Myocardial infarction – ClinCaseQuest

Killip Classification for Heart Failure

Nataliia Lopina — Mon, 29 Nov 2021 07:08:00 +0000

Killip Classification for Heart Failure could be used in patients with confirmed acute coronary syndrome in both STEMI and NSTEMI for mortality prediction.

Can be used as part of the full clinical picture to help decide among treatment options, including reperfusion therapy and intra-aortic balloon pump placement. Predicts mortality in ACS and is validated for both STEMI and NSTEMI.

Killip Classification for Heart Failure

Classification

No signs of congestion
S3 and basal rales on auscultation
Acute Pulmonary oedema
Cardiogenic shock

Class	30-day mortality*	In-hospital mortality** (historical interest only)
0	0	0

Killip classification:

Class I	No signs of congestion
Class II	S3 and basal rales on auscultation
Class III	Acute pulmonary oedema
Class IV	Cardiogenic shock

Interpretation:

Class	30-day mortality*	In-hospital mortality (historical interest only)**
I	2-3%	<6%
II	5-12%	<17%
III	10-20%	38%
IV	10-20%	81%

*From Khot 2003, which combined class III/IV owing to relatively smaller number of patients in class IV (0.3% of patients).
**From Killip 1967. Killip classification developed in the 1960s, before reperfusion therapy (thrombolytics, PCI); has been shown across several studies since then to still be predictive of mortality. However, mortality rates have declined significantly since the original study.

About the creator

Thomas Killip III, MD, is a professor of medicine and cardiology at Mount Sinai Beth Israel Hospital in New York City. He has published dozens of studies in cardiology since the 1960s. Dr. Killip is best known for the heart failure classification system that bears his name. To view Dr. Thomas Killip III’s publications, visit PubMed

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References:

Thomas Killip III, John T. Kimball Treatment of myocardial infarction in a coronary care unit. Two year experience with 250 patients. Symposium on coronary care unit. 1967, Vol.20(4):P457-464. DOI: https://doi.org/10.1016/0002-9149(67)90023-9
Khot UN, Jia G, Moliterno DJ, Lincoff AM, Khot MB, Harrington RA, Topol EJ. Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes: the enduring value of Killip classification. JAMA. 2003 Oct 22;290(16):2174-81. doi: 10.1001/jama.290.16.2174. PMID: 14570953. https://pubmed.ncbi.nlm.nih.gov/14570953/
DeGeare VS, Boura JA, Grines LL, O’Neill WW, Grines CL. Predictive value of the Killip classification in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol. 2001 May 1;87(9):1035-8. doi: 10.1016/s0002-9149(01)01457-6. PMID: 11348598. https://pubmed.ncbi.nlm.nih.gov/11348598/
Nesković AN, Otasević P, Bojić M, Popović AD. Association of Killip class on admission and left ventricular dilatation after myocardial infarction: a closer look into an old clinical classification. Am Heart J. 1999 Feb;137(2):361-7. doi: 10.1053/hj.1999.v137.89744. PMID: 9924172. https://pubmed.ncbi.nlm.nih.go v /9924172/

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Stephen Smith’s formula for Subtle Anterior STEMI online Calculator

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Stephen Smith’s formula for Subtle Anterior STEMI online Calculator

Nataliia Lopina — Tue, 16 Nov 2021 13:39:00 +0000

Differentiates normal variant ST elevation (benign early repolarization) from anterior STEMI, more sensitive than 3-variable version. Dr. Steven Smith has about 90% sensitivity and specificity.

Stephen Smith’s formula for Subtle Anterior STEMI use in chest pain patients presenting with an ECG that is non-diagnostic but suspicious for anterior MI.

NB! Before using this calculator, make sure the EKG shows ≥1 mm ST elevation (STE) in ≥1 of the precordial leads V2-V4.

If it shows any one of the following, then it is NOT normal variant, and is very likely to be LAD occlusion; such cases were excluded from the study as “obvious” MI:

>5 mm STE.
Non-concave STE.
Inferior reciprocal changes ST in II, III, aVF, V6.
Anterior ST depression.
Terminal QRS distortion in V2 or V3:

Q waves in any of V2 to V4.
Any T wave inversion from V2 to V6.

Bazett-corrected QT interval

QRS amplitude in lead V2
[Please, enter if you want to get the value according to Stephen Smith’s 4-Variable formula for receiving the highest sensitivity and specificity of the calculated values]:

R wave amplitude in lead V4:

ST segment elevation 60 ms after the J point in lead V3:

Score	Stephen Smith’s formula	Range of values	Conclusion
0	0	0	0

Score	Stephen Smith’s formula	Range of values	Conclusion
0	0	0	0

Both benign early repolarization and STEMI cause ST elevation. The challenge is to differentiate the two entities.

Some patients present with subtle ECG changes nondiagnostic for STEMI but still have 100% coronary artery occlusion and benefit from acute percutaneous coronary intervention (PCI).

Using the equation in such cases can lead to timely cath lab activation, or more intensive evaluation.

Stephen Smith’s formula for the diagnosis of “Insidious” anterior ST-segment elevation acute myocardial infarction (4 variables) includes:

Interval QTc with Bazett correction, msec
Amplitude of QRS in lead V2, mm
Amplitude of the R wave in lead V4, mm
ST segment elevation 60 ms after the J-point in lead V3 mm

Formula:

3-variable formula for subtle anterior STEMI = 3-variable = (1.196 x STE 60 elevation in V3, mm) + (0.059 x Bazett QTc interval, ms) – (0.326 x R amplitude in lead V4, mm)

4-variable formula for subtle anterior STEMI = 4-variable = (0.052 x Bazett QTc interval, ms) – (0.151 x QRS amplitude in lead V2, mm) – (0.268 x R amplitude in lead V4, mm) + (1.062 x STE 60 elevation in V3, mm)

STE – ST-elevation 60 ms after the J-point in lead V3, in mm;
QTc – QT interval corrected relative to heart rate, in ms (according to automatic ECG analysis);
RV4 – the amplitude of the R wave in lead V4, in mm;

Interpretation of 3-component formula results:

Indicators ≥23.4, probably there is PNA occlusion.
Indicators 22-23.4 – the value does not reach the diagnostic threshold of 23.4, but there is a possibility that the patient has PNA occlusion.
Indicators <23.4, low probability of PNA occlusion, possible benign early ventricular repolarization.

Interpreting the results of the 4-component formula:

Scores ≥18.2 are likely to be for anterior STEMI (sensitivity 83.3%, specificity 87.7%, and diagnostic accuracy 85.9%).
Scores <18.2 are likely to indicate early benign repolarization.

Smith’s 4-variable formula is more sensitive than the 3-variable version of the formula.

NB! The authors specifically excluded patients with obvious MI. Using the calculator in cases that were excluded in the study may lead to a wrong result.

Tips for ECG interpretation:

1). Measure STE at 60 ms in lead V3:

ST elevation at 60 ms after the J-point in lead V3, relative to the PR segment.

Measure STE 60 ms (1½ small box after J point).
The baseline is the PR segment.
In this example, STE 60 = 4 mm.

2). Measure amplitude of R wave in V4:

In this example, RV4 = 9 mm.

3). Calculate the QTc: QTc is simply read from the computerized interpretation (uses Bazett’s formula).

Corrected QT Interval Bazett’s formula online calculator

Conclusion

Activation of a cath lab team is appropriate in patients with a positive Smith formula in the appropriate clinical context. At the very least, this result should prompt the command of the heart team to carry out repeated ECG recordings, the so-called serial ECG, and echocardiography.

The Smith Formula is best used to identify patients with LAD occlusion, which was initially considered a normal option for early repolarization.

If the Smith formula (4-variable) is negative for STEMI, proceed with caution if STEMI is still suspected.

References:

Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012;60(1):45-56.e2. https://pubmed.ncbi.nlm.nih.gov/22520989/
Driver BE, Khalil A, Henry T, Kazmi F, Adil A, Smith SW. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion – Adding QRS amplitude of V2 improves the model. J Electrocardiol. 2017;50(5):561-569. https://www.sciencedirect.com/science/article/abs/pii/S0022073617301073
Bozbeyoğlu E, Aslanger E, Yıldırımtürk Ö, et al. A tale of two formulas: Differentiation of subtle anterior MI from benign ST segment elevation. Ann Noninvasive Electrocardiol. 2018;:e12568. https://onlinelibrary.wiley.com/doi/epdf/10.1111/anec.12568

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HEART Score for Major Cardiac Events online calculator

Nataliia Lopina — Mon, 08 Nov 2021 19:01:00 +0000

Predicts 6-week risk of major adverse cardiac event. A MACE (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.

Patient’s score	Scores	Interpretation
0	0	0

HEART is an acronym of its components: History, ECG, Age, Risk factors, and troponin. Each of these is scored with 0, 1 or 2 points.

Helps ED providers risk-stratify chest pain patients into low, moderate, and high-risk groups. It designed to risk stratify patients with undifferentiated chest pain, not those already diagnosed with ACS.

HEART score system identifies patients with higher risk of having a MACE (all-cause mortality, myocardial infarction, or coronary revascularization) within in the following 6 weeks.

Addition of the selected points for assessment based on the HEART score:

History Retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, patient recognizes symptoms. Low risk features of chest pain include: well localized, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation.	Slightly suspicious	0
	Moderately suspicious	+1
	Highly suspicious	+2
ECG 1 point: No ST deviation but LBBB, LVH, repolarization changes (e.g. digoxin); 2 points: ST deviation not due to LBBB, LVH, or digoxin	Normal	0
	Non-specific repolarization disturbance	+1
	Significant ST deviation	+2
Age	<45	0
	45-64	+1
	≥65	+2
Risk factors Risk factors: HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65); atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease	No known risk factors	0
	1-2 risk factors	+1
	≥3 risk factors or history of atherosclerotic disease	+2
Initial troponin Use local, regular sensitivity troponin assays and corresponding cutoffs	≤normal limit	0
	1–3× normal limit	+1
	>3× normal limit	+2

Objectively risk-stratifies patients into low, moderate, and high-risk categories, helping guide management, leading to better resource utilization, shorter hospital and ED stays for low risk patients, and earlier interventions for moderate- and high-risk patients.

	0 points	1 point	2 points
History¹	Slightly suspicious	Moderately suspicious	Highly suspicious
EKG	Normal	Non-specific repolarization disturbance²	Significant ST deviation³
Age (years)	<45	45–64	≥65
Risk factors⁴	No known risk factors	1–2 risk factors	≥3 risk factors or history of atherosclerotic disease
Initial troponin⁵	≤normal limit	1–3× normal limit	>3× normal limit

1 – e.g. Retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, patient recognizes symptoms. Low risk features of chest pain include: well localized, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation.
2 – LBBB, typical changes suggesting LVH, repolarization disorders suggesting digoxin, unchanged known repolarization disorders.
3 – Significant ST-segment deviation without LBBB, LVH, or digoxin.
4 – HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65).
5 – Use local, regular sensitivity troponin assays and corresponding cutoffs.

Results and interpretation:

Score range	Risk of adverse cardiac event	Interpretation
0–3 points	0.9–1. 7%	In the HEART Score study, these patients were discharged (0.99% in the retrospective study, 1.7% in the prospective study)
4–6 points	12–16.6%	In the HEART Score study, these patients were admitted to the hospital. (11.6% retrospective, 16.6% prospective)
≥7 points	50-65%	In the HEART Score study, these patients were candidates for early invasive measures. (65.2% retrospective, 50.1% prospective)

NB!

HEART score system may use in patients ≥21 years old presenting with symptoms suggestive of ACS.

Do not use HEART score system if new ST-segment elevation ≥1 mm or other new ECG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.

Sometimes compared to TIMI Score for UA/NSTEMI and the GRACE ACS Risk Score (older ACS scores), but the latter two differ from the HEART in that they measure risk of death for patients with diagnosed ACS.

The HEART Score outperforms the TIMI Score for UA/NSTEMI, safely identifying more low-risk patients.

Most widely validated for regular sensitivity troponin, though has also been recently studied using high sensitivity troponin (Ljung 2019).

Some experts recommended emergency physicians use the HEART Score over the TIMI or GRACE scores for emergency department risk stratification of patients with possibly cardiac complaints.

EVIDENCE OVERVIEW

The HEART Score was originally developed by Backus et al. (2008) in a cohort of 122 patients with chest pain in an emergency department setting. The study included any patients admitted to the emergency department due to chest pain irrespective of age, prehospital assumptions, and previous medical treatments. It excluded patients with chest pain and significant ST segment elevations. Endpoints in this study were acute myocardial infarction (AMI), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and death. HEART Scores of 0-3 points confer a risk of 2.5% for any endpoint and therefore was used to support discharge from the ED. Conversely, scores 4-6 points confer a risk of 20.3%, implying admission for clinical observation is necessary. ≥7 points has a risk of 72.7% and supports early invasive strategies.

In a retrospective multicenter validation study also by Backus et al. (2010), 880 patients presenting with chest pain were evaluated. The primary endpoints studied were the same as the original study. 158 patients (17.95%) reached the primary endpoint. Of the 303 patients with HEART Scores 0 to 3, three (0.99%) had a MACE. In 413 patients with scores 4 to 6, 48 cases (11.6%) resulted in a MACE, and in HEART Scores 7 to 10, MACE was identified in 107/164 cases (65.2%).

Backus et al externally validated the HEART Score with a prospective multicenter study in 2013. The study evaluated 2,440 patients presenting with chest pain to 10 emergency departments in the Netherlands. The primary endpoint was the occurrence of any MACE within 6 weeks. The performance of the HEART Score was also compared to that of the TIMI Score for UA/NSTEMI and the GRACE ACS Risk Score. In the low risk group (score 0-3), 15/870 (1.7%) of patients were found to have a MACE. In patients with HEART scores 4-6, MACE was diagnosed in 183/1101 (16.6%). In patients with high HEART scores (values 7-10), MACE occurred in 50.1%. The c-statistic of the HEART score (0.83) was significantly higher than the c-statistic of TIMI (0.75) and GRACE (0.70) respectively (p <0.0001).

Poldervaart et al. (2017) studied the HEART Score in a stepped-wedge cluster randomized trial with the objective of measuring both outcomes and use of healthcare resources. Nine Dutch hospitals were included in the study and were instructed to start usual care when assessing patients with chest pain. Every six weeks, one hospital was randomly assigned to use the HEART Score to assess patients with chest pain. A total of 3,648 patients were included (1,827 receiving usual care and 1,821 receiving HEART care). The study found that the six-week MACE incidence while using the HEART Score was 1.3% lower than with usual care, but there were no statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners.

Recent studies have compared the HEART Score head-to-head with other clinical decision rules with regards to their ability to safely identify low risk patients. A study by Poldervaart et al. (2017) comparing the HEART Score to the TIMI and GRACE Scores showed that the HEART Score outperformed the others when identifying low risk patients, with only 0.8% incidence of MACE in the low risk group.

In addition, Nieuwets et al. (2016) compared the HEART Score with the TIMI Score, with regards to identifying low risk patients without compromising safety while also evaluating expected cost reduction. They found that the HEART Score identified more patients as low risk compared with the TIMI Score, which would have led to potential cost savings of €64,107 (~USD $76,000) by using the HEART Score cutoffs versus €14,670 (~USD $17,000) for TIMI.

The HEART Pathway developed by Mahler et al. (2015) combined the HEART Score with 0- and 3-hour cardiac troponin tests in a decision aid designed to identify ED patients safe for early discharge. The study found that the HEART Pathway decreased length of stay by 12 hours, decreased objective cardiac testing by 12%, and increased early discharges by 21%. No MACE were seen within 30 days in patients who were identified for early discharge. Of note, this study (and the original HEART Score studies) uses regular sensitivity cardiac troponin.

Literature:
Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442661/
Backus BE, Six AJ, Kelder JC, et al. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010;9(3):164-9. https://pubmed.ncbi.nlm.nih.gov/20802272/
Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-8. https://pubmed.ncbi.nlm.nih.gov/23465250/
Stopyra JP, Riley RF, Hiestand BC, et al. The HEART Pathway Randomized Controlled Trial One Year Outcomes. Acad Emerg Med. 2018; https://pubmed.ncbi.nlm.nih.gov/29920834/
Ljung L, Lindahl B, Eggers KM, et al. A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions. Ann Emerg Med. 2019;73(5):491-499. https://pubmed.ncbi.nlm.nih.gov/30661856/
Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203. https://pubmed.ncbi.nlm.nih.gov/25737484/
Nieuwets A, Poldervaart JM, Reitsma JB, et al. Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis. BMJ Open. 2016;6(6):e010694. https://bmjopen.bmj.com/content/6/6/e010694
Poldervaart JM, Langedijk M, Backus BE, et al. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol. 2017;227:656-661. https://pubmed.ncbi.nlm.nih.gov/27810290/
Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Ann Intern Med. 2017. https://www.acpjournals.org/doi/10.7326/M16-1600

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The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score

Nataliia Lopina — Sun, 31 Oct 2021 11:00:00 +0000

Cardiogenic shock complicating acute myocardial infarction: IABP-SHOCK II RISK SCORE. Risk assessment of 30-day mortality.

Patient’s IABP-SHOCK II score	Risk categories	Points
0	0	0

Mortality from cardiogenic shock remains high and early recognition and risk stratification are mandatory for optimal patient allocation and to guide treatment strategy.

The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score has shown good results in predicting short-term mortality in cardiogenic shock.

The IABP-SHOCK II risk score is a simple tool that can be rapidly calculated in the catheterization laboratory setting and applied in clinical routine. It might therefore serve for identifying patients for future clinical trials and, more importantly, it might help stratify patients according to their risk for short-term mortality and thus facilitate clinical decision making. The scoring system attributed one or two points per variable.

SCORE
Variable	Points
Age > 73 years	1
History of stroke	2
Glucose > 10.6 mmol/l (191 mg/dl)	1
Creatinine > 132.6 mmol/l (1.5 mg/dl)	1
Arterial lactate > 5 mmol/l	2
TIMI flow grade < 3 after PCI	2
Maximum	9

Interpretation

RISK CATEGORIES
Category	Points
Low	0-2
Intermediate	3-4
High	5-9

Cardiogenic Shock Complicating Acute Myocardial Infarction

The IABP-SHOCK II risk score can be easily calculated in daily clinical practice and strongly correlated with mortality in patients with infarct-related CS. It may help stratify patient risk for short-term mortality and might, thus, facilitate clinical decision making.

Source:
1. Pöss J, Köster J, Fuervan G, et al. J Am Coll Cardiol 2017; 69:1913–20
2. Douglas JS. Primary PCI: Outcomes and Quality Assessment. 2018 Jul 14. In: Watson TJ, Ong PJL, Tcheng JE, editors. Primary Angioplasty: A Practical Guide [Internet]. Singapore: Springer; 2018. Fig. 23.5. Available from: https://www.ncbi.nlm.nih.gov/books/NBK543591/figure/ch23.Fig5/ doi: 10.1007/978-981-13-1114-7_23
3. Rivas-Lasarte M, Sans-Roselló J, Collado-Lledó E, et al. External validation and comparison of the CardShock and IABP-SHOCK II risk scores in real-world cardiogenic shock patients. European Heart Journal: Acute Cardiovascular Care. January 2020. doi:10.1177/2048872619895230 https://journals.sagepub.com/doi/abs/10.1177/2048872619895230?journalCode=acca

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Email (indicate if you want the results to be sent to your email)

Date of assessment

≥1 of the following (A or B)

A. Clonal bone marrow plasma cells ≥10%

B. Biopsy-proven bony or extramedullary plasmacytoma

≥1 myeloma defining event (C1 or C2)

• C1. End organ damage attributable to underlying plasma cell disorder (≥1 of the following): *

o Hypercalcemia (Serum calcium >1 mg/dL (>0.25 mmol/L) higher than upper limit of normal or >11 mg/dL (>2.75 mmol/L))

o Renal insufficiency (Creatinine clearance<40 mL per min or serum creatinine >2 mg/dL (177 μmol/L))

o Anemia (Hemoglobin >2 g/dL (20 g/L) below lower limit of normal

o Bone lesions (≥1 osteolytic lesion on skeletal x-ray

• C2. ≥1 of the following biomarkers of malignancy: *

o Clonal bone marrow plasma cells ≥60%

o Involved:uninvolved sFLC ratio ≥100

o >1 focal lesion on MRI

Result

Diagnostic result

Negative. Not positive for multiple myeloma by IMWG criteria

Diagnostic result

Positive for multiple myeloma by IMWG criteria

Details:

* Required

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SCORE2 and SCORE2-OP scales for determining cardiovascular risk

Elena Shevchenko — Tue, 14 Sep 2021 14:00:34 +0000

Concordant ST elevation >1 mm in leads with a positive QRS complex	No
	Yes
Concordant ST depression > 1 mm in V1-V3	No
	Yes
ST Elevation at the J-point, relative to QRS onset, is at least 1 mm AND has an amplitude at least 25% of the preceding S-wave An ST/S ratio of 0.20 is also very high and almost as specific as a 0.25 ratio	No
	Yes

Criteria	Value
Age < 65 years	0
Age 65-74	+2
Age ≥ 75	+3
DM or Hypertension or Angina	+1
Systolic BP < 100 mmHg	+3
Heart Rate > 100	+2
Killip Class II-IV	+2
Weight < 67kg (147.7 lbs)	+1
Anterior ST Elevation or LBBB	+1
Time to Treatment > 4 hours	+1

Score	Risk of all-cause mortality at 30 days
0 points	0.8%
1 points	1.6%
2 points	2.2%
3 points	4.4%
4 points	7.3%
5 points	12.4%
6 points	16.1%
7 points	23.4%
8 points	26.8%
9-14 points	35.9%

Criteria	Value
Age ≥65	+1
≥3 CAD risk factors*	+1
Known CAD (stenosis ≥50%)	+1
ASA use in past 7 days	+1
Severe angina (≥2 episodes in 24 hrs)	+1
EKG ST changes ≥0.5mm	+1
Positive cardiac marker	+1

Score	Risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization
0 points	4,7%
1 points	5%
2 points	8%
3 points	13%
4 points	20%
5 points	26%
6 points	41%
7 points	41%

Myocardial infarction – ClinCaseQuest

Killip Classification for Heart Failure

Killip Classification for Heart Failure

• Opening the consultation

• Availability of a defibrillator

• Presenting complaint

• History of presenting complaint

• Past medical history

• Drug history

• Physical examination

• Intravenous access

• Registration of a 12-channel ECG

• Express test for the determination of cardiac troponin, myoglobin, creatine phosphokinase-MB, if possible

• Making preliminary diagnosis

• Drug therapy (basic)

• Evaluation of the door-balloon time (the choice of further reperfusion strategy aimed as soon as possible to restore the coronary blood flow in the infarct-dependent artery)

• Call the nearest reperfusion center

• P2Y12 receptor inhibitor prescription depending on the chosen strategy of reperfusion therapy

• Carrying out thrombolytic therapy as needed

• Transportation to the nearest reperfusion center

Stephen Smith’s formula for Subtle Anterior STEMI online Calculator

Formula:

Interpretation of 3-component formula results:

Interpreting the results of the 4-component formula:

Tips for ECG interpretation:

1). Measure STE at 60 ms in lead V3:

2). Measure amplitude of R wave in V4:

3). Calculate the QTc: QTc is simply read from the computerized interpretation (uses Bazett’s formula).

Conclusion

HEART Score for Major Cardiac Events online calculator

The Intra-Aortic Balloon Counterpulsation in Acute Myocardial Infarction Complicated by Cardiogenic Shock (IABP-SHOCK II) risk score

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

SCORE2 and SCORE2-OP scales for determining cardiovascular risk

Algorithm of use

Modified Sgarbossa’s Criteria for MI in Left Bundle Branch Block

≥1 of the following (A or B)

≥1 myeloma defining event (C1 or C2)

TIMI Risk Score for STEMI

TIMI Risk Score for unstable angina/NSTEMI

Interpretation of results: