Mortality and cardiovascular morbidity within 30 days of discharge following acute coronary syndrome in a contemporary European cohort of patients: How can early risk prediction be improved? The six-month GRACE risk score.

OBJECTIVES: Given the increasing focus on early mortality and readmission rates among patients with acute coronary syndrome (ACS), this study was designed to evaluate the accuracy of the GRACE risk score for identifying patients at high risk of 30-day post-discharge mortality and cardiovascular readmission. METHODS: This was a retrospective study carried out in a single center with 4229 ACS patients discharged between 2004 and 2010. The study endpoint was the combination of 30-day post-discharge mortality and readmission due to reinfarction, heart failure or stroke. RESULTS: One hundred and fourteen patients had 30-day events: 0.7% mortality, 1% reinfarction, 1.3% heart failure, and 0.2% stroke. After multivariate analysis, the six-month GRACE risk score was associated with an increased risk of 30-day events (HR 1.03, 95% CI 1.02-1.04; p<0.001), demonstrating good discrimination (C-statistic: 0.79 ± 0.02) and optimal fit (Hosmer-Lemeshow p=0.83). The sensitivity and specificity were adequate (78.1% and 63.3%, respectively), and negative predictive value was excellent (99.1%). In separate analyses for each event of interest (all-cause mortality, reinfarction, heart failure and stroke), assessment of the six-month GRACE risk score also demonstrated good discrimination and fit, as well as adequate predictive values. CONCLUSIONS: The six-month GRACE risk score is a useful tool to predict 30-day post-discharge death and early cardiovascular readmission. Clinicians may find it simple to use with the online and mobile app score calculator and applicable to clinical daily practice.

Is 6-month GRACE risk score a useful tool to predict stroke after an acute coronary syndrome?

OBJECTIVES: The risk of stroke after an acute coronary syndrome (ACS) has increased. The aim of this study was to do a comparative validation of the 6-month GRACE (Global Registry of Acute Coronary Events) risk score and CH2DS2VASc risk score to predict the risk of post-ACS ischaemic stroke. METHODS: This was a retrospective study carried out in a single centre with 4229 patients with ACS discharged between 2004 and 2010 (66.9±12.8 years, 27.9% women, 64.2% underwent percutaneous coronary intervention). The primary end point is the occurrence of an ischaemic stroke during follow-up (median 4.6 years, IQR 2.7-7.1 years). RESULTS: 184 (4.4%) patients developed an ischaemic stroke; 153 (83.2%) had sinus rhythm and 31 (16.9%) had atrial fibrillation. Patients with stroke were older, with higher rates of hypertension, diabetes, previous stroke and previous coronary artery disease. The HR for CHA2DS2VASc was 1.36 (95% CI, 1.27 to 1.48, p<0.001) and for GRACE, HR was 1.02(95% CI, 1.01 to 1.03, p<0.001). Both risk scores show adequate discriminative ability (c-index 0.63±0.02 and 0.60±0.02 for CHA2DS2VASc and GRACE, respectively). In the reclassification method there was no difference (Net Reclassification Improvement 1.98%, p=0.69). Comparing moderate-risk/high-risk patients with low-risk patients, both risk scores showed very high negative predictive value (98.5% for CHA2DS2VASc, 98.1% for GRACE). The sensitivity of CHA2DS2VASc score was higher than the GRACE risk score (95.1% vs 87.0%), whereas specificity was lower (14.4% vs 30.2%). CONCLUSIONS: The 6-month GRACE model is a clinical risk score that facilitates the identification of individual patients who are at high risk of ischaemic stroke after ACS discharge.

Relative performance of three formulas to assess renal function at predicting in-hospital hemorrhagic complications in an acute coronary syndrome population. What does the new CKD-EPI formula provide?

AIMS: Assessment of renal function is important for bleeding risk stratification in acute coronary syndrome (ACS). There are three formulas routinely used to assess renal function: the Cockroft-Gault (C-G) formula, the MDRD-4 formula and the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Our aim was to compare the ability of these formulas to predict the risk of in-hospital bleeding in patients with ACS. METHODS: The study included 3270 patients with ACS. The performance of each formula with respect to in-hospital TIMI (Thrombolysis In Myocardial Infarction) major or TIMI minor bleeding were assessed using continuous data and by dividing patients into four subgroups according to the estimated glomerular filtration rate (eGFR): ≥90, 89-60, 30-59 and <30 ml/min/1.73 m(2). RESULTS: Bleeding predictive ability was significantly higher for the C-G formula than for MDRD-4 and CKD-EPI formulas, as evaluated by the area under the curve (AUC); continuous eGFR AUCs: 0.73, 0.69 and 0.71, respectively; categorical eGFR AUCs: 0.71, 0.66 and 0.68, respectively. Net reclassification improvement based on the eGFR categories was significantly positively favored C-G: 9.5% (95% confidence interval (CI) 1.8-17.2%) and 19.1% (95% CI 11.3-26.9%) compared with CKD-EPI and MDRD-4, respectively. After multivariable adjustment, the C-G formula predicted in-hospital bleeding better than MDRD-4 formula (severe renal dysfunction vs. normal renal function: odds ratio 7.98, 95% CI 2.61-24.38 with C-G; odds ratio 3.76, 95% CI 1.63-8.69 with MDRD-4; and odds ratio 5.77, 95% CI 2.18-15.24 with CKD-EPI. CONCLUSIONS: Our findings suggest that the C-G eGFR may improve risk prediction of in-hospital bleeding more than the MDRD-4 equation and the new CKD-EPI equation in patients with ACS.

Walking beyond the GRACE (Global Registry of Acute Coronary Events) model in the death risk stratification during hospitalization in patients with acute coronary syndrome: what do the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and GWTG [Get With the Guidelines] Database), NCDR (National Cardiovascular Data Registry), and EuroHeart Risk Scores Provide?

OBJECTIVES: This study sought to compare the in-hospital prognostic values of the original and updated GRACE (Global Registry of Acute Coronary Events) risk score (RS) and the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and the GWTG [Get With the Guidelines] Database) RS in acute coronary syndromes (ACS). To evaluate the utility of recalculating risk after percutaneous coronary intervention (PCI) with newer RS models (NCDR [National Cardiovascular Data Registry] and EHS [EuroHeart Score] RS). BACKGROUND: Defined in 2003, GRACE is among the most popular systems of risk stratification in ACS. An updated version of GRACE has since appeared and new RS have been developed, aiming to improve risk prediction. METHODS: From 2004 to 2010, 4,497 consecutive patients admitted to a single center in Spain with an ACS were included (32.1% ST-segment elevation myocardial infarction, 19.2% unstable angina). Discrimination (C-statistic) and calibration (Hosmer-Lemeshow [HL]) indexes were used to assess performance of each RS. A comparative analysis of RS designed to predict post-PCI mortality NCDR and EHS RS versus the GRACE and AR-G RS was performed in a subgroup of 1,113 consecutive patients included in the study. RESULTS: There were 265 in-hospital deaths (5.9%). Original and updated GRACE RS and the AR-G RS all demonstrated good discrimination for in-hospital death (C-statistics: 0.91, 0.90 and 0.90, respectively) with optimal calibration (HL p: 0.42, 0.50, and 0.47, respectively) in all spectra of ACS, according to different managements (PCI vs. conservative) and without significant differences between the 3 different RS. In patients undergoing PCI, EHS and NCDR RS (C-statistic = 0.80 and 0.84, respectively) were not superior to GRACE RS (C-statistic = 0.91), albeit in the subgroup of patients undergoing PCI who were categorized as high risk using the GRACE RS, both EHS and NCDR have contributed to decrease the false positive rate generated by using the GRACE RS. CONCLUSIONS: Despite having been developed over 8 years ago, the GRACE RS still maintains its excellent performance for predicting in-hospital risk of death among ACS patients.

Comparing the predictive validity of three contemporary bleeding risk scores in acute coronary syndrome.

AIMS: Haemorrhagic complications are strongly linked with adverse outcomes in acute coronary syndrome (ACS) patients. Various risk scores (RS) are available to predict bleeding risk in these patients. We compared the performance of three contemporary bleeding RS in ACS. METHODS: We studied 4500 consecutive patients with ACS. We calculated the ACTION, CRUSADE, and Mehran et al. (2010) bleeding RS, and evaluated their performance for predicting their own major bleeding events and TIMI serious (major or minor) bleeding episodes, in patients with either non-ST-elevation ACS (NSTEACS) or ST-elevation myocardial infarction (STEMI). Calibration (Hosmer-Lemeshow test, HL) and discrimination (c-statistic) for the three RS were computed and compared. RESULTS: For RS-specific major bleeding, ACTION and CRUSADE showed the best prognostic discrimination in STEMI (c=0.734 and 0.791, respectively; p=0.04), and in NSTEACS (c=0.791 and 0.810; p=0.4); being CRUSADE significantly superior to Mehran et al. in both ACS types (p<0.05). All RS performed well in patients undergoing coronary arteriography using either a radial or femoral approach (all c≥0.718); however, their discriminative capacity was modest in patients not undergoing coronary arteriography and in those previously on oral anticoagulant (all c<0.70). For TIMI serious bleeding, ACTION and CRUSADE displayed the highest c-index values in both STEMI (0.724 and 0.703, respectively; p=0.3) and NSTEACS (c=0.733 and 0.744, respectively; p=0.6); however, calibration of ACTION was poor in both ACS types (HL p<0.05). CONCLUSIONS: Of contemporary bleeding RS, the CRUSADE score was found to be the most accurate quantitative tool for NSTEACS and STEMI patients undergoing coronary arteriography.