The AHA Guidelines and Scientific Statements Handbook

Chapter 2 Unstable Angina/Non-ST-Elevation Myocardial Infarction

1.0

0 to <0.4 0.4 to <1.0 1.0 to <2.0

1.0

—

Risk ratio

95% confidence

interval

1.8

0.5–6.7

3.5

1.2–10.6

3.9

1.3–11.7

6.2

1.7–22.3

7.8

2.6–23.0

2.0 to <5.0

Cardiac troponin I (ng/ml)

5.0 to <9.0 ≥9.0

1.7

3.4

8

7

6

5

Mortality at 42 days

(% of patients)

4

3

2

1

0

3.7

6.0

7.5

831 174 148 134 50 67

Fig. 2.2 Relationship between cardiac troponin I levels and mortality rates at 42 days (without adjustment for baseline characteristics) in
patients with ACS. The numbers at the bottom of each bar are the numbers of patients with cardiac troponin I levels in each range, and the
numbers above the bars are percentages. P less than 0.001 for the increase in the mortality rate (and the risk ratio for mortality) with
increasing levels of cardiac troponin I at enrollment. Used with permission from Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-
specifi c troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996;335:1342–9.

Table 2.2 Selection of initial treatment strategy: invasive versus conservative strategy

Preferred strategy Patient characteristics

Invasive Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)
New or presumably new ST-segment depression
Signs or symptoms of HF or new or worsening mitral regurgitation
High-risk fi ndings from noninvasive testing
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 months
Prior CABG
High-risk score (e.g., TIMI, GRACE)
Reduced left ventricular function (LVEF less than 40%)

Conservative Low-risk score (e.g., TIMI, GRACE)
Patient or physician preference in the absence of high-risk features

expanded section recognizes special diagnostic and
therapeutic considerations in special patient groups,
and care processes are highlighted as important in
short- and long-term patient outcomes.
Classifi cation of Recommendations and Level of
Evidence are expressed in the ACC/AHA format.

Selected recommendations are presented below. The

reader is referred to the full-text guidelines for a

complete list of the guideline recommendations as

well as a presentation of the rationale and evidence

supporting these recommendations with literature

citations [1].