lV-96 Circulation December 13, 2005 TABlE 3. Likelih Part l. chest pain p patients Wi Ischemic Etiology and Short-Term Risk thout ST-Segment Elevation: Likelihood of Ischemic Etiology A. High likelihood B. Intermediate likelihood C, Low likelihood likelihood that chest pain is of intermediate likelihood that chest Low likelihood that chest ischemic etiology if patient has any of is of ischemic etiology if patient has ischemic etiology if pater the findings in the column belot No findings in column A and any of dings in column A or B the findings in the column below ay have any of the findings in the Chief symptom is chest or left arm lief symptom is chest or left arm Probable ischemic symptoms pain or discomfit Recent cocaine us Current pain documented · Diabetes mellitus Physical Transient mitral regurgitation Extracardiac vascular disease Chest discomfort reproduced by Pulmonary edema or rales New (or presumed new)transient ST · Fixed o waves · Normal ecg or deviation (20.5 mm)or T-wave Abnormal ST segments or T waves T-wave flattening or version(22 mm)with symptoms that are not new T-wave inversion in leads with dominant R waves Cardiac I or T Any finding in column B above PLUS Normal evaded CK-MB Normal ligh(A)or Intermediate(B) Part ll. Risk of Death or Nonfatal MI Over the Short Term in Patients With Chest Pain With High or Intermediate Likelihood of Ischemia(Columns A nd B in Part D) Intermediate risk w risk Risk is high if patient has any of the Risk is intermediate if patient has any Risk is low if patient has NO high-or of the following findings intermediate-risk features; may have any of the following Accelerating tempo of ischemic · Prior mi or ymptoms over prior 48 hours Peripheral-artery disease Cerebrovascular disease or ·CABG, pnor spinn use Character of Prolonged, continuing (20 min) Prolonged(20 min) rest angina is New-onset functional angina(Class ow resolved (moderate to high ll or M) in past 2 weeks without likelihood of CAD) prolonged rest pain(but with Rest angina(<20 min) or relieved moderate or high likelihood of CAD by rest or sublingual nitrates Physical Pulmonary edema secondary to ge >70 years ischemia New or worse mitral regurgitation murmur S3 gallop or new or worsening (0.5 mm) with rest angina Pathologic Q waves or T waves that episode of chest discomfort New or presumably new bundle are not new anch bloc Cardiac Elevated cardiac troponin I or T Any of the above findings PLUs Normal markers levated CK-MB Normal Modified from Braunwald et al. circulation. 2002- 106: 1893-1900TABLE 3. Likelihood of Ischemic Etiology and Short-Term Risk Part I. Chest Pain Patients Without ST-Segment Elevation: Likelihood of Ischemic Etiology A. High likelihood High likelihood that chest pain is of ischemic etiology if patient has any of the findings in the column below: B. Intermediate likelihood Intermediate likelihood that chest pain is of ischemic etiology if patient has NO findings in column A and any of the findings in the column below: C. Low likelihood Low likelihood that chest pain is of ischemic etiology if patient has NO findings in column A or B. Patients may have any of the findings in the column below: History • Chief symptom is chest or left arm pain or discomfort plus Current pain reproduces pain of prior documented angina and Known CAD, including MI • Chief symptom is chest or left arm pain or discomfort • Age
70 years • Male sex • Diabetes mellitus • Probable ischemic symptoms • Recent cocaine use Physical exam • Transient mitral regurgitation • Hypotension • Diaphoresis • Pulmonary edema or rales • Extracardiac vascular disease • Chest discomfort reproduced by palpation ECG • New (or presumed new) transient ST deviation (0.5 mm) or T-wave inversion (2 mm) with symptoms • Fixed Q waves • Abnormal ST segments or T waves that are not new • Normal ECG or T-wave flattening or T-wave inversion in leads with dominant R waves Cardiac markers • Elevated troponin I or T • Elevated CK-MB Any finding in column B above PLUS • Normal • Normal High (A) or Intermediate (B) Likelihood of Ischemia Part II. Risk of Death or Nonfatal MI Over the Short Term in Patients With Chest Pain With High or Intermediate Likelihood of Ischemia (Columns A and B in Part I) High risk: Risk is high if patient has any of the following findings: Intermediate risk: Risk is intermediate if patient has any of the following findings: Low risk: Risk is low if patient has NO high- or intermediate-risk features; may have any of the following: History Character of pain • Accelerating tempo of ischemic symptoms over prior 48 hours • Prolonged, continuing (
20 min) rest pain • Prior MI or • Peripheral-artery disease or • Cerebrovascular disease or • CABG, prior aspirin use • Prolonged (
20 min) rest angina is now resolved (moderate to high likelihood of CAD) • Rest angina (20 min) or relieved by rest or sublingual nitrates • New-onset functional angina (Class III or IV) in past 2 weeks without prolonged rest pain (but with moderate or high likelihood of CAD) Physical exam • Pulmonary edema secondary to ischemia • New or worse mitral regurgitation murmur • Hypotension, bradycardia, tachycardia • S3 gallop or new or worsening rales • Age
75 years • Age
70 years ECG • Transient ST-segment deviation (0.5 mm) with rest angina • New or presumably new bundle branch block • Sustained VT • T-wave inversion 2 mm • Pathologic Q waves or T waves that are not new • Normal or unchanged ECG during an episode of chest discomfort Cardiac markers • Elevated cardiac troponin I or T • Elevated CK-MB Any of the above findings PLUS • Normal • Normal Modified from Braunwald et al. Circulation. 2002;106:1893–1900. IV-96 Circulation December 13, 2005