[Prognostic stratification in non-ST-elevation acute coronary syndromes: how and why].

Prognostic stratification is essential for the correct management of acute coronary syndromes (ACS). Across the whole spectrum of ACS, prognosis is strongly differentiated and also easy to establish. Shock identifies a small subgroup of patients including more than 50% of total mortality of acute ST-elevation myocardial infarction (STEMI). In non-ST-elevation (NSTE) ACS and in STEMI, heart failure represents a clinical variable with a strong prognostic value: in the GRACE registry only 15% of patients had heart failure with a mortality of 12.4 vs 1.1% in the other patients without heart failure; this important difference was interestingly evident in non-STEMI as well as in STEMI. Age is another pivotal risk indicator like heart rate and systolic blood pressure. It is noteworthy that the prognostic benefit deriving from resource utilization increases in ACS with the level of personal risk. This is true for the use of primary angioplasty in national registries of STEMI as well as for the early invasive strategy in NSTE-ACS in several trials; conversely, the use of aggressive strategies in low-risk ACS populations is often lacking of relevant results on hard endpoints. In our healthcare system with limited resources and with an inhomogeneous structure across the country, regionalization of care is the most efficient choice. Scientific Italian Societies redefined risk criteria for ACS in order to ensure priority to complex care for high-risk subgroups.