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A scoring system to assess risk in patients admitted with non-ST-elevation acute coronary syndrome.

Assessment of acute chest pain without evidence of acute coronary syndrome such as changes in electrocardiograms or elevated troponin presents a challenge for emergency services. Although many of these patients have excellent prognosis, some are at high risk and their identification is mandatory. Certain studies have shown that normal troponin implies good prognosis while others have observed a not unappreciable frequency (4.8%) of death or myocardial infarction at 6 months. Therefore, careful risk stratification is required.

Various indices have been described for risk of non-ST-elevation acute coronary syndrome. One of the most often utilized is the TIMI risk score. These índices are derived from high risk populations (which include patients with ST segment deviation or elevated troponin). Therefore, their applicability to patients at low risk may not be adequate.

We have studied a series of patients with acute chest pain, without ST segment deviation, and with normal troponin, following a unit protocol for chest pain with an early effort testing. The objective was to develop a risk index with clinical factors and compare it with the TIMI risk score.

After one year of follow-up, 6.7% of the patients had died or had a myocardial infarction. Clinical presentation data allowed a risk stratification. Therefore, a risk index was constructed with 5 clinical variables with a demonstrated prognostic value: typical pain (assessed using a pain scale), 2 or more episodes of pain within the previous 24 hours, age 67 years or older, insulin-dependent diabetes mellitus, and previous coronary angioplasty. Using this index, the population was classified into 5 progressive categories of risk (event frequency of 0%, 3.1%, 5.4%, 17.6% and 29.6%, P <0.0001). In addition, the low probability of a negative result of the effort testing in the high and very high risk categories advised in favour of the immediate hospitalization of those patients. The new index was more precise than the TIMI risk score. This new index is now used in the emergency services for the risk stratification of patients with acute chest pain.

An initiative of

Ministerio de Economía y Competitividad Fondo Europeo de Desarrollo Regional IMIM - Parc de Salut Mar