Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non–ST‐Segment–Elevation Myocardial Infarction

Abstract

BackgroundIntensive care unit (ICU) use for initially stable patients presenting with non–ST‐segment–elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high‐risk patients with NSTEMI for ICU admission.Methods and ResultsUsing the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high‐grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU‐level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST‐segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C‐statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU.ConclusionsThe ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources.

A machine learning model to predict critical care outcomes in patient with chest pain visiting the emergency department

“…[5,6] The aim for preparing the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU score was to predict the complications requiring ICU care in patients with non-ST elevation myocardial infarction (NSTEMI), but reported low accuracy both in development and externally validated cohorts, thereby resulting in its restricted use in clinical prediction models. [7,8] Several established clinical outcome scores have been used for risk strati cation of patients with chest pain presenting to the ED, including the History, Electrocardiography (ECG), Age, Risk factors, and Troponin (HEART); [9] the Thrombolysis in Myocardial Infarction (TIMI); [10] and the Global Registry of Acute Coronary Events (GRACE) score. [11] The commonly used prediction outcome is major adverse cardiovascular events (MACE), [12] namely myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), coronary artery stenosis, cardiac arrest, all-cause mortality, etc.…”

Hyperuricemia is a Risk Factor for One-Year Overall Survival in Elderly Female Patients with Acute Coronary Syndrome

“…In fact, almost one out of two patients hospitalized for ACS is >75 years of age [9]. Despite the application of various risk stratification schemes in patients with ACS [10][11][12][13], risk stratification for elderly ACS patients remains challenging due to the lack of sufficient data and reports.…”

Which patients with acute coronary syndrome need the cardiac intensive care unit: tuning the tools for risk stratification

“…10 In patients with non-ST-segment elevation myocardial infarction (NSTEMI), the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) intensive care unit (ICU) risk score uses nine variables on admission (age, serum creatinine, HR, SBP, initial troponin, signs/symptoms of heart failure, ST depression, prior revascularization, chronic lung disease) to estimate the likelihood that an initially stable NSTEMI patient will develop a complication requiring critical care. 11 An ACTION ICU risk score of 2 or less identifies 15% of the NSTEMI population with a risk of less than 5% or a score of 5 or less captures nearly 50% of the population with a less than 10% probability of complications during the index admission (cardiac arrest, shock, high-grade atrioventricular block, respiratory failure, stroke, or death). Each of these tools uses readily available clinical data at the time of admission to stratify risk effectively.…”

“…The study illustrates the potential value of an integrated approach to risk assessment using the clinical presentation and biomarkers to stratify risk more effectively, and builds on the emergency use of high-sensitivity troponin to identify very low-risk patients with suspected ACSs. 7,11 Imagine a patient less than 70 years old, with no previous stroke, SBP of 125 mmHg, heart rate 97 beats/minute, presenting with an anterior STEMI without left main coronary involvement, and successfully treated (TIMI flow 3) with primary PCI in less than 90 minutes, without heart failure signs (Killip I), hyperglycemia (<180 mg/dL) or arrhythmia at admission. In this case, the estimated risk of shock is less than approximately 5% with the simple shock index and is 1.4% using the ORBI risk score (https://www.…”

“…6 In NSTEMI, a low ACTION ICU risk score or GRACE risk score might help to select a low-risk group. 11 Future advances may include the integration of novel biomarkers, multimarker profiling and advanced imaging to help direct the right patient to the right bed. Nevertheless, diverse structures and staffing of non-ICU units will continue to require clinicians to be aware of their own institutional capacity (e.g.…”