Risk stratifying the acute coronary syndrome patient: a focus on treatable risk.

Providing the optimal treatment for patients who present to the emergency room with chest pains or suspected acute coronary syndrome (ACS) remains a dilemma for many practitioners due to subjectivity, delayed diagnoses, and widely variable mechanisms with similar clinical presentations. In treating patients with chest pain but no obvious electrocardiogram changes, practitioners frequently utilize the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines. The guidelines group possible ACS patients together as unstable angina/non-ST-segment elevation myocardial infarction (NSTEMI) and recommend that treatment be based on level of risk. The challenge for practitioners is discriminating between "risk" and "treatable risk." Evaluation of troponin levels can help identify patients with possible ACS who are at high risk of death and MI, and guide early decision making. Available data indicate that in the troponin-negative patient, routine interventions such as unfractionated heparin, glycoprotein IIb/IIIa receptor antagonists, and invasive approaches have no benefit in terms of reducing death and MI. Although the ACC/AHA Guidelines combine patients with unstable angina and NSTEMI, it is essential to evaluate troponin status in order to optimize patient outcomes and safety in the treatment of suspected ACS.