GRACE scores or high-sensitivity troponin for timing of coronary angiography in non-ST-elevation acute coronary syndromes

BACKGROUND

The GRACE risk score is generically recommended by guidelines for timing of invasive coronary angiography without stating which score should be used. The aim was to determine the diagnostic performance of different GRACE risk scores in comparison to the ESC 0/1 h-algorithm using high-sensitivity cardiac troponin (hs-cTn).

METHODS

Prospectively enrolled patients presenting with symptoms suggestive of myocardial infarction (MI) in two large studies testing biomarker diagnostic strategies were included. Five GRACE risk scores were calculated. The amount of risk reclassification and the theoretical impact on guideline-recommended timing of invasive coronary angiography was studied.

RESULTS

Overall, 8,618 patients were eligible for analyses. Comparing different GRACE risk scores, up to 63.8% of participants were reclassified into a different risk category. The proportion of MIs identified (i.e., sensitivity) dramatically differed between GRACE risk scores (range 23.8-66.5%) and was lower for any score than for the ESC 0/1 h-algorithm (78.1%). Supplementing the ESC 0/1 h-algorithm with a GRACE risk score slightly increased sensitivity (P < 0.001 for all scores). However, this increased the number of false positive results.

CONCLUSION

The substantial amount of risk reclassification causes clinically meaningful differences in the proportion of patients meeting the recommended threshold for pursuing early invasive strategy according to the different GRACE scores. The single best test to detect MIs is the ESC 0/1 h-algorithm. Combining GRACE risk scoring with hs-cTn testing slightly increases the detection of MIs but also increases the number of patients with false positive results who would undergo potential unnecessarily early invasive coronary angiography.

Diagnostic and prognostic role of serum interleukin-6 and carotid ultrasonography to detect subclinical atherosclerosis in patients with RA and ANCA-associated vasculitis

ANCA-associated vasculitis (AAV) can affect multiple organs with severe life-threatening manifestations. Disease monitoring is difficult due to a lack of defined biomarkers. We aimed to assess the diagnostic role of serum interleukin-6 and vascular ultrasonography in AAV and subclinical atherosclerosis. The study included 20 AAV patients and two control groups of 34 patients with rheumatoid arthritis (RA) and 35 healthy controls. The levels of Il-6, carotid intima-media thickness test (CIMT), atherosclerotic plaque, and degree of stenosis were investigated. A GRACE-risk score was calculated for AAV and RA patients. The AAV patients had elevated levels of IL-6 (115 ± 23.96) compared to the RA patients (91.25 ± 42.63) and the healthy controls (15.65 ± 3.30), p < 0.001. IL-6 showed a diagnostic accuracy of 73% in distinguishing AAV from RA patients (AUC = 0.730; 95% CI 0.591 to 0834). In the AAV group, CIMT was 1.09, above the upper reference value of 0.90, p < 0.001. The AAV patients had a higher median GRACE risk score, and 60% of them had a high risk of cardiovascular events as compared to 35% of the RA patients. Sonography of extracranial vessels and serum levels of IL-6 can be used in daily clinical practice to diagnose and monitor patients with AAV.

To Evaluate Platelet Indices, Platelet to Lymphocyte Ratio and Neutrophil to Lymphocyte Ratio as Prognostic and Risk Factors in Patients with Coronary Artery Disease

To evaluate platelet indices, platelet to lymphocyte ratio and neutrophil to lymphocyte ratio as prognostic and risk factors in patients with coronary artery disease Introduction: cardiovascular diseases have 12 million deaths annually which is one of the commonest causes of death globally. Platelet parameters like Mean platelet volume (MPV), platelet distribution width (PDW) and WBC parameters like Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio(PLR) have recently been emerging as a new prognostic marker in number of coronary artery disease (CAD) with limited studies to explore their utility.

AIMS AND OBJECTIVES

this study aimed to evaluate MPV, P-LCR, PDW, PLR, NLR and GRACE risk score in CAD patients.

MATERIAL AND METHODS

this descriptive cross-sectional study was done in 330 cases of CAD and 200 healthy controls were studied.MPV, platelet-large cell ratio (P-LCR), PLR, NLR and PDW of patients were analyzed.

RESULTS

In our study, 245 were males and 85 were females. Mean PDW, MPV, Mean PLCR, Mean NLR was significantly higher in CAD cases as compared to controls (p value < 0.05). Mean PLR was not significantly different in CAD cases and controls. MPV was more associated risk predictor of CAD (8.98 times) followed by NLR (2.79 times), PDW (1.53 times) and PLCR (1.02 times).

DISCUSSION AND CONCLUSION

platelet indices, NLR and PLR are simple cost effective parameters and in future these might be useful adjuvant tests in conjunction with conventional biochemical cardiac markers in early prediction of risk of CAD in patients admitted to hospital and can guide clinicians in assessing the prognosis on short and long term follow up of these patients in terms of morbidity and mortality.

External validation of the GRACE risk score in patients with myocardial infarction in Hungary

Background

Literature confirms that the Global Registry of Acute Coronary Events (GRACE) risk score provides a better risk evaluation than clinical judgment in patients with acute myocardial infarction. We aimed to externally validate the GRACE risk score in unselected patients with myocardial infarction in Hungary.

Methods

Data from the comprehensive Hungarian Myocardial Infarction Registry (HUMIR), a national registry that collects data on consecutive acute myocardial infarction (AMI) patients, were used. Hospitals registered 102,939 infarction events in the HUMIR between January 1, 2014, and December 31, 2020. The data required to calculate GRACE risk score were available for 75,199 events. We studied the 6-months, 1-year, and 3-year outcomes. We calculated widely used metrics to characterise calibration (calibration curve, calibration intercept and slope, Eavg, Emax, and E90) and discrimination (c-score, equivalent to AUC, and Somer's D_xy).

Results

The risk of low-risk patients was underestimated, and the risk of high-risk patients was overestimated. However, the deviation was small, especially for the three-year survival (E90 was 0.15, 0.22, and 0.08). Discrimination was good, with an AUC of approximately 0.8, and was very similar in all the periods.

Conclusions

These data confirmed the usefulness of GRACE risk score in selecting high-risk patients with myocardial infarction in the Hungarian population.

Adjustment of the GRACE Risk Score by Monocyte to High-Density Lipoprotein Ratio Improves Prediction of Adverse Cardiovascular Outcomes in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Background and Aims

The monocyte to high-density lipoprotein cholesterol ratio (MHR), a novel marker for inflammation and lipid metabolism, has been demonstrated to be associated with poor prognosis in many patient populations. However, the prognostic influence of MHR in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) is poorly understood. Here, we sought to investigate the relationship between MHR and adverse cardiovascular (CV) outcomes in such patients and determine whether MHR could improve the GRACE risk score based prognostic models.

Methods and Results

MHR was applied to 1,720 patients with ACS undergoing PCI who were admitted to our CV center from June 2016 to November 2017. These patients were stratified into three groups according to MHR tertiles. The relationship between MHR and the primary endpoint (overall death, non-fatal stroke, non-fatal myocardial infarction, or unplanned repeat revascularization) was examined by Cox proportional hazards regression analysis. During a median follow-up of 31 months, 353 patients had at least one primary endpoint event. Compared with those in the lowest MHR tertile, patients in the middle and highest tertiles [adjusted HR: 1.541 (95% CI: 1.152–2.060) and 1.800 (95%CI: 1.333–2.432), respectively], had a higher risk of the primary endpoint. The addition of MHR has an incremental effect on the predictive ability of the GRACE risk score for the primary endpoint (cNRI: 0.136, P < 0.001; IDI: 0.006, P < 0.001).

Conclusion

MHR was independently and significantly associated with adverse CV outcomes in ACS patients who underwent PCI and improved the predictive ability of the GRACE risk score based prognostic models.

Registration Number

http://www.chictr.org.cn/hvshowproject.aspx?id=21397; ChiCTR1800017417.

Impact of nutritional status on prognosis in acute myocardial infarction patients undergoing percutaneous coronary intervention

BACKGROUND

Malnutrition affects the prognosis of cardiovascular disease. Acute myocardial infarction (AMI) has been a major cause of death around the world. Thus, we investigated the impact of malnutrition as defined by Geriatric Nutritional Risk Index (GNRI) on mortality in AMI patients.

METHODS

In 268 consecutive AMI patients who underwent percutaneous coronary intervention (PCI), associations between all-cause death and baseline characteristics including malnutrition (GNRI < 92.0) and Global Registry of Acute Coronary Events (GRACE) risk score were assessed.

RESULTS

Thirty-three patients died after PCI. Mortality was higher in the 51 malnourished patients than in the 217 non-malnourished patients, both within 1 month after PCI (p < 0.001) and beyond 1 month after PCI (p = 0.017). Multivariate Cox proportional hazards regression modelling using age, left ventricular ejection fraction and GRACE risk score showed malnutrition correlated significantly with all-cause death within 1 month after PCI (hazard ratio [HR] 7.04; 95% confidence interval [CI] 2.30-21.51; p < 0.001) and beyond 1 month after PCI (HR 3.10; 95% CI 1.70-8.96; p = 0.037). There were no significant differences in area under the receiver-operating characteristic (ROC) curve between GRACE risk score and GNRI for predicting all-cause death within 1 month after PCI (0.90 vs. 0.81; p = 0.074) or beyond 1 month after PCI (0.69 vs. 0.71; p = 0.87). Calibration plots comparing actual and predicted mortality confirmed that GNRI (p = 0.006) was more predictive of outcome than GRACE risk score (p = 0.85) beyond 1 month after PCI. Furthermore, comparison of p-value for interaction of malnutrition and GRACE risk score for all-cause death within 1 month after PCI, beyond 1 month after PCI, and the full follow-up period after PCI were p = 0.62, p = 0.64 and p = 0.38, respectively.

CONCLUSIONS

GNRI may have a potential for predicting the mortality in AMI patients especially in beyond 1 month after PCI, separate from GRACE risk score. Assessment of nutritional status may help stratify the risk of AMI mortality.

Combination of TyG Index and GRACE Risk Score as Long-Term Prognostic Marker in Patients with ACS Complicated with T2DM Undergoing PCI

OBJECTIVE

We aimed to investigate the prognostic value of the triglyceride-glucose (TyG) index combined the with Global Registry of Acute Coronary Events (GRACE) score in adult acute coronary syndrome (ACS) patients with type 2 diabetes mellitus (T2DM) who underwent percutaneous coronary intervention (PCI).

METHODS

The study enrolled total 899 ACS patients with T2DM who underwent PCI. TyG index and the GRACE risk score were calculated and assessed by median. The correlation was analyzed by Spearman's rank correlation coefficient. The cumulative major adverse cardiovascular event (MACE) curve was generated using the Kaplan-Meier method. Multivariate Cox regression was used to identify predictors of MACEs. Additionally, the receiver operating characteristic curve (ROC), net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) were applied to analyze the performance of each single factor index and combined multivariate index in predicting MACE.

RESULTS

In the ACS patients with T2DM after PCI, there were significant differences in the TyG index and GRACE risk score between the MACE group and the MACE-free group (P < 0.001). Kaplan-Meier analysis showed that the TyG index combined with the GRACE risk score was positively correlated with the occurrence of MACEs (log rank P < 0.001). Multivariate Cox regression analyses showed that the TyG index, the GRACE risk score, and the TyG index combined with the GRACE risk score were independent predictors of long-term MACEs (adjusted HR: 1.805; 95% CI: 1.479-2.203, P < 0.001; adjusted HR: 1.012; 95% CI: 1.009-1.016, P < 0.001; and adjusted HR: 2.337; 95% CI: 1.805-3.025, P < 0.001, respectively). Correlation analysis indicated that the TyG index was positively correlated with the GRACE risk score (R = 0.140, P < 0.001). The analysis of AUC, NRI and IDI revealed that the combined multivariate index performed better prognostic role than each single factor index in predicting the occurrence of MACE.

CONCLUSION

Both the GRACE risk score and the TyG index could be significant and independent predictors of clinical outcomes in ACS patients with T2DM after PCI. A combination of them could be enhanced predictions of clinical outcomes in these patients.

Hypofunction of Circulating Endothelial Progenitor Cells and Aggravated Severity in Elderly Male Patients With Non-ST Segment Elevation Myocardial Infarction: Its Association With Systemic Inflammation

Background: Aging patients easily suffer from non-ST segment elevation myocardial infarction (NSTEMI). Our previous studies revealed declined function of endothelial progenitor cells (EPCs) in the elderly. However, the impact of aging on EPC function and severity in male NSTEMI patients and its possible mechanism is unclear until now.

Methods: We measured the circulating EPC function including migration, proliferation, and adhesion in aging or young male patients with NSTEMI. The GRACE and TIMI risk score were evaluated. Plasma levels of interleukin-6 (IL-6) and interleukin-17 (IL-17) were also detected in all patients.

Results: Compared with the young group, the old male patients with NSTEMI had higher GRACE score and TIMI score and decreased function of circulating EPCs. EPC function was negatively correlated with GRACE score and TIMI score. IL-6 and IL-17 level were higher in the old group than those in the young group. There was a significant negative correlation between EPC function and IL-6 or IL-17. Moreover, IL-6 and IL-17 positively correlated with GRACE and TIMI score. Age was positively related with GRACE or TIMI score and plasma level of IL-6 or IL-17, but inversely correlated with EPC function.

Conclusions: The current study firstly illustrates that the age-related decrement in EPC function is related to the severity of NSTEMI in male patients, which may be connected with systemic inflammation. These findings provide novel insights into the pathogenetic mechanism and intervention target of aging NSTEMI.

External validation of the GRACE risk score 2.0 in the contemporary all-comers GLOBAL LEADERS trial

OBJECTIVES

This study aimed to assess the predictive ability of the Global Registry of Acute Coronary Events (GRACE) risk score 2.0 in contemporary acute coronary syndrome (ACS) patients, and its relation to antiplatelet strategies.

BACKGROUND

The predictive value of the GRACE risk score in the contemporary ACS cohort and the appropriate antiplatelet regimen according to the risk remain unclear.

METHODS

This is a subgroup analysis of the all-comers, randomized GLOBAL LEADERS trial, comparing ticagrelor monotherapy versus conventional dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). The GRACE risk score 2.0 with 1-year mortality prediction was implemented. The randomized antiplatelet effect was assessed in predefined three GRACE risk-groups; low-risk (GRACE <109), moderate-risk (GRACE 109-140), and high-risk (GRACE >140).

RESULTS

The GRACE risk score was available in 6,594 out of 7,487 ACS patients among whom 1,743, 2,823, and 2,028 patients were classified as low-risk, moderate-risk, and high-risk, respectively. At 1 year, all-cause mortality occurred in 120 patients (1.8%). The discrimination ability of the GRACE model was moderate (C-statistic = 0.742), whereas 1-year mortality risk was overestimated (mean predicted mortality rate: 3.9%; the Hosmer-Lemeshow chi-square: 21.47; p = 0.006). There were no significant interactions between the GRACE risk strata and effects of the ticagrelor monotherapy on ischemic or bleeding outcomes at 1 year compared to the reference strategy.

CONCLUSION

The GRACE risk score 2.0 is valuable in discriminating high risk ACS patients, however, the recalibration of the score is recommended for better risk stratification. There is no significant differences in efficacy and safety of ticagrelor monotherapy across the three GRACE risk strata.

Prognostic value of GRACE score for in-hospital and 6 months outcomes after non-ST elevation acute coronary syndrome

Background

The aim of this study was to determine the predictive value of the Global Registry of Acute Coronary Events (GRACE) score for predicting in-hospital and 6 months mortality after non-ST elevation acute coronary syndrome (NSTE-ACS).

Results

In this observational study, 300 patients with NSTE-ACS of age more than 30 years were included; 16 patients died during the hospital stay (5.3%). Of 284 patients at 6 months assessment, 10 patients died (3.5%), 240 survived (84.5%), and 34 were lost to follow-up (12%) respectively. In high risk category, 10.5% of the patients died within hospital stay and 11.8% died within 6 months (p = 0.001 and p = 0.013). In univariate analysis, gender, diabetes mellitus, family history, smoking, and GRACE score were significantly associated with in-hospital mortality whereas age, obesity, dyslipidemia, and GRACE were significantly associated with 6 months mortality. After adjustment, diabetes mellitus, family history, and GRACE score remained significantly associated with in-hospital mortality (p ≤ 0.05) and age remained significantly associated with 6 months mortality.

Conclusion

GRACE risk score has good predictive value for the prediction of in-hospital mortality and 6 months mortality among patients with NSTE-ACS.

Prognostic Value of GRACE Risk Scores in Patients With Non-ST-Elevation Myocardial Infarction With Non-obstructive Coronary Arteries

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a special type of myocardial infarction (MI). The GRACE risk score is commonly used to predict major adverse cardiovascular events (MACE) in non-ST-elevation myocardial infarction patients, and the suitability of the GRACE risk score for prognostic stratification in patients with MINOCA remains uncertain. This study aimed to investigate whether the GRACE risk score is capable of predicting MACE in MINOCA patients with NSTE. We calculated the GRACE risk score for 340 consecutive MINOCA patients with NSTE. Patients were divided into a low-intermediate risk group (≤ 140, 48.8%) and a high risk group (>140, 51.2%) according to their GRACE risk scores. The clinical characteristics and outcomes of the patients were assessed. Patients in the high risk group tended to be older and to have more comorbidities. At the 1-year follow-up, the rate of cardiac death in the high risk group was significantly higher than that in the low-intermediate-risk group (p = 0.010). There was no significant difference in non-fatal MI, stroke, heart failure, or cardiovascular-related rehospitalization. The incidence of total MACE was significantly higher in patients with high GRACE risk scores than in patients with low GRACE risk scores (p = 0.006). ROC curve analysis showed that the GRACE risk score has moderate value in predicting MACE in NSTE-MINOCA patients. The area under the ROC curve was 0.710 (95% CI 0.625–0.796, P < 0.001). The GRACE risk score provides potentially valuable prognostic information on clinical outcome when applied to MINOCA patients with NSTE.

The predictive value of the HEART and GRACE scores for major adverse cardiac events in patients with acute chest pain

The history, electrocardiogram, age, risk factors, troponin (HEART) and global registry of acute coronary events (GRACE) scoring systems are commonly used to risk stratify patients with chest pain. This study investigated the application of these scores in predicting the short-term risk of a major adverse cardiac event (MACE) in patients with chest. A total of 509 patients were analyzed. All patients were followed up for 30 days after visiting our emergency department. At 30 days post-admission, the primary outcome (MACE) was recorded in 92 patients (18.1%), 88 (95.6%) of whom had experienced an acute myocardial infarction. Thirty-seven (40.2%) of the patients with a MACE underwent percutaneous coronary intervention and six patients (6.5%) died. The HEART and GRACE scores were both significantly higher in patients who developed a MACE than in those without (P < 0.05). The HEART and GRACE scores had c-statistic values of 0.811 (95% CI 0.774-0.844) and 0.648 (95% CI 0.603-0.688), respectively. The Hosmer-Lemeshow statistic revealed that the HEART and GRACE scores had values of 8.68 (P = 0.39) and 10.45 (P = 0.11), respectively. The percentages of patients with HEART scores of 0-3, 4-6, and 7-10 were 3.0%, 26.2%, and 46.3%, respectively, in those with a MACE within 30 days. The findings show that while both scoring systems are useful, the HEART score is superior to the GRACE score for predicting the occurrence of MACE within 30 days in patients with chest pain.

Impact of Cardio-Ankle Vascular Index on Long-Term Outcome in Patients with Acute Coronary Syndrome

Aim: The purpose of this study is to investigate the impact of arterial stiffness assessed using Cardio-ankle Vascular Index (CAVI) on long-term outcome after acute coronary syndrome (ACS).

Methods: A total of 387 consecutive patients (324 males; age, 64 ± 11 years) with ACS were enrolled. We examined CAVI and brachial-ankle pulse wave velocity (ba PWV) as the parameters of arterial stiffness. The patients were divided into two groups according to the cut-off value of CAVI determined using the receiver operating characteristic curve for the prediction of major adverse cardiovascular events (MACE): low-CAVI group, 177 patients with CAVI < 8.35; high-CAVI group, 210 patients with CAVI ≥ 8.35. The primary endpoint was the incidence of MACE (cardiovascular death, recurrence of ACS, heart failure requiring hospitalization, or stroke).

Results: A total of 62 patients had MACE. Kaplan-Meier analysis demonstrated a significantly higher probability of MACE in the high-CAVI group than in the low-CAVI group (median follow-up: 62 months; log-rank, p < 0.001). Multivariate analysis suggested that CAVI was an independent predictor of MACE (hazard ratio [HR], 1.496; p = 0.02) and cardiovascular death (HR, 2.204; p = 0.025), but ba PWV was not. We investigated the incremental predictive value of adding CAVI to the GRACE score (GRS), a validated scoring system for risk assessment in ACS. Stratified by CAVI and GRS, a significantly higher rate of MACE was seen in patients with both higher CAVI and higher GRS than the other groups (p < 0.001). Furthermore, the addition of CAVI to GRS enhanced net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI, 0.337, p = 0.034; and IDI, 0.028, p = 0.004).

Conclusion: CAVI was an independent long-term predictor of MACE, especially cardiovascular death, adding incremental clinical significance for risk stratification in patients with ACS.

Value of the fT3/fT4 ratio and its combination with the GRACE risk score in predicting the prognosis in euthyroid patients with acute myocardial infarction undergoing percutaneous coronary intervention: a prospective cohort study

Background

Thyroid hormones deeply influence the cardiovascular system; however, the association between the fT3/fT4 ratio and the clinical outcome in euthyroid patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) is not well defined. Therefore, the present study aimed to assess the prognostic performance of the fT3/fT4 ratio in predicting the long-term prognosis in euthyroid patients with AMI undergoing PCI.

Methods

In a prospective cohort study with a 1-year follow-up, according to the clinical end point, 953 euthyroid individuals (61.0 ± 11.6; female, 25.8%) were divided into two groups: (1) the survival group (n = 915) and (2) the death group (n = 38).

Results

According to Cox regression multivariate analysis, fT4 (HR: 1.249, 95% CI: 1.053–1.480, p = 0.010) and the fT3/fT4 ratio (HR: 3.546, 95% CI: 1.705–7.377, p = 0.001) were associated with an increased risk of 1-year all-cause mortality. The prognostic performance of the fT3/fT4 ratio was similar to the Global Registry of Acute Coronary Events (GRACE) score in predicting 1-year all-cause mortality (C-statistic: z = 0.261, p = 0.794; IDI: -0.017, p = 0.452; NRI: -0.049, p = 0.766), but better than fT4 (C-statistic: z = 2.438, p = 0.015; IDI: 0.053, p = 0.002; NRI: 0.656, p < 0.001). The fT3/fT4 ratio also significantly improved the prognostic performance of the GRACE score (GRACE score vs GRACE score + fT3/fT4 ratio: C-statistic: z = 2.116, p = 0.034; IDI: 0.0415, p = 0.007; NRI: 0.614, p < 0.001).

Conclusions

In euthyroid patients with AMI undergoing PCI, the fT3/fT4 ratio was an independent predictor of 1-year all-cause mortality. Its prognostic performance was similar to the GRACE score, and also improved its prognostic performance (GRACE score vs GRACE score + fT3/fT4 ratio).

Risk evaluation of new-onset atrial fibrillation complicating ST-segment elevation myocardial infarction: a comparison between GRACE and CHA2DS2-VASc scores

Purpose

New-onset atrial fibrillation (NOAF) is a common finding in patients with myocardial infarction (MI), but few studies are available regarding the prediction model for its risk estimation. Although Global Registry of Acute Coronary Events (GRACE) risk score (RS) has been recognized as an effective tool for the risk evaluation of clinical outcomes in patients with MI, its usefulness in the prediction of post-MI NOAF remains unclear. In this study, we sought to validate the discrimination performance of GRACE RS in the prediction of post-MI NOAF and to make a comparison with that of the CHA₂DS₂-VASc score in patients with ST-segment elevation myocardial infarction (STEMI).

Patients and methods

A total of 488 patients with STEMI who were admitted to our hospital between May 2015 and October 2016 without a history of atrial fibrillation were retrospectively evaluated in this study. GRACE and CHA₂DS₂-VASc scores were calculated for each patient. Patients were divided into low (GRACE RS≤125)-, intermediate (GRACE RS 126–154)-, and high (GRACE RS≥155)-risk groups. Receiver operating characteristic curve analyses were performed to evaluate the discrimination performance of both RSs. Model calibration was evaluated by using Hosmer–Lemeshow goodness-of-fit test (HLS).

Results

Of the 488 eligible patients, 49 (10.0%) developed NOAF during hospitalization. In the overall cohort, the discrimination performance of GRACE RS (C-statistic: 0.76, 95% CI: 0.72–0.80) was significantly better than that of CHA₂DS₂-VASc score (C-statistic: 0.68, 95% CI: 0.64–0.72; comparison p=0.03). For subgroup analysis, GRACE RS tended to be better than the CHA₂DS₂-VASc score in all but the intermediate-risk group as evidenced by C-statistics of 0.60 and 0.65 for GRACE and CHA₂DS₂-VASc scores, respectively. Excellent calibration was achieved except for GRACE RS in females (HLS p=0.05).

Conclusion

The diagnostic performance of GRACE RS is relatively high as well as better than that of the CHA₂DS₂-VASc score with respect to the prediction of post-MI NOAF.

Angiographic severity of coronary artery disease and cardiovascular risk in acute coronary syndrome in patients with metabolic syndrome

BACKGROUND

The extent of angiographic lesions, size of infarct, and in-hospital and long-term prognosis in patients with metabolic syndrome (MS) have not been clearly determined.

AIM

The aim of the study was to investigate the effect of MS on the severity of coronary artery disease (CAD) and cardio-vascular risk evaluated using the GRACE 2.0 risk score and left ventricular ejection fraction (LVEF) in patients with first acute coronary syndrome (ACS) treated with coronary angioplasty.

METHODS

The study was conducted in a group of 160 consecutive patients hospitalised for their first ACS. Coronary angiogra-phy was assessed and an echocardiographic evaluation of LVEF was performed. MS was diagnosed according to the National Cholesterol Education Programme-Adult Treatment Panel III criteria. Cardiovascular risk was evaluated using the GRACE 2.0 score. Statistical analysis was performed using the STATISTICA software version 12.0.

RESULTS

Diagnostic criteria for MS were met by 53.5% of the patients. Patients with and without MS did not differ in angio-graphic severity of CAD and cardiovascular risk as evaluated with the GRACE 2.0 score. LVEF was significantly elevated in patients with MS. In the examined group the angiographic severity of CAD correlated positively with age, body mass index (BMI) and the homeostatic model assessment for insulin resistance (HOMA-IR) index. The cardiovascular risk correlated positively with age, BMI, fasting insulin levels, and HOMA-IR, and inversely with blood pressure and triglyceride levels. The multivariable regression model for predicting the LVEF value indicated that the strongest prognostic factor was the type of ACS.

CONCLUSIONS

The associations between the angiographic severity of CAD and age, BMI, and insulin resistance (IR) confirm the involvement of these parameters in coronary atherosclerosis. The correlations between the estimated cardiovascular risk and IR indicate the prognostic value of metabolic parameters in patients after first ACS. The type of ACS is the strongest predictor of LVEF at discharge in this population.

In-hospital mortality analysis of Japanese patients with acute coronary syndrome using the Tokyo CCU Network database: Applicability of the GRACE risk score

BACKGROUND

The GRACE risk score was developed to predict in-hospital mortality for acute coronary syndrome (ACS) using multinational registries, but did not include Japanese data. Therefore, GRACE risk scores are not extensively used in Japan. The present study aimed to evaluate the relationship between the GRACE risk score and in-hospital mortality among Japanese patients with ACS using the Tokyo CCU (cardiovascular care unit) Network Database.

METHODS AND RESULTS

A total of 9460 patients with ACS hospitalized at 67 Tokyo CCUs between January 2011 and December 2013 were retrospectively reviewed and GRACE risk scores were calculated. Patients in the Tokyo CCU Network database had more severe conditions compared to those of the original GRACE study. There was a strong correlation between the GRACE risk score and in-hospital mortality for patients with ST-segment elevation myocardial infarction (STEMI) or non ST-segment elevation myocardial infarction (NSTEMI) (r=0.99, p<0.001); however, the correlation was not significant for patients with unstable angina (r=0.35, p=0.126). For STEMI+NSTEMI patients, the discrimination ability of the GRACE risk score was excellent, with a c statistic of 0.87 (95% confidence interval, 0.86-0.89).

CONCLUSIONS

The GRACE risk score is a good predictor of in-hospital mortality for Japanese patients with STEMI or NSTEMI, and can help clinicians stratify patients by risk for optimal patient triage and early treatment management.

Fibrinogen is related to long-term mortality in Chinese patients with acute coronary syndrome but failed to enhance the prognostic value of the GRACE score

Fibrinogen (Fib) is considered to be a potential risk factor for the prognosis of patients with acute coronary syndrome (ACS), but it is unclear whether Fib level have synergistic effects to enhance the prognostic value of the GRACE score in patients with ACS. A retrospective analysis was conducted from a single registered database. 2253 consecutive patients with ACS confirmed by coronary angiography were enrolled and were grouped into 3 categories by the tertiles of admission plasma Fib levels. The end points were all-cause mortality and cardiac mortality. The mean follow-up time was 27.2 ± 13.1 months and death events occurred in 223 cases and cardiac death events occurred in 130 cases. Cumulative survival curves indicated that the risk of all-cause death increased with increasing Fib level (mortality rates for Tertile 1 vs. Tertile 2 vs. Tertile 3 = 6.6% vs. 10.8 %vs. 12.3%, p < 0.001). Cox multivariate regression analysis indicated that compared with other traditional risk factors, plasma Fib level is independently correlated with all-cause death (HR 1.33, 95% CI 1.04-1.70). However, incorporating elevated Fib level into the GRACE model did not significantly increase the predictive value of the GRACE score; for instance, AUC only increased from 0.703 to 0.713 (p = 0.765). In conclusion, Fib level at admission was independently associated with death risk among Chinese patients with ACS. However, the incorporation of Fib level at admission into the GRACE score did not improve this score’s predictive value for death risk among these patients.

GRACE risk score: Sex-based validity of in-hospital mortality prediction in Canadian patients with acute coronary syndrome

BACKGROUND

Although there are sex differences in management and outcome of acute coronary syndromes (ACS), sex is not a component of Global Registry of Acute Coronary Events (GRACE) risk score (RS) for in-hospital mortality prediction. We sought to determine the prognostic utility of GRACE RS in men and women, and whether its predictive accuracy would be augmented through sex-based modification of its components.

METHODS

Canadian men and women enrolled in GRACE and Canadian Registry of Acute Coronary Events were stratified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS). GRACE RS was calculated as per original model. Discrimination and calibration were evaluated using the c-statistic and Hosmer-Lemeshow goodness-of-fit test, respectively. Multivariable logistic regression was undertaken to assess potential interactions of sex with GRACE RS components.

RESULTS

For the overall cohort (n=14,422), unadjusted in-hospital mortality rate was higher in women than men (4.5% vs. 3.0%, p<0.001). Overall, GRACE RS c-statistic and goodness-of-fit test p-value were 0.85 (95% CI 0.83-0.87) and 0.11, respectively. While the RS had excellent discrimination for all subgroups (c-statistics >0.80), discrimination was lower for women compared to men with STEMI [0.80 (0.75-0.84) vs. 0.86 (0.82-0.89), respectively, p<0.05]. The goodness-of-fit test showed good calibration for women (p=0.86), but suboptimal for men (p=0.031). No significant interaction was evident between sex and RS components (all p>0.25).

CONCLUSIONS

The GRACE RS is a valid predictor of in-hospital mortality for both men and women with ACS. The lack of interaction between sex and RS components suggests that sex-based modification is not required.

Global Registry of Acute Coronary Events risk score predicts mortality and neurological outcome in out-of hospital cardiac arrest

PURPOSE

The aim of this study was to assess the usefulness of the Global Registry of Acute Coronary Events (GRACE) risk score in predicting in-hospital mortality and neurological outcome of patients resuscitated after out-of-hospital cardiac arrest (OHCA).

METHODS

We retrospectively analyzed the data of patients admitted to our hospital between October 2009 and October 2015 with OHCA and shockable initial cardiac rhythm who were resuscitated via conventional cardiopulmonary resuscitation. We calculated the GRACE risk score on admission and assessed its usefulness in predicting in-hospital mortality and neurological outcome.

RESULTS

Among 91 patients, 42 (46%) had acute myocardial infarction (AMI), 19 (21%) died in-hospital, and 52 (57%) had favorable neurological outcome. Among all the study patients, GRACE risk score was lower in survivors than in non-survivors (median 211 [interquartile range 176-240] vs. 266 [219-301], p<0.001, respectively) and in favorable than in unfavorable neurological outcome group (202 [167-237] vs. 242 [219-275], p<0.001, respectively). Multivariate analysis showed significant association between GRACE risk score and favorable neurological outcome (odds ratio, 0.975; 95% confidence interval, 0.961-0.990). Areas under receiver-operating characteristic curves, that describe the accuracy of GRACE risk score in predicting in-hospital mortality and favorable neurological outcome, were both 0.79.

CONCLUSION

GRACE risk score may predict the in-hospital mortality and neurological outcome associated with resuscitated patients with OHCA and shockable initial cardiac rhythm, regardless of the cause of arrest.

Predictive value of NT-proBNP for 30-day mortality in patients with non-ST-elevation acute coronary syndromes: a comparison with the GRACE and TIMI risk scores

Background

The biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP) predicts outcome in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Whether NT-proBNP has incremental prognostic value beyond established risk strategies is still questionable.

Purpose

To evaluate the predictive value of NT-proBNP for 30-day mortality over and beyond the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis In Myocardial Infarction (TIMI) risk scores in patients with NSTE-ACS.

Methods

Patients included in our ACS registry were candidates. NT-proBNP levels on admission were measured and the GRACE and TIMI risk scores were assessed. We compared the predictive value of NT-proBNP to both risk scores and evaluated whether NT-proBNP improves prognostication by using receiver operator curves and measures of discrimination improvement.

Results

A total of 1324 patients were included and 50 patients died during follow-up. On logistic regression analysis NT-proBNP and the GRACE risk score (but not the TIMI risk score) both independently predicted mortality at 30 days. The predictive value of NT-proBNP did not differ significantly compared to the GRACE risk score (area under the curve [AUC]) 0.85 vs 0.87 p=0.67) but was considerably higher in comparison to the TIMI risk score (AUC 0.60 p<0.001). Adjustment of the GRACE risk score by adding NT-proBNP did not improve prognostication: AUC 0.86 (p=0.57), integrated discrimination improvement 0.04 (p=0.003), net reclassification improvement 0.12 (p=0.21).

Conclusion

In patients with NSTE-ACS, NT-proBNP and the GRACE risk score (but not the TIMI risk score) both have good and comparable predictive value for 30-day mortality. However, incremental prognostic value of NT-proBNP beyond the GRACE risk score could not be demonstrated.

The prognostic utility of GRACE risk score in predictive cardiovascular event rate in STEMI patients with successful fibrinolysis and delay intervention in non PCI-capable hospital: a retrospective cohort study

BACKGROUND

Fibrinolytic therapy is the main reperfusion therapy for most STEMI patients in several countries. Current practice guidelines recommended routine early pharmacoinvasive (within 3-24 h after successful fibrinolysis, however it cannot be performed in timely fashion due to limitation of PCI-capable hospitals. This study aimed to evaluate the prognostic utility of the GRACE score in patients receiving delayed intervention after successful fibrinolysis in non PCI-capable hospital.

METHODS

We retrospectively analysed the data from the Maharaj Nakorn Chiang Mai Hospital acute ST-elevation myocardial infarction (STEMI) registry during the period 2007-2012. The STEMI patients who had successfully fibrionolysis in non PCI-capable hospital and received delayed PCI (during 24 h to 14 days after successful fibrinolytic therapy) at Maharaj Nakorn Chiang Mai hospital were included. The primary end point for this analysis was the composite outcomes, which included all-cause mortality, re-hospitalization with acute coronary syndrome (ACS), re-hospitalization with heart failure (HF) and stroke at 1 and 6-month.

RESULTS

A total of 152 patients were included. 88 patients and 64 patients were in low GRACE group (GRACE risk score ≤ 125) and intermediate to high GRACE group (GRACE risk score above 126), respectively. The median time from fibrinolysis to coronary intervention in low GRACE group was 8.5 days (interquartile range, 4.6-10.9) and 7.9 days (interquartile range,3.2,12.0) in intermediate to high GRACE group (p = 0.482). At 1 month, the composite cardiovascular outcome at 1 month occurred in 2 patients (2.3 %) in low GRACE group and 10 patients (15.6 %) in intermediate to high GRACE group (P = 0.003). During 6 months, the composite cardiovascular outcomes occurred in 6 patients (6.8 %) in low GRACE group and 12 patients (18.7 %) in intermediate to high GRACE group (P = 0.024). The cumulative of composite cardiovascular outcome was significant higher in intermediate to high GRACE group than in low GRACE group (Hazard ratio: 2.97, 95 % CI 1.11-7.90; p = 0.030).

CONCLUSION

The long delay pharmacoinvasive strategy in intermediate to high GRACE score after successful fibrinolysis in non PCI-capable facilities were associated with worse cardiovascular outcomes than the patients with low GRACE score at 1 and 6 months. GRACE risk score may be helpful and guided the clinicians in non PCI-capable center in early transferred to early intervention in STEMI patients after fibrinolytic therapy.

Validation of the 6-Month GRACE Score in Predicting 1-Year Mortality of Patients With Acute Coronary Syndrome Admitted to the Arabian Gulf Hospitals

Acute coronary syndromes (ACS) are the most common cardiovascular diseases and are associated with a significant risk of mortality and morbidity. The Global Registry of Acute Coronary Events (GRACE) risk score postdischarge is a widely used ACS prediction model for risk of mortality (low, intermediate, and high); however, it has not yet been validated in patients from the Arabian Gulf. This prospective multicenter study (second Gulf Registry of Acute Coronary Events) provides detailed information of the GRACE risk score postdischarge in patients from the Arabian Gulf. Its prognostic utility was validated at 1-year follow-up in over 5000 patients with ACS from 65 hospitals in 6 Arabian Gulf countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates, and Yemen). Overall, the goodness of fit (Hosmer and Lemeshow statistic P value = .826), calibration, and discrimination (area under the receiver operating characteristic curve = 0.695; 95% confidence interval: 0.668-0.722) were good. The GRACE risk score postdischarge can be used to stratify 1 year mortality risk in the Arabian Gulf population; it does not require further calibration and has a good discriminatory ability.

Global Registry of Acute Coronary Events (GRACE) Risk Score as a Predictor of In-hospital Mortality for Acute Coronary Syndrome in Trinidad and Tobago

Objective

To determine whether risk stratification using the Global Registry of Acute Coronary Events (GRACE) risk score is a predictor of in-hospital mortality for patients with acute coronary syndrome (ACS) in a multi-ethnic Caribbean population.

Method

During a six-month period, all patients meeting the GRACE diagnostic criteria for one of the acute coronary syndromes were entered into a prospective single-centre study at one of the major public hospitals in Trinidad and Tobago. Clinical data, the GRACE risk score and in-hospital morbidity and mortality were recorded. Patients were placed into three GRACE risk categories: low, intermediate or high risk.

Results

There were 372 patients (mean age 63 years; males 56% and females 44%; hypertension 69%, diabetes mellitus 58%, positive smoking history 43%, previous myocardial infarction 34%), of which 25% were ST-segment elevation myocardial infarction, 56% non-ST-segment myocardial infarction and 19% unstable angina pectoris. In-hospital mortality was 8.3%. There were 35%, 33% and 32% of patients in the high, intermediate and low GRACE risk categories, respectively. The GRACE risk score demonstrated good discrimination (C statistic 0.82, 95% CI 0.755, 0879; p < 0.001) and good calibration (Hosmer-Lemeshow; p = 0.096) for in-hospital mortality in this ACS cohort.

Conclusion

The GRACE risk score was found to be a reliable predictor of in-hospital mortality in this ACS population and therefore can be used to identify those high-risk patients who may benefit from aggressive management strategies, thereby allowing for more effective use of limited resources.

The relationship of TIMI risk index with SYNTAX and Gensini risk scores in predicting the extent and severity of coronary artery disease in patients with STEMI undergoing primary percutaneous coronary intervention

OBJECTIVE

The prognostic value of the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) and the Thrombolysis in Myocardial Infarction (TIMI) risk index (TRI) have been reported in patients with coronary artery disease (CAD). In this study, we sought to evaluate the association between TRI and the extent and severity of CAD evaluated by SYNTAX score (SS) and Gensini score in patients with ST elevation myocardial infarction (STEMI).

METHODS

A total of 290 patients with STEMI were included in the study. GRS and TRI were calculated on admission using specified variables. The extent and severity of CAD were evaluated using the SS and Gensini scores. The patients were divided into low (TRI ⩽19), intermediate (TRI 19-30), and high (TRI ⩾30) risk groups. A Pearson correlation analysis was used for the relationship between TRI, GRS, Gensini score and SS.

RESULTS

There were significant differences in the mean age (p < 0.001), admission heart rate (p < 0.001), admission systolic blood pressure (p = 0.009), SS (p < 0.001), GRS (p < 0.001) and in-hospital major adverse cardiac events (MACE) in all patients between the low, intermediate and high TRI risk groups. There was a positive significant correlation between TRI and SS (r = 0.24, p < 0.001), Gensini score (r = 0.18, p = 0.002), GRS (r = 0.74, p = 0.001) and in-hospital MACE (r = 0.29, p < 0.001).

CONCLUSION

TRI is significantly related to SS and Gensini score in predicting the extent and severity of CAD in patients with STEMI.

Relation of the aortic stiffness with the GRACE risk score in patients with the non ST-segment elevation myocardial infarction

BACKGROUND

Current guidelines recommend clinical risk scoring systems for the patients diagnosed and determinated treatment strategy with in Non-ST-elevation elevation myocardial infarction (NSTEMI). Previous studies demonstrated association between aortic elasticity properties, stiffness and severity CAD. However, the associations between Aortic stiffness, elasticity properties and clinical risk scores have not been investigated. In the present study we have evaluated the relation between the Global Registry of Acute Coronary Events (GRACE) risk score and aortic stiffness in patients with NSTEMI.

METHOD

We prospectively analyzed 87 consecutive patients with NSTEMI. Aortic elastic parameter and stiffness parameter were calculated from the echocardiographically derived thoracic aortic diameters (mm/m(2)), and the measurement of pulse pressure obtained by cuff sphygmomanometry. We have categorized the patients in to two groups as low ((n = 45) (GRACE risk score ≤ 140)) and high ((n = 42) (GRACE risk score > 140)) risk group according to GRACE risk score and compare the both groups.

RESULTS

Table 1 shows baseline characteristics of patients. Our study showed that Aortic strain was significantly low (3.5 ± 1.4, 7.9 ± 2.3 respectively, p < 0.001) and aortic stiffness index was significantly high (3.9 ± 0.38; 3 ± 0.35, respectively, p < 0.001) in the high risk group values compared to those with low risk group. The aortic stiffness index was the only independent predictor of GRACE risk score (OR: 119.390; 95% CI: 2.925-4872.8; p = 0.011) in multivariate analysis.

CONCLUSION

We found a significant correlation between aortic stiffness, impaired elasticity and GRACE risk score. Aortic stiffness index was the only independent variable of the high GRACE risk score. The inclusion of aortic stiffness into the GRACE risk score could allow improved risk classification of patients with ACS at admission and this may be important in the diagnosis, follow up and treatment of the patients.

Predictive impact on medium-term mortality of hematological parameters in Acute Coronary Syndromes: added value on top of GRACE risk score

BACKGROUND

Red Cell Distribution Width (RDW) prognostic value in patients with Acute Coronary Syndrome (ACS) has been well validated whereas that of Platelet Distribution Width (PDW) is less well known.

OBJECTIVES

Investigate the incremental prognostic value, on top of GRACE risk score, of a new variable resulting from the combination of RDW and PDW.

METHODS

Consecutive patients with ACS. Complete blood count, with RDW and PDW, was obtained. Primary endpoint was one-year all-cause mortality and Cox regression models were used to measure the influence of RDW and PDW on patients' survival time. A new combination categorical variable (RDW/PDW) was created with both discretized RDW and PDW and logistic regression models were used. Predictive value and discriminative ability of the model with GRACE risk score alone and of the model with inclusion of RDW/PDW was assessed.

RESULTS

We included 787 patients. Hospital and one-year mortality rates were 5.1% and 7.8%, respectively. Both continuous RDW and PDW were independent predictors of death. The best cut-off for RDW was 13.9%, and 14.5% for PDW. Inclusion of RDW/PDW in a model with GRACE risk score improved the AUC from 0.81 (95% CI 0.75-0.86) to 0.84 (95% CI 0.79-0.90) (p=0.024) with an improvement in total NRI (56%) and IDI (0.048).

CONCLUSIONS

Simple markers such as RDW and PDW can be useful in risk stratification of death after ACS. Combining both markers with GRACE risk score improved the predictive value for all-cause mortality and reduced the estimated risk of those who did not die.

Relationship Between Hematologic Indices and Global Registry of Acute Coronary Events Risk Score in Patients With ST-Segment Elevation Myocardial Infarction

The aim of this study was to evaluate the relationship between hematologic indices and the Global Registry of Acute Coronary Events (GRACE) score in patients with ST-segment elevation myocardial infarction (STEMI). A total of 800 patients who consecutively and retrospectively presented with STEMI within 12 hours of symptom onset. After accounting for exclusion criteria, a total of 379 patients remained in the study. We enrolled 379 patients with STEMI (mean age 61.7 ± 13.6 years; men 73%). Neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), red cell distribution width (RDW), and monocyte count were associated with increased worse GRACE risk score (P = .008, P = .012, P = .005, P = .022, respectively). In multivariate linear regression analysis, NLR, PLR, RDW, and monocyte count were found to be independent predictors of GRACE risk score. We demonstrate for the first time that PLR, RDW, and monocyte were associated with the GRACE score in patients with STEMI.

Prognostic impact of admission blood glucose for all-cause mortality in patients with acute coronary syndromes: added value on top of GRACE risk score

BACKGROUND

Abnormal glucose metabolism is a predictor of worse outcome after acute coronary syndrome (ACS). However, this parameter is not included in risk prediction scores, including GRACE risk score. We sought to evaluate whether the inclusion of blood glucose at admission in a model with GRACE risk score improves risk stratification.

METHODS

Study of consecutive patients included in a single centre registry of ACS. Our primary endpoint was the occurrence of all-cause mortality at one-year follow-up. The ability of the two logistic regression models (GRACE risk score alone and in combination with blood glucose) to predict death was analysed. Continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI), with corresponding 95% confidence intervals (CIs), were also calculated.

RESULTS

We included 2099 patients, with a mean age of 64 (SD=13) years, 69% males. In our sample, 55.1% presented with ST-segment elevation ACS and 13.1% in Killip class ≥ 2. Only 25% were known diabetic at admission. In-hospital mortality was 5.8% and 9.7% at one-year follow-up. The best cut-point for blood glucose was 160 mg/dl (sensitivity 62% and specificity 68%), and 35.2% of the patients had increased levels. This group was elderly, had more prevalence of cardiovascular risk factors, worse renal function and GRACE score as well as more frequently Killip class ≥2. Treatment was similar in both groups besides less frequent use of clopidogrel in high glycaemic patients. The hyperglycaemia group had higher one-year mortality (17.2% vs. 5.6%, p<0.001). Moreover, binary blood glucose remained a predictor of death independently of the GRACE risk score and the presence of diabetes (odds ratio (OR) 1.99, 95% CI 1.40-2.84, p<0.001). The inclusion of blood glucose, as a continuous variable, in a logistic regression model with GRACE score, increased the area under the ROC curve from 0.80 to 0.82 (p=0.018) as well as the goodness-of-fit and was associated with an improvement in both the NRI (37%) and the IDI (0.021), suggesting effective reclassification.

CONCLUSIONS

A blood glucose level on admission ≥ 160 mg/dl is an independent predictor of mortality in medium-term follow-up. It offers an incremental predictive value when added to the GRACE risk score, although with a modest magnitude of improvement, probably due to the high predictive performance of the GRACE risk score alone.

ACHTUNG-Rule: a new and improved model for prognostic assessment in myocardial infarction

BACKGROUND

THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI), PLATELET GLYCOPROTEIN IIB/IIIA IN UNSTABLE ANGINA: Receptor Suppression Using Integrilin (PURSUIT) and Global Registry of Acute Coronary Events (GRACE) scores have been developed for risk stratification in myocardial infarction (MI). The latter is the most validated score, yet active research is ongoing for improving prognostication in MI.

AIM

Derivation and validation of a new model for intrahospital, post-discharge and combined/total all-cause mortality prediction - ACHTUNG-Rule - and comparison with the GRACE algorithm.

METHODS

1091 patients admitted for MI (age 68.4 ± 13.5, 63.2% males, 41.8% acute MI with ST-segment elevation (STEMI)) and followed for 19.7 ± 6.4 months were assigned to a derivation sample. 400 patients admitted at a later date at our institution (age 68.3 ± 13.4, 62.7% males, 38.8% STEMI) and followed for a period of 7.2 ± 4.0 months were assigned to a validation sample. Three versions of the ACHTUNG-Rule were developed for the prediction of intrahospital, post-discharge and combined (intrahospital plus post-discharge) all-cause mortality prediction. All models were evaluated for their predictive performance using the area under the receiver operating characteristic (ROC) curve, calibration through the Hosmer-Lemeshow test and predictive utility within each individual patient through the Brier score. Comparison through ROC curve analysis and measures of risk reclassification - net reclassification improvement index (NRI) or Integrated Discrimination Improvement (IDI) - was performed between the ACHTUNG versions for intrahospital, post-discharge and combined mortality prediction and the equivalent GRACE score versions for intrahospital (GRACE-IH), post-discharge (GRACE-6PD) and post-admission 6-month mortality (GRACE-6).

RESULTS

Assessment of calibration and overall performance of the ACHTUNG-Rule demonstrated a good fit (p value for the Hosmer-Lemeshow goodness-of-fit test of 0.258, 0.101 and 0.550 for ACHTUNG-IH, ACHTUNG-T and ACHTUNG-R, respectively) and high discriminatory power in the validation cohort for all the primary endpoints (intrahospital mortality: AUC ACHTUNG-IH 0.886 ± 0.035 vs. AUC GRACE-IH 0.906 ± 0.026; post-discharge mortality: AUC ACHTUNG-R 0.827 ± 0.036 vs. AUC GRACE-6PD 0.811 ± 0.034; combined/total mortality: AUC ACHTUNG-T 0.831 ± 0.028 vs. AUC GRACE-6 0.815 ± 0.033). Furthermore, all versions of the ACHTUNG-Rule accurately reclassified a significant number of patients in different, more appropriate, risk categories (NRI ACHTUNG-IH 17.1%, p (2-sided) = 0.0021; NRI ACHTUNG-R 22.0%, p = 0.0002; NRI ACHTUNG-T 18.6%, p = 0.0012). The prognostic performance of the ACHTUNG-Rule was similar in both derivation and validation samples.

CONCLUSIONS

All versions of the ACHTUNG-Rule have shown excellent discriminative power and good calibration for predicting intrahospital, post-discharge and combined in-hospital plus post-discharge mortality. The ACHTUNG version for intrahospital mortality prediction was not inferior to its equivalent GRACE model, and ACHTUNG versions for post-discharge and combined/total mortality demonstrated apparent superiority. External validation in wider, independent, preferably multicentre, registries is warranted before its potential clinical implementation.

[Acute coronary syndrome in nonagenarians: clinical evolution and validation of the main risk scores]

INTRODUCTION

Several risk scores regarding the probability of death/complications in the acute setting and during the follow-up of patients admitted with acute coronary syndromes (ACS) have been published, such as the GRACE, TIMI and ZWOLLE risk score. Our objective was to assess the prognosis of nonagenarians admitted to a coronary care unit with an ACS, as well as the usefulness of each of these scores.

MATERIAL AND METHODS

A retrospective analysis was performed on nonagenarians with an ACS admitted between 2003 and 2011. Vital status was determined at 14, 30 days, and 6 months after the ACS, and later during the follow-up. The risk scores were evaluated by area under the curve ROC (AUC).

RESULTS

A total of 45 patients with an ACS, 26 (57.8%) with ST-segment elevation and 19 (42.2%) with non-ST elevation. The GRACE- AUC for in-hospital mortality was excellent, 0.91, (95% CI: 0.82-1; P<.001), and for the combined event (in-hospital mortality and re-infarction) was 0.83 (95% CI: 0.66-1.0; P<.01). However, the GRACE-AUC at 6 months for mortality was 0.34 (95% CI: 0.09-0.58; P=.45), and for the combined event it was 0.51 (95% CI: 0.26-0.77; P=.95). The TIMI-AUC and ZWOLLE-AUC did not reach statistical significance.

CONCLUSIONS

It is useful calculate the GRACE risk score in order to estimate risk and survival in the acute phase of ACS in nonagenarians. This can help appropriate in making invasive or conservative treatment decisions.