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UA/NSTEMI (ACC)

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Early Risk Stratification ÎÎA rapid clinical determination of the risk of obstructive CAD (ie, high, intermediate, or low) should be made in all patients with chest discomfort or other symptoms suggestive of an ACS and considered in patient management. (I-C) ÎÎPatients who present with chest discomfort or other ischemic symptoms should undergo early stratification for the risk of cardiovascular events (eg, death or MI) that focuses on history, including anginal symptoms, physical findings, ECG findings, and biomarkers of cardiac injury. Results should be considered in patient management. (I-C) ÎÎA 12-lead ECG should be performed and shown to an experienced emergency physician as soon as possible after ED arrival, with a goal of within 10 min of ED arrival for all patients with chest discomfort (or anginal equivalent) or other symptoms suggestive of ACS. (I-B) ÎÎIf the initial ECG is not diagnostic but the patient remains symptomatic and there is high clinical suspicion for ACS, serial ECGs, initially at 15- to 30-minute intervals, should be performed to detect the potential for development of ST-segment elevation or depression. (I-B) ÎÎCardiac biomarkers should be measured in all patients who present with chest discomfort consistent with ACS. (I-B) ÎÎA cardiac-specific troponin is the preferred marker. If available, it should be measured in all patients who present with chest discomfort consistent with ACS. (I-B) ÎÎPatients with negative cardiac biomarkers within 6 h of the onset of symptoms consistent with ACS should have biomarkers remeasured 8-12 h after symptom onset. (The exact timing of serum marker measurement should take into account the uncertainties often present with the exact timing of onset of pain and the sensitivity, precision, and institutional norms of the assay being utilized, as well as the release kinetics of the marker being measured.) (I-B) ÎÎThe initial evaluation of the patient with suspected ACS should include the consideration of noncoronary causes for the development of unexplained symptoms. (I-C) 7

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