Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Assessing Risk Post Intervention for an Acute Coronary Syndrome: A Review of the Risk Assessment Tools and Their Development

Academic journal article Contemporary Nurse : a Journal for the Australian Nursing Profession

Assessing Risk Post Intervention for an Acute Coronary Syndrome: A Review of the Risk Assessment Tools and Their Development

Article excerpt

In 2010 an estimated 785,000 Americans had a new coronary event (American Heart Association, 2010). Effective risk stratification is required for the 5 million patients arriving with chest pain in emergency departments (EDs) in the United States of America (Cannon & Greenberg, 2008). The first essential component is the diagnosis of Acute Coronary Syndrome (ACS) and the identification of those patients at high risk of either a major or non major cardiac event post intervention for the ACS. To achieve this the clinician needs to use validated risk score instruments for risk stratification. ACS is the most common cause of mortality in the western world (Alter, Ventkatesh & Chong, 2008). The early diagnosis and stratification of ST-segment elevation Myocardial Infarction (STEMI), non ST-segment elevation Myocardial Infarction (NSTEMI), and unstable angina (UA) is critical for assessing risk, guiding therapy and ultimately improving outcomes. Prediction of risk of a secondary event using valid and reliable instruments needs to be established to ensure that the most effective therapy and management of the primary event is chosen to decrease those secondary risks.

Guidelines advocate that eligible patients receive definitive reperfusion therapy with fibrinolytic administration within 30 minutes of arrival to the ED or Percutaneous Coronary Intervention (PCI) to be commenced no later than 90 minutes of admission to the ED. These benchmarks have been identified as important quality indicators in the management and reduction of mortality in patients diagnosed with STEMI by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (TJC) (Bradley et al., 2006; McNamara et al., 2006).

PCI is increasingly used to treat complex coronary lesions that involve multiple vessels increasing the risk for the patient. Secondary risk scoring instruments are needed to identify high risk patients for major cardiac and non cardiac events up to 1 year after ACS. Several risk instruments (clinical prediction models) using demographic and electrocardiographic variables have been developed, and integrated into national guidelines (Anderson et al., 2007). A number of multivariate prognostic models have been developed in populations with STEMI and NSTEMI. Most of the models have been derived from databases from clinical trials. Other predictive models have been developed using large databases. Some of the most robust clinical prediction tools have been developed in selected populations of patients with STEMI (Granger et al., 2006; Ramsay, Podogrodzka, McClure, & Flox, 2007). This paper will identify the secondary clinical risk assessment prediction models and compare their psychometric properties in the ACS population with a focus on their use in the PCI era for STEMI patients.

METHODS

The following databases were searched: Medline, Cumulative Index to Nursing and Allied Health Literature, Psychology and Behavioral Sciences Collection, Medline Plus and ProQuest between the dates of 1990 and 2010. The following search terms were used: Secondary cardiovascular risk scoring tools/statistics and numerical data/PCI/ STEMI/Primary PCI/mortality/morbidity associated with PCI. Literature that explored the tools for predictability of events post ACS was reviewed by the author. The search strategy and results were verified with the assistance of a medical librarian skilled in systematic reviews. Only tools that reported estimates of reliability and validity were included in this review. Review of the psychometric (design and analysis) properties of the secondary cardiovascular risk scoring tools were based on the criteria developed by Melnyk and Fineout- Overholt (2005); use of appropriate methods to test validity; adequate validity; reassessment of validity and reliability in contrasted samples; appropriate methods to test reliability and adequate reliability; discussion of strengths and weaknesses of instrument reliability and validity; sensitivity and specificity methods; and report on responsiveness in relation to clinically important differences. …

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