Risk factors for adverse outcomes after non-ST elevation acute coronary syndromes
- 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.
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- 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