Risk Stratification and Prognostic Factors in the Post-Myocardial Infarction Patient
Section snippets
Risk Stratification Methods for Acute Coronary Syndrome
The approach to the 5 million patients arriving in the emergency department with chest pain each year requires careful risk stratification, which involves 2 steps: (1) establishing the diagnosis of ACS (as opposed to noncardiac chest pain), and (2) identifying high- versus low-risk patients.2, 10 The early diagnosis and stratification of ST-segment elevation MI (STEMI), non-STEMI, and unstable angina is essential for assessing risk, guiding therapy, and improving outcomes. Despite improvements
Use of Biomarkers for Risk Stratification
A better understanding of the pathophysiology of ACS has led to substantial advances in the treatment of acute MI over the past several years, which, in turn, have greatly increased the likelihood of survival. Several studies have shown the significant benefit of immediate reperfusion therapy with fibrinolysis or percutaneous coronary intervention.18, 19, 20 The improved treatment strategies have resulted in fewer patients developing post-MI LVD; however, patients with LVD remain a high-risk
Risk Stratification Can Guide the Use of Targeted Therapies
Cardiac markers not only can predict the risk of mortality and morbidity, but they also can guide decision making and choice of therapy in the emergency department. A major challenge for physicians is to identify patients with ACS who may benefit from treatment with various reperfusion strategies (pharmacologic or invasive). Early reperfusion of patients with STEMI results in the reduction in infarct size, an improved LVEF, and the reduction of in-hospital mortality.20 Patients with non-STEMI
Risk Stratification Can Be Used to Monitor Therapy
Landmark clinical trials have established angiotensin-converting enzyme inhibitors and β-blockers as the standard of care in post-MI and HF patients.39, 40, 41 However, even with intensive treatment, morbidity and mortality remain high. Current treatment strategies ignore plasma neurohormone concentrations, yet they are independent markers of cardiac status and prognosis in cardiac disease and could help monitor the effect of therapies, such as β-blockers.
Concentrations of BNP and NT-proBNP are
Practical Use of Biomarkers at the Bedside
The practicality of using many biomarkers in the emergency department or at the bedside for rapid assessment has been questioned. The TIMI HF risk score, a tool involving assessment of basic clinical findings as well as a biomarker, is particularly useful because none of its components requires difficult or intensive measurements. The TIMI risk score is a relatively new risk assessment tool focused on the risk of developing post-ACS HF leading to hospitalization.52 In multivariate analysis,
Distinguishing Between Markers of Disease Versus Pathogenesis
Biomarkers may indicate the severity of disease and/or underlying pathology. An ideal marker for the underlying pathology should be specific to myocardial injury, be sensitive to small injuries, be rapidly released after injury, last long enough in the blood to permit delayed diagnosis, produce blood levels that are proportionate to infarct size, permit risk assessment, and be technically easy to measure. CRP, for example, is a marker indicating inflammation that appears to play a role in the
Conclusion
The potential for finding new and useful biomarkers is great, and as this technology continues to advance, these biomarkers may be incorporated into a single bedside assessment tool that can rapidly and conveniently obtain much more information about the pathologic processes in a patient than we currently are able to surmise by clinical presentation, signs, and symptoms. The next generation of cardiac markers should have a high sensitivity for ischemia (unstable angina and silent ischemia). The
Author Disclosures
The authors who contributed to this article have disclosed the following industry relationships.
Christopher P. Cannon, MD, receives research grants/support from Accumetrics, AstraZeneca, Bristol Myers Squibb, GlaxoSmithKline, Merck Schering Plough Partnership, and sanofi-aventis.
Barry H. Greenberg, MD, has served as a member of the advisory committee for GlaxoSmithKline, NitroMed, and Novartis; and served as a member of the Speakers' Bureau for AstraZeneca, GlaxoSmithKline, Merck, NitroMed, and
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Statement of author disclosure: Please see the Author Disclosures section at the end of this article.