Risikostratifizierung des NSTE-ACS

Zusammenfassung

Mit zunehmender Verbesserung der Prognose der NSTE-ACS-Patientenkollektive in den letzten Jahren spielt eine standardisierte, schnelle und gute diskriminierende Risikostratifizierung eine erhebliche Rolle. Verschiedene Merkmale des langfristig erwartbaren ischämischen Risikos, wie z.B. klinische Parameter, EKG-Indikatoren, Biomarker und klinische Scores, werden zusammen mit dem individuellen Blutungsrisiko erfasst und integriert. So ist z.B. die absolute Höhe der Troponin-Konzentration prädiktiv für die Gesamtletalität. Der GRACE-Risk-Score wird nicht nur zusätzlich zur objektiven Risikostratifizierung empfohlen, sondern ein Punktwert >140 ist eines der Kriterien für eine frühe Koronarangiografie innerhalb von 24 Stunden. Die Abschätzung des Blutungsrisikos entsprechend der ARC-HBR-Kriterien hat einen Einfluss auf das antithrombotische Therapieregime.

Abstract

With increasing improvement in prognosis of the majority of NSTE-ACS patients in recent years, standardized, fast and well discriminating risk stratification is gaining importance. Different characteristics of the long-term expected ischemic risk such as clinical parameters, ECG indicators, biomarkers, or clinical risk scores are recorded and integrated in coordination with the individual risk of bleeding. For example, the absolute level of troponin concentration is predictive for all-cause mortality. The GRACE risk score is not only recommended for additional objective risk stratification, but is also one of the parameters indicating the need for an early invasive angiography within 24 hours. The assessment of the bleeding risk according to ARC-HBR criteria has an impact on the anti-thrombotic therapy.

Schlüsselwörter

NSTE-ACS - akutes Koronarsyndrom - Risikostratifizierung - ischämisches Risiko - GRACE-Risk-Score

Keywords

NSTE-ACS - acute coronary syndrome - risk stratification - ischemic risk - GRACE risk score

• Literatur

• 1 Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311-322
• 2 Braunwald E, Antman EM, Beasley JW. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina). Circulation 2000; 102: 1193-1209
• 3 Deutscher Herzbericht 2019. Frankfurt am Main: Deutsche Herzstiftung e.V.; 2020
• 4 Jobs A, Mehta SR, Montalescot G. Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet 2017; 390: 737-746
• 5 Mehran R, Pocock SJ, Nikolsky E. A risk score to predict bleeding in patients with acute coronary syndromes. J Am Coll Cardiol 2010; 55: 2556-2566
• 6 Collet JP, Thiele H, Barbato E. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2020;
• 7 Rubini Gimenez M, Reiter M, Twerenbold R. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med 2014; 174: 241-249
• 8 Antman EM, Cohen M, Bernink PJ. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000; 284: 835-842
• 9 Persson A, Hartford M, Herlitz J. Long-term prognostic value of mitral regurgitation in acute coronary syndromes. Heart 2010; 96: 1803-1808
• 10 Granger CB, Goldberg RJ, Dabbous O. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003; 163: 2345-2353
• 11 Fox KAA, Dabbous OH, Goldberg RJ. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006; 333: 1091
• 12 Holmvang L, Clemmensen P, Lindahl B. Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment. J Am Coll Cardiol 2003; 41: 905-915
• 13 Kaul P, Fu Y, Chang WC. Prognostic value of ST segment depression in acute coronary syndromes: insights from PARAGON-A applied to GUSTO-IIb. PARAGON-A and GUSTO IIb Investigators. Platelet IIb/IIIa Antagonism for the Reduction of Acute Global Organization Network. J Am Coll Cardiol 2001; 38: 64-71
• 14 Mueller C, Neumann FJ, Perach W. Prognostic value of the admission electrocardiogram in patients with unstable angina/non-ST-segment elevation myocardial infarction treated with very early revascularization. Am J Med 2004; 117: 145-150
• 15 Savonitto S, Cohen MG, Politi A. Extent of ST-segment depression and cardiac events in non-ST-segment elevation acute coronary syndromes. Eur Heart J 2005; 26: 2106-2113
• 16 Damman P, Wallentin L, Fox KAA. Long-term cardiovascular mortality after procedure-related or spontaneous myocardial infarction in patients with non-ST-segment elevation acute coronary syndrome: a collaborative analysis of individual patient data from the FRISC II, ICTUS, and RITA-3 trials (FIR). Circulation 2012; 125: 568-576
• 17 Holmvang L, Lüscher MS, Clemmensen P. Very early risk stratification using combined ECG and biochemical assessment in patients with unstable coronary artery disease (A thrombin inhibition in myocardial ischemia TRIM substudy). The TRIM Study Group. Circulation 1998; 98: 2004-2009
• 18 Jacobsen MD, Wagner GS, Holmvang L. Quantitative T-wave analysis predicts 1 year prognosis and benefit from early invasive treatment in the FRISC II study population. Eur Heart J 2005; 26: 112-118
• 19 Lemkes JS, Janssens GN, van der Hoeven. Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial. Eur Heart J 2019; 40: 283-291
• 20 Patel JH, Gupta R, Roe MT. Influence of presenting electrocardiographic findings on the treatment and outcomes of patients with non-ST-segment elevation myocardial infarction. Am J Cardiol 2014; 113: 256-261
• 21 Blondheim DS, Kleiner-Shochat M, Asif A. Characteristics, Management, and Outcome of Transient ST-elevation Versus Persistent ST-elevation and Non-ST-elevation Myocardial Infarction. Am J Cardiol 2018; 121: 1449-1455
• 22 de Zwaan C, Bär FW, Janssen JH. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989; 117: 657-665
• 23 de Winter RJ, Verouden NJ, Wellens HJ. A New ECG Sign of Proximal LAD Occlusion. N Engl J Med 2008; 359: 2071-2073
• 24 Gerson MC, McHenry PL. Resting U wave inversion as a marker of stenosis of the left anterior descending coronary artery. Am J Med 1980; 69: 545-550
• 25 Batra G, Svennblad B, Held C. All types of atrial fibrillation in the setting of myocardial infarction are associated with impaired outcome. Heart 2016; 102: 926-933
• 26 Mueller C. Biomarkers and acute coronary syndromes: an update. Eur Heart J 2014; 35: 552-556
• 27 Reichlin T, Schindler C, Drexler B. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med 2012; 172: 1211-1218
• 28 Rubini Gimenez M, Twerenbold R, Reichlin T. Direct comparison of high-sensitivity-cardiac troponin I vs. T for the early diagnosis of acute myocardial infarction. Eur Heart J 2014; 35: 2303-2311
• 29 Thygesen K, Mair J, Mueller C. Recommendations for the use of natriuretic peptides in acute cardiac care: a position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J 2012; 33: 2001-2006
• 30 Fox KAA, Anderson FA, Dabbous OH. Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE). Heart 2007; 93: 177-182
• 31 Fox KA, Eagle KA, Gore JM. The Global Registry of Acute Coronary Events, 1999 to 2009 – GRACE. Heart 2010; 96: 1095-1101
• 32 Chew DP, Junbo G, Parsonage W. Perceived risk of ischemic and bleeding events in acute coronary syndromes. Circ Cardiovasc Qual Outcomes 2013; 6: 299-308
• 33 Elbarouni B, Goodman SG, Yan RT. Validation of the Global Registry of Acute Coronary Event (GRACE) risk score for in-hospital mortality in patients with acute coronary syndrome in Canada. Am Heart J 2009; 158: 392-399
• 34 Lin A, Devlin G, Lee M. Performance of the GRACE scores in a New Zealand acute coronary syndrome cohort. Heart 2014; 100: 1960-1966
• 35 Bing R, Goodman SG, Yan AT. Use of clinical risk stratification in non-ST elevation acute coronary syndromes: an analysis from the CONCORDANCE registry. Eur Heart J Qual Care Clin Outcomes 2018; 4: 309-317
• 36 Chew DP, Astley CM, Luker H. A cluster randomized trial of objective risk assessment versus standard care for acute coronary syndromes: Rationale and design of the Australian GRACE Risk score Intervention Study (AGRIS). Am Heart J 2015; 170: 995-1004.e1
• 37 Everett CC, Fox KA, Reynolds C. Evaluation of the impact of the GRACE risk score on the management and outcome of patients hospitalised with non-ST elevation acute coronary syndrome in the UK: protocol of the UKGRIS cluster-randomised registry-based trial. BMJ Open 2019; 9: e032165
• 38 Mehta SR, Cannon CP, Fox KA. Routine vs Selective Invasive Strategies in Patients With Acute Coronary Syndromes. A Collaborative Meta-analysis of Randomized Trials. JAMA 2005; 293: 2908-2917
• 39 Mehta SR, Granger CB, Boden WE. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 2009; 360: 2165-2175
• 40 Kofoed KF, Kelbæk H, Hansen PR. Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. Circulation 2018; 138: 2741-2750
• 41 Chang WC, Boersma E, Granger CB. Dynamic prognostication in non-ST-elevation acute coronary syndromes: insights from GUSTO-IIb and PURSUIT. Am Heart J 2004; 148: 62-71
• 42 Bricker RS, Valle JA, Plomondon ME. Causes of Mortality After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2019; 12: e005355
• 43 Abu-Assi E, Raposeiras-Roubin S, Lear P. Comparing the predictive validity of three contemporary bleeding risk scores in acute coronary syndrome. Eur Heart J Acute Cardiovasc Care 2012; 1: 222-231
• 44 Subherwal S, Bach RG, Chen AY. Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score. Circulation 2009; 119: 1873-1882
• 45 Urban P, Mehran R, Colleran R. Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the Academic Research Consortium for High Bleeding Risk. Eur Heart J 2019; 40: 2632-2653
• 46 Costa F, van Klaveren D, James S. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 2017; 389: 1025-1034