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Acute Coronary SyndromesEvaluation and Risk StratificationNew Terminology in ACSACS,acute coronary syndrome;MI,myocardial infarction;UA,unstable angina;NSTEMI,nonST-segment elevation myocardial infarction;STEMI,ST-segment elevation myocardial infarction;PCI,percutaneous coronary intervention.Cannon CP.J Thromb Thrombolysis.1995;2:205-218.AntithromboticTherapyStable AnginaUnstableAnginaNonQ-wave MIThrombolysisPrimary PCIQ-wave MIMinutes-hoursDays-weeksSTEMIUA/NSTEMIAtherothrombosisNew termOld termPlaqueRuptureTroponin I(TnI),C-Reactive Protein(CRP),and B-type Natriuretic Peptide(BNP)as Determinants of 30-Day Mortality Risks in Acute Coronary Ischemia:A Multimarker ApproachP=.014P50%)Aspirin in last 7 days2 anginal events in 24 hoursST deviation Elevated cardiac markers(CK-MB or troponin)TIMI Risk Score For UA/NSTEMIAntman EM,et al.JAMA.2000;284:835-442.(with permission)Age 65 years3CAD Risk FactorsPrior Stenosis 50%ST deviation2 Anginal events 24 hoursASA in last 7 daysElev Cardiac Markers(CK-MB or troponin)4.78.313.219.926.240.9010203040500/123456/7D/MI/Urg Revasc(%)Number of Risk FactorsPopulation(%):4.317.332.029.313.03.4C Statistic=0.65c c2 trend P.001P.001P=.004P.001P.001Scirica BM,et al.Am J Cardiol.2002;90:303-305.(with permission)TIMI Risk Score vs Prognosis in Unselected Patients(TIMI 3 Registry)TRS 0-2TRS 3-4TRS 5-70%10%20%30%40%50%DeathMIDeath/MIDeath/MI/RIEvent Rate at 1 year(%)Prognostic Value of Troponin T or I in ACS:A Meta-analysis%RR 3.9(2.9-5.3)RR 3.8(2.6-5.5)No.Studies:136 NegPos(Trop I+T)36341849737322Heidenreich PA,J Am Coll Cardiol.2001;38:478-485.TIMI IIIB:Troponin I Levels Predict Mortality In UA/NSTEMI1.01.73.43.76.07.5024680 to 0.40.4 to 1.01.0 to 2.0 2.0 to 5.05.0 to 9.08311741481346750Risk Cardiac Troponin I(ng/ml)Ratio1.0 1.83.5 3.96.27.8Mortality at 42 Days(%of Patients)Antman EA,et al.N Engl J Med.1996;335:1342-1349.(with permission)Lindahl B,et al.N Engl J Med.2000;343:1139-1147.(with permission)Predictive Value of Troponin T and hs-CRP for Mortality from ACS in FRISC Substudy201000612182430364248Cumulative Probability of Death(%)MonthsTroponin T 0.60 g/l(n=377)Troponin T 0.60-0.59 g/l(n=367)Troponin T 10mg/l(n=309)CRP 2mg/l(n=314)P=.001P=.29CRPTroponinMonthsRisk Stratification With CRP and Troponin TChi Square:P=.00079.1%4.7%0.4%012345678910RcTnT Neg AND CRP 1.55RcTnT(early+)ANDCRP 1.5514-Day Mortality(%)N=277N=129N=22Morrow DA,et al.J Am Coll Cardiol.1998;31:1460-1465.WBC Count(x103)30-Day Mortality0510152005%10%15%20%White Blood Cell Count vs MortalityCannon CP,et al.Am J Cardiol.2001;87:636-639.(with permission)B-type Natriuretic Peptide(BNP)and Mortality in ACS Patientsde Lemos JA,et al.N Engl J Med.2001;345:1014-1021.(with permission)0246810Mortality(%)050100150200250300Days After RandomizationP.001Quartile 4(n=630)Quartile 3(n=632)Quartile 2(n=632)Quartile 1(n=631)ST MINon-ST MIUnstable Angina8255651133 P=.02P.0001P=.001de Lemos JA,et al.N Engl J Med.2001;345:1014-1021.(with permission)BNP and Risk of Death in ACSMultimarker Approach:Troponin I,CRP,and BNP to Predict 30-Day Mortality in ACSSabatine M,et al.Circulation.2002;105:1760-1763.(with permission)P=.014P=.001671501557850471732490 30 Day Mortality(%)30-Day Mortality Rel RiskInflammation,ACS,and CD-40L*SCD40L=soluble CD40LAndre P,et al.Circulation.2002;106:896-899.(with permission)Varo N,et al.Circulation.2003;108:1049-1052.(with permission)Clinical Investigation ReportsSoluble CD40LRisk Prediction After Acute Coronary Syndromes3.532.521.510.50DeathMIDIMICHFDIMI CHFQ1Q2Q3Q4Hazard Ratios(HR)*P.01 compared to first quartile P.03 compared to first quartileSoluble CD-40L in ACSHeeschen C,et al.N Engl J Med.2003;348:1104-1111.(with permission)Association between soluble CD40 ligand levels and the rate of cardiac events(death or nonfatal myocardial infarction)at 24 hours,72 hours,30 days,and 6 months among 544 patients receiving placebo.TimeDeath or Nonfatal Myocardial Infarction(%)24 hours72 hours30 hours6 monthsP=.13P=.003P=.004P=.0011st quartile2nd quartile3rd quartile4th quartile5th quartileClopidogrel,but not ASA,Reduces ADP-Induced Expression of CD40LHermann A,et al.Platelets.2001;12:74-82.(with permission)ADP,30 MControl00.10.20.30.40.5CD40L Expression(Mn X)ControlASAClopidogrelASA+ClopidogrelP.05 vs ADP-stimulated controlsEffect of Treatment with Abciximab According to the Levels of Troponin T and Soluble CD40 LigandHeeschen C,et al.N Eng J Med.2003;348:1104-1111.(with permission)0.00.51.01.52.02.5Quintile of Soluble CD40 Ligand12345All patientsHazard Ratio for Death or Nonfatal Myocardial InfarctionP=.10 P=.50 P=.48 P=.02 P=.02 P=.04Vascular DamageInflammationMyocyte NecrosisAccelerated AtherosclerosisHemodynamic StressHbA1cBlood glucoseCrClMicroalbuminuriaTroponinBNP,NT-proBNPhs-CRP,CD40LMorrow DA,et al.Circulation.2003;108:250-252.Multimarker Strategy in ACS
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