Current status of risk stratification methods in acute coronary syndromes

Abstract

Distinguishing which patients with chest pain are at high risk versus which are at low risk remains an important clinical problem despite modern risk stratification strategies. Current approaches often over-utilize hospital resources, yet still miss a significant number of true acute coronary syndromes (ACS). This review focuses on important developments in risk stratification in ACS from 2004 through 2005. Risk models have been developed that use readily available patient characteristics, and head to head comparisons of the various models have been performed to guide clinicians in selecting between the different options. The most powerful models now include measurement of renal function, which has emerged as an important marker of risk. In addition to cardiac troponins, B-type natriuretic peptide (BNP) clearly augments risk prediction, and in the past year serial BNP measurement after discharge has shown promise as a simple way to monitor patient risk following ACS. Newer biomarkers are on the horizon but have not yet established their clinical value. Finally, advances in coronary CT angiography and bedside echocardiography offer hope that noninvasive imaging may play a more important role in early risk stratification in the near future.

Guanylyl cyclase / atrial natriuretic peptide receptor-A: role in the pathophysiology of cardiovascular regulation

“…ANP and BNP genes are overexpressed in hypertrophied hearts, suggesting that the autocrine and/or paracrine effects of natriuretic peptides predominate and might endogenously protect against maladaptive pathological cardiac hypertrophy (Ellmers et al, 2007; Felker et al, 2006; Knowles et al, 2001; Vellaichamy et al, 2005; Vellaichamy et al, 2007; Xue et al, 2008). Plasma levels of both ANP and BNP are markedly elevated under the pathophysiological conditions of cardiac dysfunction, including diastolic dysfunction, congestive heart failure, pulmonary embolism, and cardiac hypertrophy (Felker et al, 2006; Jaffe et al, 2006; Reinhart et al, 2006; See & de Lemos, 2006; Vellaichamy et al, 2005). There are indications that ventricular expression of ANP and BNP is more closely associated with local cardiac hypertrophy and fibrosis than are plasma ANP levels and systemic blood pressures (Vellaichamy et al, 2005; Vellaichamy et al, 2007).…”

Prognostic value of plasma N-terminal probrain natriuretic peptide levels in the acute respiratory distress syndrome*

“…These cardiac markers have proven utility for diagnosis and/or prognostication in a variety of clinical settings, including myocardial infarction, shock, and pulmonary embolism (10 –13). Given the evidence that extrapulmonary complications and cardiopulmonary strain play a major role in ARDS, it is likely that natriuretic peptide levels would be correspondingly elevated.…”

Preoperative Plasma N-Terminal Pro-Brain Natriuretic Peptide Concentration and Perioperative Cardiovascular Risk in Elderly Patients

“…13 The plasma concentration of NT-proBNP does not appear to be affected by inhibition of neutral endopeptidase. Both BNP and NT-proBNP are widely used in the diagnosis and prognosis of congestive heart failure and ischemic heart disease, [14][15][16][17][18][19][20] and can be measured easily at low cost and in a short time.…”