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)
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