The prognostic value of increased concentrations of cardiac troponin (cTn(+)) in patients with acute coronary syndromes (ACS) for short and long term mortality is well established by both meta-analyses of clinical trials and cohort studies. The clinical implications, however, of acute myocardial infarction (AMI) diagnosed on the basis of cTn(+) in the absence of creatine kinase (CK) rise (CK(–)) among unselected patients with ACS is unclear. Several studies noted that cTn(+)/CK(+) patients had the worst prognosis, whereas others found that CK(+) did not confer any incremental prognostic value above cTn(+).^1–4 In risk stratification of patients with non-ST elevation (NSTE) ACS another important tool is the ECG, particularly when ST segment depression is observed. Whether this information is independent of and additive to that provided by a biomarker rise is insufficiently studied. The main purpose of this study was to examine whether cTn, CK, and ST depression offer complementary prognostic information in the risk stratification of unselected patients presenting with NSTE-ACS in the “real world”.

METHODS

ACSIS (acute coronary syndrome Israeli survey) was a prospective observational national survey of all patients with ACS hospitalised in all 25 coronary care units and cardiology wards in all general hospitals in Israel from 1 February to 30 March 2002. For the present study we analysed all patients with an admission diagnosis of NSTE-ACS. All biomarkers were measured at local hospital laboratories. CK assays were considered CK(+) if they were > 2 times the …