Savonitto S, Fusco R, Granger C B, Cohen M G, Thompson T D, Ardissino D, Califf R M
Dipartment of Cardiology Angelo De Gasperis, Niguarda Ca' Granda Hospital, Milan, Italy.
Ann Noninvasive Electrocardiol. 2001 Jan;6(1):64-77. doi: 10.1111/j.1542-474x.2001.tb00088.x.
The recent evolution in therapeutic options for acute coronary syndromes (ACS) mandates early risk stratification in order to select the appropriate treatment strategy for individual patients. Simple clinical data derived from the patient's medical history and physical examination, a standard twelve-lead electrocardiogram (ECG), and determinations of biochemical markers of myocardial damage can be obtained in the emergency room and serve as a guide for deciding appropriate medical management and optimal use of available resources. Even the most important classification of the ACS is based upon a simple and dichotomous description of the ECG, where the presence of ST-segment elevation mandates an immediate attempt to restore coronary perfusion (either pharmacologically or mechanically), whereas its absence suggests pharmacological stabilization before further evaluation. Across the whole spectrum of ACS, clinical history data (such as older age, previous coronary events, and diabetes) and clinical variables (such as higher heart rate, lower blood pressure, and higher Killip class) are the most powerful prognostic determinants at multivariate analyses derived from large databases. The ECG adds significant and independent prognostic information using the analysis of qualitative (direction of ST-segment shift, associated T-wave inversion, and presence of conduction disturbances) and quantitative (number of leads involved, amount of ST- segment shifts, duration of QRS) characteristics. Biochemical markers of myocardial damage have also been identified as independent predictors of events. In addition, retrospective analyses of clinical trials have suggested that biochemical markers might serve as a guide to select pharmacological therapy. However, how to best combine electrocardiographic and biochemical data for immediate risk stratification remains to be further elucidated.
急性冠状动脉综合征（ACS）治疗选择的最新进展要求进行早期风险分层，以便为个体患者选择合适的治疗策略。从患者病史和体格检查中获取的简单临床数据、标准的十二导联心电图（ECG）以及心肌损伤生化标志物的测定，可在急诊室获得，并作为决定适当医疗管理和优化利用现有资源的指导。即使是ACS最重要的分类也是基于对心电图的简单二分法描述，其中ST段抬高的存在要求立即尝试恢复冠状动脉灌注（通过药物或机械方法），而ST段未抬高则提示在进一步评估之前进行药物稳定治疗。在整个ACS范围内，临床病史数据（如老年、既往冠状动脉事件和糖尿病）和临床变量（如心率较高、血压较低和Killip分级较高）是来自大型数据库的多变量分析中最有力的预后决定因素。通过对定性（ST段移位方向、相关T波倒置和传导障碍的存在）和定量（涉及导联数、ST段移位量、QRS持续时间）特征的分析，心电图增加了重要且独立的预后信息。心肌损伤的生化标志物也已被确定为事件的独立预测因子。此外，对临床试验的回顾性分析表明，生化标志物可能作为选择药物治疗的指导。然而，如何最好地结合心电图和生化数据进行即时风险分层仍有待进一步阐明。
