State-of-the-Art Paper
Acute Coronary Syndrome: Emerging Tools for Diagnosis and Risk Assessment

https://doi.org/10.1016/j.jacc.2009.09.071Get rights and content
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Acute coronary syndrome encompasses a broad and heterogeneous population that challenges the clinician at each step of treatment in terms of: 1) diagnosis; 2) appropriate risk stratification; 3) therapeutic decision making; and 4) monitoring response to therapy. Although there are many established tools for diagnosis, prognosis, and clinical decision making, understanding the advantages and limitations of each tool according the clinical scenario is essential. Several emerging tools, such as novel biomarkers (e.g., high-sensitivity troponin and growth differential factor-15), ECG techniques (e.g., heart rate turbulence or T-wave alternans), and imaging modalities (computed tomography angiography and cardiac magnetic resonance) may potentially improve clinical care; however, they must be fully evaluated and validated in different scenarios and patient cohorts before they are incorporated into clinical practice. This review identifies promising new or emerging techniques, as well as established tools, and reviews their current or potential role in clinical practice.

Key Words

acute coronary syndrome
diagnosis
myocardial infarction
risk stratification

Abbreviations and Acronyms

ACS
acute coronary syndrome
CAD
coronary artery disease
CK-MB
creatine kinase-myocardial bound
CMR
cardiac magnetic resonance
CRP
C-reactive protein
CTA
computed tomography angiography
ECG
electrocardiographic
GDF
growth differentiation factor
HRT
heart rate turbulence
HRV
heart rate variability
MDCT
multidetector computed tomography
MI
myocardial infarction
MPI
myocardial perfusion imaging
NP
natriuretic peptide
NSTE-ACS
non–ST-segment elevation acute coronary syndrome
STEMI
ST-segment elevation myocardial infarction

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Dr. Scirica has received research grants via the TIMI Study Group and Brigham and Women's Hospital from CV Therapeutics, Novartis, AstraZeneca, Daiichi-Sankyo, Merck, Johnson and Johnson, Bayer Healthcare, and Bristol-Myers Squibb. He has received honoraria for educational presentations from CV Therapeutics, Novartis, Merck, and Schering-Plough; and has served as a consultant for AstraZeneca, Novartis, CV Therapeutics, Congentus, Shionegi, and Gilead Sciences.