title: Risk stratification in non-ST elevation acute coronary syndromes: Risk scores, biomarkers and clinical judgment.
abstract: Undifferentiated chest pain is one of the most common reasons for emergency department attendance and admission to hospitals. Non-ST elevation acute coronary syndrome (NSTE-ACS) is an important cause of chest pain, and accurate diagnosis and risk stratification in the emergency department must be a clinical priority. In the future, the incidence of NSTE-ACS will rise further as higher sensitivity troponin assays are implemented in clinical practice. In this article, we review contemporary approaches for the diagnosis and risk stratification of NSTE-ACS during emergency care. We consider the limitations of current practices and potential improvements. Clinical guidelines recommend an early invasive strategy in higher risk NSTE-ACS. The Global Registry of Acute Coronary Events (GRACE) risk score is a validated risk stratification tool which has incremental prognostic value for risk stratification compared with clinical assessment or troponin testing alone. In emergency medicine, there has been a limited adoption of the GRACE score in some countries (e.g. United Kingdom), in part related to a delay in obtaining timely blood biochemistry results. Age makes an exponential contribution to the GRACE score, and on an individual patient basis, the risk of younger patients with a flow-limiting culprit coronary artery lesion may be underestimated. The future incorporation of novel cardiac biomarkers into this diagnostic pathway may allow for earlier treatment stratification. The cost-effectiveness of the new diagnostic pathways based on high-sensitivity troponin and copeptin must also be established. Finally, diagnostic tests and risk scores may optimize patient care but they cannot replace patient-focused good clinical judgment.
authors.affiliation: West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, UK.
authors.forename: David
authors.initials: D
authors.lastname: Corcoran
authors.affiliation: Department of Emergency Medicine, Glasgow Royal Infirmary, G4 0SF, UK.
authors.forename: Patrick
authors.initials: P
authors.lastname: Grant
authors.affiliation: West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, UK; BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK.
authors.forename: Colin
authors.initials: C
authors.lastname: Berry
keywords: GRACE score; Myocardial infarction; NSTE-ACS; Risk stratification