Verheggen PWHM, de Maa MPM, Manger Cats V, et al. Inflammatory status as a main determinant of outcome in patients with unstable angina, independent of coagulation activation and endothelial function. Eur Heart J 1999;20:567–574. [DOI] [PubMed] [Google Scholar]
  • 64. Libby P, Ridker PM. Novel inflammatory markers of coronary risk. Theory versus practice. Circulation 1999;100: 1148–1150. [DOI] [PubMed] [Google Scholar]
  • 65. Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST‐segment elevation. Results from an international trial of 9461 patients. Circulation 2000;101: 2557–2567. [DOI] [PubMed] [Google Scholar]
  • 66. Norgaard BL, Andersen K, Dellborg M, et al. Admission risk assessment by cardiac troponin T in unstable coronary artery disease: Additional prognostic information from continuous ST segment monitoring. J Am Coll Cardiol 1999;33:1519–1527. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Noninvasive Electrocardiology are provided here courtesy of International Society for Holter and Noninvasive Electrocardiology, Inc. and Wiley Periodicals, Inc.

RESOURCES