![]() Cardiac computed tomography angiography (CCTA) may be an option in patients with low to- modest clinical likelihood of unstable angina, as a normal scan excludes coronary artery disease (CAD). The PRECISE-DAPT score may be used to guide and inform decision making on DAPT duration with a modest predictive value for major bleeding, but their value in improving patient outcomes remains unclear.Ĭlinical assessment may indicate elective noninvasive or invasive imaging even after the rule-out of MI. The use of Academic Research Consortium for High Bleeding Risk (ARC-HBR) assessment is a pragmatic approach for bleeding risk assessment that includes the most recent trials performed in high bleeding risk patients, who were previously excluded from clinical trials of dual antiplatelet therapy (DAPT) duration or intensity. In addition, natriuretic peptides may provide incremental prognostic information. Serum creatinine and eGFR should also be determined in all patients with NSTE-ACS because they affect prognosis and are key elements of the GRACE risk score, in which assessment is superior to (subjective) physician assessment for the occurrence of death or MI. The higher the hs-cTn levels, the greater the risk of death. Initial cTn levels add prognostic information in terms of short- and long-term mortality to clinical and ECG variables. very low estimated glomerular filtration rate (eGFR) up to 300%), chest pain onset (>300%), and sex (~40%). ‘healthy’ very old individuals up to 300%), renal dysfunction (differences with very high vs. Used in conjunction with clinical and electrocardiography (ECG) findings, the 0 h/1 h and 0 h/2 h algorithm allows the identification of appropriate candidates for early discharge and outpatient management.įour clinical variables significantly affect hs-cTn concentrations including age (differences between healthy very young vs. It is recommended to use the 0 h/1 h algorithm (best option, blood draw at 0 h and 1 h) or the 0 h/2 h algorithm (second-best option, blood draw at 0 h and 2 h). The time interval to the second cTn assessment can be shortened with the use of hs-cTn assays due to the higher sensitivity and diagnostic accuracy for the detection of MI at presentation. The routine use of copeptin as an additional biomarker for the early rule-out of MI is recommended in the very uncommon setting where hs-cTn assays are not available. ![]() Creatine kinase-myocardial band (CK-MB) shows a more rapid decline after MI and may provide added value for detection of early reinfarction. Other biomarkers may have clinical relevance in specific clinical settings when used in combination with non–hs-cTn T/I. Of note, many cardiac pathologies other than myocardial infarction (MI) also result in cardiomyocyte injury and, therefore, cardiac troponin (cTn) elevations. High-sensitivity troponin (hs-Tn) assay measurements are recommended over less sensitive ones, as they provide higher diagnostic accuracy at identical low cost. In general, individuals with unstable angina have a substantially lower risk of death and derive less benefit from an aggressive pharmacological and invasive approach. The pathological correlate for ACS in patients presenting without persistent ST-segment elevation (NSTE-ACS) at the myocardial level is cardiomyocyte necrosis, measured by troponin release, or, less frequently, myocardial ischemia without cell damage (unstable angina). The following are key points to remember from the 2020 European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation:
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