![]() ![]() Known history of coronary artery disease, including myocardial infarction Probable ischemic symptoms in absence of any of the intermediate-likelihood characteristics Low Likelihood (absence of high- or intermediate-likelihood features but may have)Ĭhest or left arm pain or discomfort as chief symptom reproducing prior documented anginaĬhest or left arm pain or discomfort as chief symptom Intermediate Likelihood (absence of high-likelihood features and presence of any of the following) Likelihood That Signs/Symptoms Represent ACS due to CAD Feature If answer is No to all of the above stepwise questions then the patient can have early discharge with close follow-up for further provocative testing.Age ≥50, or does pain radiate to neck, jaw, or left arm?.Is there an abnormal ECG, positive troponin at 2 hrs or prior ACS nitrate use?.Is the same for c-TnI assay and hs-TnI assay but sensitivity differences by a percentage point.The new rule was validated in 2014 on 1635 patients and published in 2014.The old Vancouver chest pain rule was not properly validated.Useful for screening patient with low risk for ACS.≥7: 72.7% risk of adverse cardiac event, suggesting early invasive measures with these patients and close coordination with inpatient cardiology.Patients should be admitted to the hospital for trending of troponin and provocative testing. 4-6: 20.3% risk of adverse cardiac event.Patient's can be discharged with follow-up. 0-3: 2.5% risk of adverse cardiac event.≥ 3 risk factors or history of atherosclerotic disease Risk Factors (Hypercholesterolemia, Hypertension, Diabetes Mellitus, Smoking,Obesity) ![]() Low risk patients have a score 0-3 and have a less than 2% risk of MACE at 6 weeks.The score has been derived and validated in an ED population and predicts 6 week adverse cardiac events.3 Likelihood That Signs/Symptoms Represent ACS due to CAD.After adjustment for baseline risk, an early invasive strategy tended toward a more favorable result in TACTICS-TIMI 18 than in TIMI IIIB (OR, 0.79 95% CI, 0.56 to 1.11).Īdvances in the care of patients with UA/NSTEMI, including glycoprotein IIb/IIIa inhibition and stenting, were associated with lower rates of death, MI, and rehospitalization for acute coronary syndromes and a trend toward a greater benefit of an early invasive strategy. Across both trials, the benefit of an early invasive strategy was significantly greater with increasing baseline risk: OR, 1.39 in low-risk, 0.80 in intermediate-risk, and 0.57 in high-risk patients (P< or =0.004 for interactions). Compared with patients in TIMI IIIB and adjusting for baseline risk, patients in TACTICS-TIMI 18 had lower rates of death, MI, or rehospitalization for acute coronary syndromes (OR, 0.62 P<0.0001). Within each risk category, the rates of clinical outcomes and the benefit of an early invasive strategy were compared. Patients were stratified on the basis of their TIMI risk score into low-, intermediate-, and high-risk categories. We sought to examine the effect of these advances on clinical outcomes and the benefits of an early invasive strategy in UA/NSTEMI. TIMI IIIB and TACTICS-TIMI 18 were 2 trials of an early invasive strategy in unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI) that were conducted nearly a decade apart but with virtually identical enrollment criteria and designs, except that upstream glycoprotein IIb/IIIa inhibition was mandated and coronary artery stenting was routinely used in TACTICS-TIMI 18. ![]()
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