[Acute coronary syndromes without persistent ST-segment elevation: is risk stratification correctly applied?].

Risk stratification of patients with acute coronary syndromes is of paramount importance in achieving maximal benefit from current therapeutic modalities and for correct resource allocation. Since risk prediction based on the integration of key prognostic variables is relatively inaccurate, the clinical guidelines of the European Society of Cardiology (which have been endorsed by the Italian Federation of Cardiology) suggest an univariate approach favoring the sensitivity of the detection of high-risk patients compromising specificity. Such an approach is likely to identify a large population of high-risk patients possibly causing a mismatch between the number of patients in need of invasive evaluation and treatment, and the availability of interventional resources. Most of the risk of adverse cardiac events can be captured by the observation of three prognostic indicators: the presence of heart failure, the finding of ST-segment shifts (both elevation or depression) in the presenting electrocardiogram, and the elevation of markers of myocardial damage. The risk can be even higher in subjects who concurrently display additional risk features such as diabetes, renal insufficiency, advanced age, or previous revascularization procedures. Such patients are likely to be less treated both medically and invasively, than patients without such characteristics. The results of Italian regional registries show a favorable temporal trend toward a more a aggressive approach in such neglected high-risk subgroups.