Risk factors for adverse outcomes after non-ST elevation acute coronary syndromes
- Jeffrey A Breall, MD, PhD
Jeffrey A Breall, MD, PhD
- Professor of Clinical Medicine
- Indiana University School of Medicine
- Michael Simons, MD
Michael Simons, MD
- Robert W Berliner Professor of Medicine
- Yale University School of Medicine
- Joseph S Alpert, MD
Joseph S Alpert, MD
- Professor of Medicine
- University of Arizona Health Sciences Center
- Pamela S Douglas, MD
Pamela S Douglas, MD
- Ursula Geller Professor of Research in Cardiovascular Diseases
- Duke University Medical Center
- Peter WF Wilson, MD
Peter WF Wilson, MD
- Professor of Medicine
- Emory University School of Medicine
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Allan S Jaffe, MD
Allan S Jaffe, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Mayo Medical School
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
Patients with an acute coronary syndrome (ACS) should undergo risk stratification to predict those who are at high risk for short- and long-term adverse outcomes. Among patients with non-ST elevation acute coronary syndrome (NSTEACS), which includes non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA), risk stratification begins soon after presentation to detect patients at high risk during the early hospital phase. Subsequent risk stratification is aimed at predicting which patients are at increased risk after discharge.
The individual risk factors that influence prognosis will be discussed here. The use of these risk factors in risk prediction models and the prognosis of patients after myocardial infarction (MI) are discussed separately. (See "Risk stratification after non-ST elevation acute coronary syndrome" and "Prognosis after myocardial infarction".)
Although we recognize that there is significant overlap in the risk factors for NSTEACS and ST-elevation myocardial infarction (STEMI), the latter are presented separately. (See "Risk factors for adverse outcomes after ST-elevation myocardial infarction".)
FACTORS PRESENT BEFORE MI
Number of CHD risk factors — The four modifiable coronary heart disease (CHD) risk factors (hypertension, smoking, dyslipidemia, and diabetes), as well as a family history of premature CHD, predict the development of atherosclerosis and its clinical consequences in a high percentage of patients. (See "Overview of the risk equivalents and established risk factors for cardiovascular disease", section on 'Established risk factors for atherosclerotic CVD'.)
The relationship between the number of these risk factors and in-hospital mortality was evaluated in a study of 542,008 patients with first myocardial infarction (MI) and without prior cardiovascular disease from the National (United States) Registry of Myocardial Infarction (NRMI) . Over 85 percent of patients had at least one CHD risk factor. After adjustment for age and other clinical risk factors, there was a significant inverse increase in risk between the number of CHD risk factors and in-hospital mortality (odds ratios of 1.54, 1.39, 1.30, 1.10, 1.09, and 1.00 with 0, 1, 2, 3, 4, and 5 risk factors, respectively). The explanation for this surprising finding is unknown.
- Canto JG, Kiefe CI, Rogers WJ, et al. Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction. JAMA 2011; 306:2120.
- Goldberg RJ, McCormick D, Gurwitz JH, et al. Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975-1995). Am J Cardiol 1998; 82:1311.
- Stone PH, Thompson B, Anderson HV, et al. Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: The TIMI III registry. JAMA 1996; 275:1104.
- Greenland P, Reicher-Reiss H, Goldbourt U, Behar S. In-hospital and 1-year mortality in 1,524 women after myocardial infarction. Comparison with 4,315 men. Circulation 1991; 83:484.
- Gottlieb S, Harpaz D, Shotan A, et al. Sex differences in management and outcome after acute myocardial infarction in the 1990s: A prospective observational community-based study. Israeli Thrombolytic Survey Group. Circulation 2000; 102:2484.
- Vaccarino V, Parsons L, Every NR, et al. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med 1999; 341:217.
- Gan SC, Beaver SK, Houck PM, et al. Treatment of acute myocardial infarction and 30-day mortality among women and men. N Engl J Med 2000; 343:8.
- Stone GW, Grines CL, Browne KF, et al. Comparison of in-hospital outcome in men versus women treated by either thrombolytic therapy or primary coronary angioplasty for acute myocardial infarction. Am J Cardiol 1995; 75:987.
- Malacrida R, Genoni M, Maggioni AP, et al. A comparison of the early outcome of acute myocardial infarction in women and men. The Third International Study of Infarct Survival Collaborative Group. N Engl J Med 1998; 338:8.
- Mak KH, Kark JD, Chia KS, et al. Ethnic variations in female vulnerability after an acute coronary event. Heart 2004; 90:621.
- Vaccarino V, Parsons L, Peterson ED, et al. Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006. Arch Intern Med 2009; 169:1767.
- Berger JS, Elliott L, Gallup D, et al. Sex differences in mortality following acute coronary syndromes. JAMA 2009; 302:874.
- Hochman JS, McCabe CH, Stone PH, et al. Outcome and profile of women and men presenting with acute coronary syndromes: a report from TIMI IIIB. TIMI Investigators. Thrombolysis in Myocardial Infarction. J Am Coll Cardiol 1997; 30:141.
- Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation and outcome of unstable angina. JAMA 2000; 283:646.
- Chang WC, Kaul P, Westerhout CM, et al. Impact of sex on long-term mortality from acute myocardial infarction vs unstable angina. Arch Intern Med 2003; 163:2476.
- Hochman JS, Tamis JE, Thompson TD, et al. Sex, clinical presentation, and outcome in patients with acute coronary syndromes. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes IIb Investigators. N Engl J Med 1999; 341:226.
- Vaccarino V, Krumholz HM, Berkman LF, Horwitz RI. Sex differences in mortality after myocardial infarction. Is there evidence for an increased risk for women? Circulation 1995; 91:1861.
- Køber L, Torp-Pedersen C, Ottesen M, et al. Influence of gender on short- and long-term mortality after acute myocardial infarction. TRACE study group. Am J Cardiol 1996; 77:1052.
- Wagner S, Burczyk U, Schiele R, et al. The 60 Minutes Myocardial Infarction Project. Characteristics on admission and clinical outcome in patients with reinfarction compared to patients with a first infarction. Eur Heart J 1998; 19:879.
- Shotan A, Gottlieb S, Goldbourt U, et al. Prognosis of patients with a recurrent acute myocardial infarction before and in the reperfusion era--a national study. Am Heart J 2001; 141:478.
- Dönges K, Schiele R, Gitt A, et al. Incidence, determinants, and clinical course of reinfarction in-hospital after index acute myocardial infarction (results from the pooled data of the maximal individual therapy in acute myocardial infarction [MITRA], and the myocardial infarction registry [MIR]). Am J Cardiol 2001; 87:1039.
- Narins CR, Zareba W, Moss AJ, et al. Relationship between intermittent claudication, inflammation, thrombosis, and recurrent cardiac events among survivors of myocardial infarction. Arch Intern Med 2004; 164:440.
- Cotter G, Cannon CP, McCabe CH, et al. Prior peripheral arterial disease and cerebrovascular disease are independent predictors of adverse outcome in patients with acute coronary syndromes: are we doing enough? Results from the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis In Myocardial Infarction (OPUS-TIMI) 16 study. Am Heart J 2003; 145:622.
- Januzzi JL Jr, Buros J, Cannon CP, Tactics TIMI 18 Investigators. Peripheral arterial disease, acute coronary syndromes, and early invasive management: the TACTICS TIMI 18 trial. Clin Cardiol 2005; 28:238.
- Stefan MS, Bannuru RR, Lessard D, et al. The impact of COPD on management and outcomes of patients hospitalized with acute myocardial infarction: a 10-year retrospective observational study. Chest 2012; 141:1441.
- Al Suwaidi J, Reddan DN, Williams K, et al. Prognostic implications of abnormalities in renal function in patients with acute coronary syndromes. Circulation 2002; 106:974.
- Anavekar NS, McMurray JJ, Velazquez EJ, et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med 2004; 351:1285.
- Freeman RV, Mehta RH, Al Badr W, et al. Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors. J Am Coll Cardiol 2003; 41:718.
- Roe MT, Chen AY, Thomas L, et al. Predicting long-term mortality in older patients after non-ST-segment elevation myocardial infarction: the CRUSADE long-term mortality model and risk score. Am Heart J 2011; 162:875.
- Borzak S, Cannon CP, Kraft PL, et al. Effects of prior aspirin and anti-ischemic therapy on outcome of patients with unstable angina. TIMI 7 Investigators. Thrombin Inhibition in Myocardial Ischemia. Am J Cardiol 1998; 81:678.
- Alexander JH, Harrington RA, Tuttle RH, et al. Prior aspirin use predicts worse outcomes in patients with non-ST-elevation acute coronary syndromes. PURSUIT Investigators. Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy. Am J Cardiol 1999; 83:1147.
- Becker RC, Burns M, Gore JM, et al. Early assessment and in-hospital management of patients with acute myocardial infarction at increased risk for adverse outcomes: a nationwide perspective of current clinical practice. The National Registry of Myocardial Infarction (NRMI-2) Participants. Am Heart J 1998; 135:786.
- Bahit MC, Lopes RD, Clare RM, et al. Heart failure complicating non-ST-segment elevation acute coronary syndrome: timing, predictors, and clinical outcomes. JACC Heart Fail 2013; 1:223.
- Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 2005; 111:295.
- Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol 1967; 20:457.
- Steg PG, Dabbous OH, Feldman LJ, et al. Determinants and prognostic impact of heart failure complicating acute coronary syndromes: observations from the Global Registry of Acute Coronary Events (GRACE). Circulation 2004; 109:494.
- Khot UN, Jia G, Moliterno DJ, et al. Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes: the enduring value of Killip classification. JAMA 2003; 290:2174.
- Al-Khatib SM, Granger CB, Huang Y, et al. Sustained ventricular arrhythmias among patients with acute coronary syndromes with no ST-segment elevation: incidence, predictors, and outcomes. Circulation 2002; 106:309.
- Piccini JP, White JA, Mehta RH, et al. Sustained ventricular tachycardia and ventricular fibrillation complicating non-ST-segment-elevation acute coronary syndromes. Circulation 2012; 126:41.
- Al-Khatib SM, Pieper KS, Lee KL, et al. Atrial fibrillation and mortality among patients with acute coronary syndromes without ST-segment elevation: results from the PURSUIT trial. Am J Cardiol 2001; 88:A7, 76.
- Poçi D, Hartford M, Karlsson T, et al. Role of the CHADS2 score in acute coronary syndromes: risk of subsequent death or stroke in patients with and without atrial fibrillation. Chest 2012; 141:1431.
- Damman P, Holmvang L, Tijssen JG, et al. Usefulness of the admission electrocardiogram to predict long-term outcomes after non-ST-elevation acute coronary syndrome (from the FRISC II, ICTUS, and RITA-3 [FIR] Trials). Am J Cardiol 2012; 109:6.
- Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999; 281:707.
- Haim M, Hod H, Reisin L, et al. Comparison of short- and long-term prognosis in patients with anterior wall versus inferior or lateral wall non-Q-wave acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group. Am J Cardiol 1997; 79:717.
- Kao W, Khaja F, Goldstein S, Gheorghiade M. Cardiac event rate after non-Q-wave acute myocardial infarction and the significance of its anterior location. Am J Cardiol 1989; 64:1236.
- Stone PH, Raabe DS, Jaffe AS, et al. Prognostic significance of location and type of myocardial infarction: independent adverse outcome associated with anterior location. J Am Coll Cardiol 1988; 11:453.
- Brilakis ES, Mavrogiorgos NC, Kopecky SL, et al. Usefulness of QRS duration in the absence of bundle branch block as an early predictor of survival in non-ST elevation acute myocardial infarction. Am J Cardiol 2002; 89:1013.
- Akkerhuis KM, Klootwijk PA, Lindeboom W, et al. Recurrent ischaemia during continuous multilead ST-segment monitoring identifies patients with acute coronary syndromes at high risk of adverse cardiac events; meta-analysis of three studies involving 995 patients. Eur Heart J 2001; 22:1997.
- James SK, Armstrong P, Barnathan E, et al. Troponin and C-reactive protein have different relations to subsequent mortality and myocardial infarction after acute coronary syndrome: a GUSTO-IV substudy. J Am Coll Cardiol 2003; 41:916.
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354.
- de Lemos JA, Morrow DA, Bentley JH, et al. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes. N Engl J Med 2001; 345:1014.
- Richards AM, Nicholls MG, Espiner EA, et al. B-type natriuretic peptides and ejection fraction for prognosis after myocardial infarction. Circulation 2003; 107:2786.
- Tapanainen JM, Lindgren KS, Mäkikallio TH, et al. Natriuretic peptides as predictors of non-sudden and sudden cardiac death after acute myocardial infarction in the beta-blocking era. J Am Coll Cardiol 2004; 43:757.
- Mega JL, Morrow DA, De Lemos JA, et al. B-type natriuretic peptide at presentation and prognosis in patients with ST-segment elevation myocardial infarction: an ENTIRE-TIMI-23 substudy. J Am Coll Cardiol 2004; 44:335.
- Morrow DA, de Lemos JA, Blazing MA, et al. Prognostic value of serial B-type natriuretic peptide testing during follow-up of patients with unstable coronary artery disease. JAMA 2005; 294:2866.
- Blankenberg S, McQueen MJ, Smieja M, et al. Comparative impact of multiple biomarkers and N-Terminal pro-brain natriuretic peptide in the context of conventional risk factors for the prediction of recurrent cardiovascular events in the Heart Outcomes Prevention Evaluation (HOPE) Study. Circulation 2006; 114:201.
- Kistorp C. Risk stratification in secondary prevention: advances in multimarker profiles, or back to basics? Circulation 2006; 114:184.
- James SK, Lindahl B, Siegbahn A, et al. N-terminal pro-brain natriuretic peptide and other risk markers for the separate prediction of mortality and subsequent myocardial infarction in patients with unstable coronary artery disease: a Global Utilization of Strategies To Open occluded arteries (GUSTO)-IV substudy. Circulation 2003; 108:275.
- Jernberg T, Stridsberg M, Venge P, Lindahl B. N-terminal pro brain natriuretic peptide on admission for early risk stratification of patients with chest pain and no ST-segment elevation. J Am Coll Cardiol 2002; 40:437.
- Omland T, Persson A, Ng L, et al. N-terminal pro-B-type natriuretic peptide and long-term mortality in acute coronary syndromes. Circulation 2002; 106:2913.
- Jernberg T, Lindahl B, Siegbahn A, et al. N-terminal pro-brain natriuretic peptide in relation to inflammation, myocardial necrosis, and the effect of an invasive strategy in unstable coronary artery disease. J Am Coll Cardiol 2003; 42:1909.
- Bazzino O, Fuselli JJ, Botto F, et al. Relative value of N-terminal probrain natriuretic peptide, TIMI risk score, ACC/AHA prognostic classification and other risk markers in patients with non-ST-elevation acute coronary syndromes. Eur Heart J 2004; 25:859.
- Heeschen C, Hamm CW, Mitrovic V, et al. N-terminal pro-B-type natriuretic peptide levels for dynamic risk stratification of patients with acute coronary syndromes. Circulation 2004; 110:3206.
- Lindahl B, Lindbäck J, Jernberg T, et al. Serial analyses of N-terminal pro-B-type natriuretic peptide in patients with non-ST-segment elevation acute coronary syndromes: a Fragmin and fast Revascularisation during In Stability in Coronary artery disease (FRISC)-II substudy. J Am Coll Cardiol 2005; 45:533.
- Toss H, Lindahl B, Siegbahn A, Wallentin L. Prognostic influence of increased fibrinogen and C-reactive protein levels in unstable coronary artery disease. FRISC Study Group. Fragmin during Instability in Coronary Artery Disease. Circulation 1997; 96:4204.
- Lindahl B, Toss H, Siegbahn A, et al. Markers of myocardial damage and inflammation in relation to long-term mortality in unstable coronary artery disease. FRISC Study Group. Fragmin during Instability in Coronary Artery Disease. N Engl J Med 2000; 343:1139.
- Biasucci LM, Liuzzo G, Grillo RL, et al. Elevated levels of C-reactive protein at discharge in patients with unstable angina predict recurrent instability. Circulation 1999; 99:855.
- Glatz JF, Kleine AH, van Nieuwenhoven FA, et al. Fatty-acid-binding protein as a plasma marker for the estimation of myocardial infarct size in humans. Br Heart J 1994; 71:135.
- Seino Y, Ogata K, Takano T, et al. Use of a whole blood rapid panel test for heart-type fatty acid-binding protein in patients with acute chest pain: comparison with rapid troponin T and myoglobin tests. Am J Med 2003; 115:185.
- O'Donoghue M, de Lemos JA, Morrow DA, et al. Prognostic utility of heart-type fatty acid binding protein in patients with acute coronary syndromes. Circulation 2006; 114:550.
- Sabatine MS, Morrow DA, de Lemos JA, et al. Multimarker approach to risk stratification in non-ST elevation acute coronary syndromes: simultaneous assessment of troponin I, C-reactive protein, and B-type natriuretic peptide. Circulation 2002; 105:1760.
- Goyal A, Spertus JA, Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA 2012; 307:157.
- Donahoe SM, Stewart GC, McCabe CH, et al. Diabetes and mortality following acute coronary syndromes. JAMA 2007; 298:765.
- Madjid M, Awan I, Willerson JT, Casscells SW. Leukocyte count and coronary heart disease: implications for risk assessment. J Am Coll Cardiol 2004; 44:1945.
- Barron HV, Harr SD, Radford MJ, et al. The association between white blood cell count and acute myocardial infarction mortality in patients > or =65 years of age: findings from the cooperative cardiovascular project. J Am Coll Cardiol 2001; 38:1654.
- Cannon CP, McCabe CH, Wilcox RG, et al. Association of white blood cell count with increased mortality in acute myocardial infarction and unstable angina pectoris. OPUS-TIMI 16 Investigators. Am J Cardiol 2001; 87:636.
- Sabatine MS, Morrow DA, Cannon CP, et al. Relationship between baseline white blood cell count and degree of coronary artery disease and mortality in patients with acute coronary syndromes: a TACTICS-TIMI 18 (Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy- Thrombolysis in Myocardial Infarction 18 trial)substudy. J Am Coll Cardiol 2002; 40:1761.
- Yen MH, Bhatt DL, Chew DP, et al. Association between admission white blood cell count and one-year mortality in patients with acute coronary syndromes. Am J Med 2003; 115:318.
- Grau AJ, Boddy AW, Dukovic DA, et al. Leukocyte count as an independent predictor of recurrent ischemic events. Stroke 2004; 35:1147.
- Sabatine MS, Morrow DA, Giugliano RP, et al. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation 2005; 111:2042.
- Aronson D, Suleiman M, Agmon Y, et al. Changes in haemoglobin levels during hospital course and long-term outcome after acute myocardial infarction. Eur Heart J 2007; 28:1289.
- Eikelboom JW, Mehta SR, Anand SS, et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation 2006; 114:774.
- Wang TY, Xiao L, Alexander KP, et al. Antiplatelet therapy use after discharge among acute myocardial infarction patients with in-hospital bleeding. Circulation 2008; 118:2139.
- Dorsch MF, Lawrance RA, Sapsford RJ, et al. Poor prognosis of patients presenting with symptomatic myocardial infarction but without chest pain. Heart 2001; 86:494.
- Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet 1999; 354:708.
- Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001; 344:1879.
- Tu JV, Austin PC, Chan BT. Relationship between annual volume of patients treated by admitting physician and mortality after acute myocardial infarction. JAMA 2001; 285:3116.
- Casale PN, Jones JL, Wolf FE, et al. Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction. J Am Coll Cardiol 1998; 32:885.
- Jollis JG, DeLong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med 1996; 335:1880.
- Thiemann DR, Coresh J, Oetgen WJ, Powe NR. The association between hospital volume and survival after acute myocardial infarction in elderly patients. N Engl J Med 1999; 340:1640.
- Ayanian JZ, Landrum MB, Guadagnoli E, Gaccione P. Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med 2002; 347:1678.
- FACTORS PRESENT BEFORE MI
- Number of CHD risk factors
- Older age
- Prior MI
- Peripheral artery disease
- Obstructive sleep apnea
- Chronic kidney disease
- Prior stroke
- Recent aspirin use
- HEART FAILURE
- Ischemic MR
- Killip class
- Sustained ventricular arrhythmias
- Atrial fibrillation
- SILENT ISCHEMIA
- BNP and N-pro-BNP
- C-reactive protein
- Heart-type fatty acid binding protein
- Multimarker approach
- INCOMPLETE REVASCULARIZATION
- SERUM POTASSIUM
- GLYCEMIC CONTROL
- WHITE BLOOD CELL COUNT
- ANEMIA AND MAJOR BLEEDING
- PSYCHOSOCIAL AND OTHER SOCIAL FACTORS
- MI WITHOUT CHEST PAIN
- MI WITH NORMAL CORONARY ARTERIES
- CLINICIAN AND HOSPITAL EXPERIENCE