The association between GRACE score at admission for myocardial infarction and the incidence of sudden cardiac arrests in long-term follow-up - the MADDEC study.

Background. Sudden cardiac arrest (SCA), often also leading to sudden cardiac death (SCD), is a common complication in coronary artery disease. Despite the effort there is a lack of applicable prediction tools to identify those at high risk. We tested the association between the validated GRACE score and the incidence of SCA after myocardial infarction. Material and methods. A retrospective analysis of 1,985 patients treated for myocardial infarction (MI) between January 1st 2015 and December 31st 2018 and followed until the 31st of December of 2021. The main exposure variable was patients' GRACE score at the point of admission and main outcome variable was incident SCA after hospitalization. Their association was analyzed by subdistribution hazard (SDH) model analysis. The secondary endpoints included SCA in patients with no indication to implantable cardioverter-defibrillator (ICD) device and incident SCD. Results. A total of 1985 patients were treated for MI. Mean GRACE score at baseline was 118.7 (SD 32.0). During a median follow-up time of 5.3 years (IQR 3.8-6.1 years) 78 SCA events and 52 SCDs occurred. In unadjusted analyses one SD increase in GRACE score associated with over 50% higher risk of SCA (SDH 1.55, 95% CI 1.29-1.85, p < 0.0001) and over 40% higher risk for SCD (1.42, 1.12-1.79, p = 0.0033). The associations between SCA and GRACE remained statistically significant even with patients without indication for ICD device (1.57, 1.30-1.90, p < 0.0001) as well as when adjusting with patients LVEF and omitting the age from the GRACE score to better represent the severity of the cardiac event. The association of GRACE and SCD turned statistically insignificant when adjusting with LVEF. Conclusions. GRACE score measured at admission for MI associates with long-term risk for SCA.

What is already known about this subject?Nearly 50% of cardiac mortality is caused by sudden cardiac death, often due to sudden cardiac arrest.Despite the effort, there is a lack of applicable prediction tools to identify those at high risk.What does this study add?This study shows that GRACE score measured at the point of admission for myocardial infarction can be used to evaluate patients' risk for sudden cardiac arrest in a long-term follow-up.How might this impact on clinical practice?Based on our findings, the GRACE score at the point of admission could significantly affect the patients' need for an ICD device after hospitalization for MI and should be considered as a contributing factor when evaluating the patients' follow-up care.

Prehospital Adenosine Diphosphate Receptor Blocker Use, Culprit Artery Flow, and Mortality in STEMI: The MADDEC Study.

BACKGROUND AND OBJECTIVE: The newer adenosine diphosphate (ADP) receptor blockers ticagrelor and prasugrel are superior to clopidogrel in the long-term management of acute coronary syndrome (ACS). We evaluated the acute performance (prehospital loading) of these ADP receptor blockers in a primary percutaneous coronary intervention (PCI) for an ST-elevation myocardial infarction (STEMI). METHODS: In a retrospective, single-center registry study, data on all STEMI patients admitted for their first primary PCI between January 2007 and April 2020 were analyzed (n = 3218). The three ADP receptor blockers were mainly used during consecutive periods (clopidogrel 2007-2010, prasugrel 2011-2014, and ticagrelor 2014-2020), and were compared with risk factor-adjusted multivariate logistic regression for acute 3- and 7-day mortality and culprit artery flow before and after PCI. RESULTS: Of the 3218 total patients, 47.6% (n = 1532) were treated with ticagrelor, 22.1% (n = 711) were treated with prasugrel, and 30.3% (n = 975) were treated with clopidogrel. The use of ticagrelor or prasugrel as opposed to clopidogrel was associated with better culprit artery flow before PCI (odds ratio [OR] 1.21 for moderate or good flow, 95% confidence interval [CI] 1.03-1.42, p = 0.022), as well as lower acute mortality (OR 0.66 for 3-day mortality, 95% CI 0.46-0.95, p = 0.025; and OR 0.71 for 7-day mortality, 95% CI 0.52-0.98, p = 0.039). The results in regard to acute mortality were highlighted among patients with short treatment delays (disappearing with longer treatment delays; p < 0.05 for interaction). CONCLUSIONS: The newer ADP receptor blockers are associated with lower mortality and better culprit artery flow at presentation when compared with clopidogrel. There are no significant differences between the two newer drugs. As the drugs were mainly used during three consecutive periods, unmeasured confounding related to the development of cardiac care and changes in the population may contribute to the results.

The association between charlson comorbidity index and mortality in acute coronary syndrome - the MADDEC study.

Objectives. Acute coronary syndrome (ACS) is associated with high mortality. Charlson comorbidity index (CCI) was designed over 30 years ago to measure the impact of pre-existing comorbidities on long-term survival of the patient. We wanted to re-evaluate the performance of CCI and its components in modern setting. Design. This is a retrospective study of 1576 consecutive patients undergoing invasive evaluation and treated for ACS in single tertiary center between 2015-2016. Mortality was analyzed in timeframes of 1, 6 and 24 months. CCI-scores were retrieved from written medical records and complimented with data from electronic sources. The performance of CCI and its components was compared to the GRACE-score measuring patients' status upon hospital admission. Results. Population mean age at baseline was 69.3 (SD 11.8) years and 69.1% of the patients were male (n = 1089). Most of the components of CCI associated significantly with mortality at all timeframes despite adjusting for age but only diabetes and congestive heart failure associated with mortality at all time points after adjusting for GRACE-score. CCI associated with mortality [GRACE adjusted HR-values of single unit increase of CCI after 1, 6 and 24-month follow-up: 1.12(95% CI:1.00-1.25), 1.17(1.07-1.29) and 1.24(1.16-1.33)]. CCI performed modestly with its AUC-values ranging between 0.755 and 0.784, with prognostic performance increasing with longer follow-up. Adding components of CCI did not significantly improve risk prediction over GRACE-score. Conclusions. In conclusion, CCI or its individual components measuring the impact of comorbidities on overall mortality does not provide any significant value compared to GRACE-score during up to 2 years of follow-up.

Left ventricular ejection fraction adds value over the GRACE score in prediction of 6-month mortality after ACS: the MADDEC study.

Background: Reduced left ventricular ejection fraction (LVEF) is a risk marker for mortality after an acute coronary syndrome (ACS). Global Registry of Acute Coronary Events (GRACE) risk score, developed almost two decades ago, is the preferred scoring system for risk stratification in ACS. The aim of this study was to validate the GRACE score and evaluate whether LVEF has incremental predictive value over the GRACE in predicting 6-month mortality after ACS in a contemporary setting. Methods: A retrospective analysis of all 1576 consecutive patients who were admitted to Tays Heart Hospital and underwent coronary angiography for a first episode of ACS (2015-2016). Clinical risk factors were extensively recorded. Adjusted Cox regression analysis was used to analyse the associations between LVEF and the GRACE score with 6-month all-cause mortality. The incremental predictive value was assessed by the change in C-statistic by Delong's method for paired samples and by index of discrimination improvement (IDI). Results: In univariable analysis, both LVEF and the GRACE were associated with 6-month mortality, and after applying both variables into the same model, the results remained significant (GRACE score: HR: 1.036, 95% CI 1.030 to 1.042; LVEF: HR: 0.965, 95% CI 0.948 to 0.982, both HRs corresponding to a one unit change in the exposure variable). The GRACE score demonstrated good discrimination for mortality (C-statistic: 0.833, 95% CI 0.795 to 0.871). Adding LVEF to the model with the GRACE score improved model performance significantly (C-statistic: 0.848, 95% CI 0.813 to 0.883, p=0.029 for the improvement and IDI 0.0171, 95% CI 0.0016 to 0.0327, p=0.031). Conclusions: Adding LVEF to the GRACE score significantly improves risk prediction of 6-month mortality after ACS.