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Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes
  1. R Navin Balasubramanian1,
  2. Greg B Mills1,
  3. Chris Wilkinson2,3,
  4. Roxana Mehran4,
  5. Vijay Kunadian1,3
  1. 1 Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
  2. 2 Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
  3. 3 Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
  4. 4 The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Professor Vijay Kunadian, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne NE2 4HH, UK; vijay.kunadian{at}


We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients’ baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.

  • Cardiac Catheterization
  • Acute Coronary Syndrome
  • Atherosclerosis
  • Coronary Stenosis

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  • Contributors VK conceived the idea and undertook multiple revisions. RNB wrote multiple drafts. GBM, CW and RM performed critical review and revisions.

  • Funding VK has received research funding from the British Heart Foundation (CS/15/7/31679). CW is funded by the NIHR as an Academic Clinical Lecturer. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.