Behavioral Influence of Known Prognostic Markers on the Cardiologist's Decision following Acute Coronary Syndrome: the GRACE Score Paradox / Influência comportamental da predição de risco no processo de decisão do cardiologista: o paradoxo do Escore GRACE

Abstract Background: Behavioral scientists consistently point out that knowledge does not influence decisions as expected. GRACE Score is a well validated risk model for predicting death of patients with acute coronary syndromes (ACS). However, whether prognostic assessment by this Score modulates medical decision is not known. Objective: To test the hypothesis that the use of a validated risk score rationalizes the choice of invasive strategies for higher risk patients with non-ST-elevation ACS. Methods: ACS patients were consecutively included in this prospective registry. GRACE Score was routinely used by cardiologists as the prognostic risk model. An invasive strategy was defined as an immediate decision of the coronary angiography, which in the selective strategy was only indicated in case of positive non-invasive test or unstable course. Firstly, we evaluated the association between GRACE and invasiviness; secondly, in order to find out the actual determinants of the invasive strategy, we built a propensity model for invasive decision. For this analysis, a p-value < 0.05 was considered as significant. Results: In a sample of 570 patients, an invasive strategy was adopted for 394 (69%). GRACE Score was 118 ± 38 for the invasive group, similar to 116 ± 38 for the selective group (p = 0.64). A propensity score for the invasive strategy was derived from logistic regression: positive troponin and ST-deviation (positive associations) and hemoglobin (negative association). This score predicted an invasive strategy with c-statistics of 0.68 (95%CI: 0.63-0.73), opposed to GRACE Score (AUC 0.51; 95%CI: 0.47-0.57). Conclusion: The dissociation between GRACE Score and invasive decision in ACS suggests that the knowledge of prognostic probabilities might not determine medical decision.

Resumo Fundamento: Cientistas behavioristas ressaltam consistentemente que conhecimento não influencia decisão como esperado. O escore GRACE é um modelo de risco bem validado para prever morte de pacientes com síndromes coronarianas agudas (SCA). Todavia, não se sabe se a avaliação prognóstica pelo GRACE modula decisão médica. Objetivo: Testar a hipótese de que a utilização de escore de risco validado racionaliza a escolha de estratégias invasivas para pacientes de alto risco com SCA sem supradesnivelamento do segmento ST. Métodos: Pacientes com SCA foram consecutivamente incluídos neste registro prospectivo. O escore GRACE foi rotineiramente utilizado pelos cardiologistas como modelo de risco prognóstico. Estratégia invasiva foi definida como decisão imediata de cinecoronariografia, que na conservadora só era indicada se teste não invasivo positivo ou curso instável. Primeiro, avaliamos a associação entre GRACE e invasividade; segundo, a fim de descobrir atuais determinantes da estratégia invasiva, construímos um modelo de propensão para ela. Foi considerado significante um valor de p < 0,05 para esta análise. Resultados: Em amostra de 570 pacientes, estratégia invasiva foi adotada para 394 (69%). O escore GRACE foi de 118 ± 38 para o grupo invasivo, semelhante a 116 ± 38 do conservador (p = 0,64). O escore de propensão para estratégia invasiva foi derivado da regressão logística: troponina positiva e desvio de ST (associações positivas) e hemoglobina (associação negativa). Esse escore predisse estratégia invasiva com estatística-c de 0,68 (IC95%: 0,63-0,73), contrariando o Escore GRACE (AUC 0,51; IC95%: 0,47-0,57). Conclusão: A dissociação observada entre o valor do Escore GRACE e decisão invasiva em SCA sugere que o pensamento probabilístico pode não ser um importante determinante da decisão médica.

Option for the radial versus femoral access in coronary intervention in acute coronary syndromes: a risk-treatment paradox / Opção para o acesso radial versus femoral na intervenção coronária em síndromes coronárias agudas: um paradoxo de tratamento de risco

Background: In coronary procedures, although the radial approach protects patients from hemorrhagic complications, it is technically more complex than the femoral approach. Objectives: To test the hypothesis that the radial approach is the procedure of choice in ACS patients due to the high risk of bleeding; and to identify independent predictors of the choice for radial access. Methods: Patients admitted for ACS who underwent invasive coronary procedure were included. We registered the type of access (femoral or radial) chosen by the physician for the first angiography; the investigators did not interfere with this choosing process. Student's t-test was used for comparisons between the CRUSADE and ACUITY scores. Predictors of radial access were compared between the groups. Statistical significance was defined by p < 0,05.Results: Radial access was chosen in 67% of 347 consecutive patients. Patients who underwent radial approach had lower risk of bleeding determined by CRUSADE (30 ± 14 vs. 37 ± 15; p < 0.001) as compared with femoral access. In multivariate analysis, four variables were identified as independent predictors negatively associated with radial access ­ age (OR = 0.98; 95%CI = 0.96 ­ 0.99), creatinine (OR = 0.54; 95%CI = 0.3 ­ 0.98), signs of left ventricular failure (OR = 0.45; 95% CI = 0.22 ­ 0.92) and previous CABG (OR = 0.022; 95%CI = 0.003 ­ 0.166). Conclusion: The propensity to choose radial over femoral access in coronary intervention was not primarily influenced by patients' bleeding risk. Predictors of this decision, identified in the study, indicated less complex patients, suggesting that the difficulty in performing the technique was a stronger determinant than its potential antihemorrhagic effect

Prognostic Accuracy of the GRACE Score in Octogenarians and Nonagenarians with Acute Coronary Syndromes / Acurácia Prognóstica do Escore GRACE em Octogenários e Nonagenários com Síndromes Coronarianas Agudas

Abstract Background: The GRACE Score was derived and validated from a cohort in which octogenarians and nonagenarians were poorly represented. Objective: To test the accuracy of the GRACE score in predicting in-hospital mortality of very elderly individuals with acute coronary syndromes (ACS). Methods: Prospective observational study conducted in the intensive coronary care unit of a tertiary center from September 2011 to August 2016. Patients consecutively admitted due to ACS were selected, and the very elderly group was defined by age ≥ 80 years. The GRACE Score was based on admission data and its accuracy was tested regarding prediction of in-hospital death. Statistical significance was defined by p value < 0,05. Results: A total of 994 individuals was studied, 57% male, 77% with non-ST elevation myocardial infarction and 173 (17%) very elderly patients. The mean age of the sample was 65 ± 13 years, and the mean age of very elderly patients subgroup was 85 ± 3.7 years. The C-statistics of the GRACE Score in very elderly patients was 0.86 (95% CI = 0.78 - 0.93), with no difference when compared to the value for younger individuals 0.83 (95% CI = 0.75 - 0.91), with p = 0.69. The calibration of the score in very elderly patients was described by χ2 test of Hosmer-Lemeshow = 2.2 (p = 0.98), while the remaining patients presented χ2 = 9.0 (p = 0.35). Logistic regression analysis for death prediction did not show interaction between GRACE Score and variable of very elderly patients (p = 0.25). Conclusion: The GRACE Score in very elderly patients is accurate in predicting in-hospital ACS mortality, similarly to younger patients.

Resumo Fundamento: O Escore GRACE foi derivado e validado por coorte de questionável representatividade de indivíduos octogenários e nonagenários. Objetivo: Testar a acurácia do Escore GRACE na predição de óbito hospitalar em indivíduos muito idosos com síndromes coronarianas agudas (SCAs). Métodos: Coleta prospectiva realizada em unidade coronariana de hospital terciário, durante o período de setembro de 2011 a agosto de 2016. Indivíduos consecutivamente internados com SCA foram selecionados e o grupo muito idoso definido por idade ≥ 80 anos. A acurácia do Escore GRACE foi testada quanto à predição de óbito hospitalar. A significância estatística foi definida por valor p < 0,05. Resultados: Foram estudados 994 indivíduos, sendo 57% do sexo masculino, 77% com SCA sem supradesnível do segmento ST e 173 pacientes muito idosos. A média geral de idade foi 65 ± 13 anos, e a média de idade dos pacientes muito idosos, 85 ± 3,7 anos. A estatística-C do Escore GRACE em indivíduos muito idosos foi de 0,86 (95% IC = 0,78 - 0,93), sem diferença em relação aos indivíduos mais jovens (0,83; 95% IC = 0,75 - 0,91), com p = 0,69. A calibração do escore em muito idosos foi descrita por Teste χ2 de Hosmer-Lemeshow = 2,2 (p = 0,98), enquanto os demais pacientes apresentaram χ2 = 9,0 (p = 0,35). A análise de regressão logística para predição de óbito não revelou interação entre Escore GRACE e a variável muito idoso (p = 0,25). Conclusão: O Escore GRACE em indivíduos muito idosos é acurado para predição de mortalidade hospitalar em SCA, semelhante para indivíduos mais jovens.

Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score / Valor Prognóstico Incremental da Incorporação de Dados Clínicos à Anatomia Coronária em Síndromes Coronarianas Agudas: Escore SYNTAX-GRACE

Abstract Background: When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data. Objective: To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS. Methods: Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model. Results: This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 - 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 - 0.96; p = 0.04). Conclusion: In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

Resumo Fundamento: Uma vez realizada a coronariografia em pacientes com síndrome coronariana aguda (SCA), a extensão anatômica da doença coronária prevalece no raciocínio prognóstico. Não está estabelecido se dados clínicos devem também ser contabilizados na estimativa de risco, uma vez que se tenha conhecimento da anatomia coronária. Objetivo: Testar a hipótese de que dados clínicos incrementam o valor prognóstico da avaliação anatômica em pacientes com SCA. Métodos: Indivíduos admitidos com critérios objetivos de SCA e que realizaram coronariografia durante o internamento foram incluídos no estudo. Desfecho primário foi definido como óbito cardiovascular hospitalar, sendo comparado o valor prognóstico do Escore SYNTAX (anatomia) com o do escore SYNTAX-GRACE, resultante da incorporação do Escore GRACE ao Escore SYNTAX. O cálculo do Integrated Discrimination Improvement (IDI) foi realizado para avaliar a capacidade do modelo SYNTAX-GRACE para reclassificar corretamente a informação do modelo SYNTAX tradicional. Resultados: Foram estudados 365 pacientes, idade 64±14 anos, 58% masculinos. A mortalidade cardiovascular durante hospitalização foi de 4,4% e o Escore SYNTAX foi preditor desse desfecho com estatística-C de 0,81 (IC 95% = 0,70 - 0,92; p < 0,001). O Escore GRACE mostrou-se preditor de óbito cardiovascular intra-hospitalar, independente do Escore SYNTAX (p < 0,001 por regressão logística). Ao ser incorporado ao modelo preditor, o Escore GRACE incrementou a capacidade discriminatória do SYNTAX de 0,81 para 0,92 (IC 95% = 0,87 - 0,96; p = 0,04). Conclusão: Em pacientes com SCA, dados clínicos complementam o valor prognóstico da anatomia coronária, devendo a estratificação de risco ser baseada no paradigma clínico-anatômico e não apenas em dados angiográficos.