The sum of scores is applied to a reference nomogram to determine all-cause mortality from hospital discharge to 6 months. The GRACE clinical applica- tion tool is a web-based downloadable application available at http://www.outcomes-umassmed.org/grace/ (Figure 2).44,135 Among patients with a higher TIMI risk score (eg, 3), there is a greater benefit from therapies such as low-molecular- weight heparin (LMWH),133,136 platelet GP IIb/IIIa inhibitors,137 and an invasive strategy.138 Similarly, the GRACE risk model can identify patients who would benefit from an early invasive Patients with elevated cardiac troponin benefit from more aggressive therapy, whereas those without elevated car- diac troponins may not.140 This is especially true for women in whom some data suggest adverse effects from invasive thera- pies in the absence of an elevated cardiac troponin value.141 Although B-type natriuretic peptide and N-terminal pro B- type natriuretic peptide are not useful for the diagnosis of ACS per se (but rather HF, which has many etiologies), they add The 12-lead ECG is pivotal in the decision pathway for the eval- uation and management of patients presenting with symptoms suggestive of ACS.58,59,85 Transient ST changes ( 0.5 mm [0.05 mV]) during symptoms at rest strongly suggest ischemia and underlyingsevereCAD.Patientswithoutacuteischemicchanges on ECG have a reduced risk of MI and a very low risk of in- hospital life-threatening complications, even in the presence of confounding electrocardiographic patterns such as LV hypertro- ST depression (especially horizontal or downsloping) is highly suggestive of NSTE-ACS.21,146,147 Marked symmetrical precordial T-wave inversion ( 2 mm [0.2 mV]) suggests acute ischemia, particularly due to a critical stenosis of the left anterior descending coronary artery148,149 ; it may also be seen with acute pulmonary embolism and right-sided ST-T changes. 