“Do GRACE (Global Registry of Acute Coronary events) risk scores still maintain their performance for predicting mortality in the era of contemporary management of acute coronary syndromes?”

doi:10.1016/j.ahj.2010.06.053

American Heart Journal

Volume 160, Issue 5, November 2010, Pages 826-834.e3

https://doi.org/10.1016/j.ahj.2010.06.053 Get rights and content

Background

Although the GRACE risk scores (RS) are the preferred scoring system for risk stratification in acute coronary syndromes (ACS), little is known whether these RS still maintain their performance in the current era. We aimed to investigate this issue in a contemporary population with ACS.

Methods

The study population composed of patients enrolled in the MASCARA national registry. The GRACE RS were calculated for each patient. Discrimination and calibration were evaluated with the C statistic and the Hosmer-Lemeshow test, in the whole population and according to the type of ACS, risk strata, and whether the patient had a history of diabetes and/or chronic renal failure. We determined if left ventricular ejection fraction (LVEF) provides incremental prognostic information above that established by the RS and whether percutaneous coronary intervention (PCI) during admission affects the performance of the score for predicting 6-month mortality.

Results

The 5,985 patients constituted the validation cohort for the in-hospital mortality RS and 5,635 the validation cohort for the 6-month mortality RS. Overall, both GRACE RS demonstrated excellent discrimination (C > 0.80) and calibration (all P values in Hosmer-Lemeshow >.1). Although similar results were seen in all subgroups, the 6-month mortality RS performed significantly less well in patients undergoing PCI compared to those patients who did not (C = 0.73 vs 0.76, P < .004). Adding LVEF to the RS did not convey significant prognostic information.

Conclusions

The GRACE RS for predicting in-hospital and 6-month mortality still maintain their excellent performance in a contemporary cohort of patients with ACS. Further studies are needed to investigate the performance of the 6-month mortality GRACE score in patients undergoing in-hospital PCI. Left ventricular ejection fraction did not convey significant information over that provided by the RS.

Section snippets

Data sources

The MASCARA study design has been previously reported.15, 16 MASCARA was designed to assess the impact that guidelines had had on practice and clinical outcomes throughout a wide range of Spanish hospitals. Thirty-two randomly selected hospitals fulfilled the quality requirements to participate in MASCARA. From October 2004 to June 2005, all consecutive patients ≥18 years old within 24 hours of the onset of angina at rest and who were hospitalized in any study center were eligible. Patients

Patient characteristics

Compared to GRACE, patients in MASCARA study showed, overall, worse baseline cardiovascular risk profile (Table I). MASCARA patients were older and had higher prevalence of hypertension, diabetes, hyperlipidemia, and peripheral arteriopathy. In addition, they were more likely to be in Killip II to IV class, to present ST-segment deviation, and to be in cardiac arrest at admission than the patients enrolled in GRACE. A smaller proportion of the MASCARA patients had smoking history, previous AMI

Discussion

In this unselected and contemporary sample of ACS, GRACE RS have shown an excellent discriminative power and calibration for predicting both in-hospital and 6-month postdischarge mortality. This is true for the whole population, regardless of the baseline risk, and for subgroups of patients with and without history of diabetes and/or CRF. However, model performance was significantly lower in patients who had undergone in-hospital PCI. In addition, our study shows that LVEF is not useful to

Clinical implications and conclusions

GRACE risk score is a valid and powerful predictor of in-hospital and 6-month postdischarge mortality across the wide range of current patients with ACS. Although the RS for predicting mortality at 6 months performed significantly less well in patients undergoing in-hospital PCI, its performance overall is excellent and to be maintained in all patients subgroups despite the time elapsed since its development. In AMI patients, LVEF did not convey significant prognostic information over that

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Cited by (63)

A novel risk stratification system “Angiographic GRACE Score” for predicting in-hospital mortality of patients with acute myocardial infarction: Data from the K-ACTIVE Registry
2021, Journal of Cardiology
Citation Excerpt :
The angiographic GRACE score only slightly improved the accuracy of the original GRACE risk score. However, it might be a useful predictor which compensates for weakness of the original GRACE score reported to be less useful in the patients treated with early PCI [15] who now constitute the great majority of AMI patients. Finally, the results of our study did not present strong evidence whether we would have saved the patients who died if we had performed the risk stratification by using the angiographic GRACE score because the causes of mortality were not evaluated in detail.
The Global Registry of Acute Coronary Events (GRACE) score is the most accurate risk assessment system for acute myocardial infarction (AMI), which was proposed in Western countries. However, it is unclear whether GRACE score is applicable to the present Japanese patients with a high prevalence of emergent percutaneous coronary intervention (PCI) and vasospasm. This study aimed to clarify the usefulness of GRACE risk score for risk stratification of Japanese AMI patients treated with early PCI and to evaluate a novel risk stratification system, “angiographic GRACE score,” which is the GRACE risk score adjusted by the information of the culprit coronary artery and its flow at pre- and post-PCI, to improve its predicting availability.
The subjects were 1817 AMI patients who underwent PCI within 24 h of onset between October 2015 and August 2017 and were registered in Kanagawa Acute Cardiovascular (K-ACTIVE) Registry via survey form. The association between the clinical parameters and in-hospital mortality was investigated.
A total of 79 (4.3%) in-hospital deaths were identified. The C-statistics for the in-hospital mortality of the GRACE score was 0.86, which was higher than that of the other conventional risk factors, including age (0.65), systolic blood pressure (0.70), heart rate (0.62), Killip classification (0.77), and serum levels of creatinine (0.68) and peak creatine kinase (0.74). The angiographic GRACE score improved the C-statistics from 0.86 of the original GRACE score to 0.89 (p < 0.05). In the setting of the cut-off value at 200, in-hospital mortality in the patients with the angiographic GRACE score <200 was 0.6%, which was relatively lower than those with ≥200, 9.4%.
The GRACE score is a useful predictor of in-hospital mortality among Japanese AMI patients in the PCI era. Moreover, the angiographic GRACE score could improve the predicting availability.
Identifying low-risk chest pain in the emergency department: Obstructive coronary artery disease and major adverse cardiac events
2020, American Journal of Emergency Medicine
Accurate risk stratification for obstructive coronary artery disease (CAD) and major cardiac adverse events (MACE) is important in emergency departments. We compared six established chest pain risk scores (the HEART score, CAD basic model, CAD clinical model, TIMI, GRACE, uDF) for prediction of obstructive CAD and MACE.
Patients who presented to the emergency department with chest pain or symptoms of suspected CAD and underwent coronary computed tomographic angiography were analyzed. The primary endpoint was adverse outcomes including the presence of obstructive CAD (≥50% stenosis) and the occurrence of MACE within 6 weeks. We compared the risk scores by the area under the receiver-operating characteristic curve (AUC) and calculated their respective net reclassification index (NRI).
Adverse outcomes occurred in 285 (28.4%) out of the 1002 patients included. For the prediction of adverse outcomes, the AUC of the HEART score (0.792) was superior to those of the CAD clinical model (0.760), CAD basic model (0.749), TIMI (0.749), uDF (0.703), and GRACE (0.653). In terms of the NRI, the HEART score significantly improved the reclassification abilities of the uDF (0.39), GRACE score (0.27), CAD basic model (0.11), TIMI (0.10), and CAD clinical model (0.08) (all P < 0.05). The HEART score also had the highest negative predictive value as well (0.893).
The HEART score was superior to other cardiac risk scores in predicting both obstructive CAD and MACE. However, due to the high false-negative rate (11%) of the HEART score, its use for identifying low-risk patients should be considered with caution.
Recurrent Cardiovascular Events in Survivors of Myocardial Infarction With ST-Segment Elevation (from the AMI-QUEBEC Study)
2018, American Journal of Cardiology
The characteristics and predictors of long-term recurrent ischemic cardiovascular events (RICEs) after myocardial infarction with ST-segment elevation (STEMI) have not yet been clarified. We aimed to characterize the 10-year incidence, types, and predictors of RICE. We obtained 10-year follow-up of STEMI survivors at 17 Quebec hospitals in Canada (the AMI-QUEBEC Study) in 2003. There were 858 patients; mean age was 60 years and 73% were male. The majority of patients receive reperfusion therapy; 53.3% and 39.2% of patients received primary percutaneous coronary intervention (PCI) and fibrinolytic therapy, respectively. Seventy-five percent of patients underwent in-hospital PCI (elective, rescue, and primary). At 10 years, 42% of patients suffered a RICE, with most RICEs (88%) caused by recurrent cardiac ischemia. The risk of RICE was the highest during the first year (23.5 per patient-year). At 10 years, the all-cause mortality was 19.3%, with 1/3 of deaths being RICE-related. Previous cardiovascular event, heart failure during the index STEMI hospitalization, discharge prescription of calcium blocker increased the risk of RICE by almost twofold. Each point increase in TIMI (Thrombolysis In Myocardial Infarction) score augmented the risk of RICE by 6%, whereas discharge prescription of dual antiplatelets reduced the risk of RICE by 23%. Our findings suggested that survivors of STEMI remain at high long-term risk of RICE despite high rate of reperfusion therapy and in-hospital PCI. Patients with previous cardiovascular event, in-hospital heart failure, and high TIMI score were particularly susceptible to RICE. Future studies are needed to confirm the impacts of calcium blocker and dual antiplatelets on long-term risk of RICE.
In-hospital mortality analysis of Japanese patients with acute coronary syndrome using the Tokyo CCU Network database: Applicability of the GRACE risk score
2018, Journal of Cardiology
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.
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).
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.
Predicting death after acute myocardial infarction
2018, Trends in Cardiovascular Medicine
Recognizing and understanding the risk factors for mortality after acute myocardial infarction (AMI) provide clinicians and patients important information to determine prognosis and guide treatment. Most risk stratification models use demographic and clinical information that exists prior to hospitalization plus clinical presentation characteristics to estimate a patient's risk of mortality. In this review, we summarize the most important risk factors and discuss current models to predict mortality.
Comparing TIMI, HEART, and GRACE Risk Scores to Predict Angiographic Severity of Coronary Artery Disease and 30-Day Major Adverse Cardiac Events in Emergency Department Patients with NSTEACS
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View all citing articles on Scopus

: See online Appendix C for a complete listing of MASCARA study researches.

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Clinical InvestigationAcute Ischemic Heart Disease“Do GRACE (Global Registry of Acute Coronary events) risk scores still maintain their performance for predicting mortality in the era of contemporary management of acute coronary syndromes?”

Background

Methods

Results

Conclusions

Section snippets

Data sources

Patient characteristics

Discussion

Clinical implications and conclusions

Am Heart J

Am Heart J

Am Heart J

Med Clin (Barc)

Rev Esp Cardiol

Am Heart J

Am Heart J

Am J Cardiol

Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation

Eur Heart J

Guidelines for the diagnosis and treatment of non–ST-segment elevation acute coronary syndromes

Eur Heart J

Focused updated: ACC/AHA guidelines for the management of patients with ST elevation myocardial infarction

Circulation

ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST elevation myocardial infarction

Circulation

Predictors of hospital mortality in the global registry of acute coronary events

Arch Intern Med

Clinical Investigation
Acute Ischemic Heart Disease
“Do GRACE (Global Registry of Acute Coronary events) risk scores still maintain their performance for predicting mortality in the era of contemporary management of acute coronary syndromes?”