Acute Coronary Syndrome Risk Score Research Articles

N-terminal pro-B-type natriuretic peptide and pulmonary echography are predictors of acute heart failure needing early mechanical ventilation in acute coronary syndrome.

The aim of this study was to determine the best clinical predictors of acute heart failure needing mechanical ventilation (MV) in the first 48 h of evolution of patients admitted because of acute coronary syndrome (ACS). We analyzed a cohort of patients admitted for ACS between February 2017 and February 2018. A pulmonary ultrasound was performed on admission and was considered positive (PE+) when there were three or more B-lines in two quadrants or more of each hemithorax. It was compared with N-terminal pro-B-type natriuretic peptide (NT-proBNP), peak troponin T-us value GRACE (Global Registry of Acute Coronary Events), CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology and American Heart Association guidelines - Bleeding Score), CACS (Canada Acute Coronary Syndrome risk score), and HAMIOT (Heart Failure after Acute Myocardial Infarction with Optimal Treatment score) scores, shock index, ejection fraction, chest X-ray, and Killip class at admission as predictors of MV in the first 48 h of admission. A total of 119 patients were included: 54.6% with ST elevation and 45.4% without ST elevation. Twelve patients (10.1%) required MV in the first 48 h of evolution. The sensitivity of PE+ was 100% (73.5-100%), specificity 91.6% (84.6-96.1%), and area under the curve was 0.96 (0.93-0.96). The sensitivity of an NT-proBNP value more than 3647 was 88.9% (51.9-99.7%), specificity 92.1% (84.5-96.8%), and area under the curve was 0.905 (0.793-1). The κ statistic between both predictors was 0.579. All the other scores were significantly worse than PE + . Lung ultrasound and a high NT-proBNP (3647 ng/L in our series) on admission are the best predictors of acute heart failure needing MV in the first 48 h of ACS. The agreement between both tests was only moderate.

No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score.

Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI. We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort). A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively. The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.

Usefulness of canada acute coronary syndrome risk score for predicting no-/slow-reflow in ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background The no-/slow-reflow phenomenon following primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) patients is associated with a poor prognosis. Early identification of high-risk patients of no-/slow-reflow is critical. This study sought to evaluate the predictive ability of the Canada Acute Coronary Syndrome (C-ACS) risk score for no-/slow-reflow in these patients. Methods STEMI patients who underwent primary PCI were consecutively enrolled and divided into three groups based on the C-ACS score: 0, 1, and ≥2. The C-ACS score was computed using the four clinical variables evaluated at admission (1 point for each): age ≥75 years, heart rate &amp;gt;100 beats/min, systolic blood pressure &amp;lt;100 mmHg, and Killip class &amp;gt;1. No-/slow-reflow was defined as thrombolysis in myocardial infarction flow grade 0 to 2 after primary PCI. The predictive ability of the C-ACS score for no-/slow-reflow was evaluated by the receiver operating characteristic curve. Results Overall, 834 patients were enrolled, with 109 (13.1%) developing no-/slow-reflow. The incidence of no-/slow-reflow increased from the C-ACS 0 group to C-ACS ≥2 group (10.7% vs 17.7% vs 32.2%, respectively, p&amp;lt;0.001). After multivariable adjustment, the C-ACS score was an independent predictor of no-/slow-reflow (odd ratio 2.623, 95% confidence interval 1.948-3.532, p&amp;lt;0.001). Furthermore, the C-ACS score possessed good discrimination for no-/slow-reflow (area under the curve 0.707, 95% CI 0.653-0.762, p&amp;lt;0.001). Further subgroup analyses indicated a significant interaction of C-ACS score with patient sex (p for interaction =0.011). The independent association between C-ACS score and no-/slow-reflow was only observed in male patients (odd ratio 3.061, 95% confidence interval 1.931-4.852, p&amp;lt;0.001). During a median follow-up duration of 4.3 years, the C-ACS score was independently associated with major adverse cardiovascular events independently of the occurrence of no-/slow-reflow (p for interaction =0.212). Conclusion The C-ACS risk score could independently predict the no-/slow-reflow in STEMI patients undergoing primary PCI, particularly in male patients.

Canada acute coronary syndrome risk score predicts no-/slow-reflow in ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

BackgroundThe no-/slow-reflow phenomenon following primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI)is associated with poor prognosis. The early identification of high-risk patients with no-/slow-reflow is critical. This study aimed to evaluate the predictive ability of the Canada Acute Coronary Syndrome (C-ACS) risk score for no-/slow-reflow in these patients. MethodsPatients with STEMI who underwent primary PCI were consecutively enrolled and divided into three groups based on their C-ACS scores: 0, 1, and ≥2. The C-ACS score was computed using the four clinical variables evaluated at admission (one point for each): age ≥75 years, heart rate >100 beats/min, systolic blood pressure <100 mmHg, and Killip class >1. No-/slow-reflow was defined as thrombolysis in a myocardial infarction flow grade of 0–2 after primary PCI. The predictive ability of the C-ACS score for no-/slow-reflow was evaluated using a receiver operating characteristic curve. ResultsA total of 834 patients were enrolled, of whom 109 (13.1 %) developed no-/slow-reflow. The incidence of no-/slow-reflow increased from the C-ACS 0 group to the C-ACS ≥2 group (6.1 % vs 17.7 % vs 34.3 %, respectively, p < 0.001). After multivariable adjustment, the C-ACS score was an independent predictor of no-/slow-reflow (odd ratio 2.623, 95 % confidence interval 1.948–3.532, p < 0.001). Furthermore, the C-ACS score showed good discrimination for no-/slow-reflow (area under the curve 0.707, 95 % confidence interval 0.653–0.762, p < 0.001). Further subgroup analyses indicated a significant interaction between the C-ACS score and patient sex (p for interaction = 0.011). The independent association between the C-ACS score and no-/slow-reflow was only observed in male patients (odd ratio 3.061, 95 % confidence interval 1.931–4.852, p < 0.001). During a median follow-up duration of 4.3 years, the C-ACS score was independently associated with major adverse cardiovascular events independent of the occurrence of no-/slow-reflow (p for interaction = 0.212). ConclusionThe C-ACS risk score could independently predict the no-/slow-reflow in patients with STEMI undergoing primary PCI, particularly in male patients.

Comparative analysis of four established risk scores for predicting contrast induced acute kidney injury after primary percutaneous coronary interventions.

This study aimed to compare Mehran Risk Score (MRS) with three well -known scoring systems namely CHA2DS2-VASc score, Canada Acute Coronary Syndrome Risk Score (C-ACS), and Thrombolysis in Myocardial Infarction risk index (TRI) to predict the contrast-induced acute kidney injury (CI-AKI) after primary percutaneous coronary intervention (PCI). CI-AKI is a common complication after primary PCI associated with an adverse prognosis. In this study consecutive patients of primary PCI were included. Patients with chronic kidney diseases, exposure to the contrast medium within the past 7days, and Killip class IV at presentation were excluded. MRS along with three risk scores namely CHA2DS2-VASc, C-ACS, and TRI were calculated for all patients and CI-AKI was defined as either 0.5mg/dL or 25% relative increase in post-procedure serum creatinine. The area under the curve (AUC) curve was reported. Post primary PCI CI-AKI was observed in 63 (9.1%) patients out of 691 patients. The AUC was 0.745 [0.679-0.810] for MRS, 0.725 [0.662-0.788] for CHA2DS2-VASc, 0.671 [0.593-0.749] for C-ACS, and 0.734 [0.674-0.795] for TRI. Sensitivity and specificity were 61.9% [48.8-73.8%] and 76.0% [72.4-79.3%] for MRS≥6.5, 66.7% [53.7-78.0%] and 66.7% [62.9-70.4%] for CHA2DS2-VASc≥2, 52.4% [39.4-65.1%] and 79.9% [76.6-83.0%] for C-ACS≥1, and 87.3% [76.5-94.4%] and 49.2% [45.2-53.2%] for TRI≥16 respectively. The MRS has shown higher discriminating power than CHA2DS2-VASc, C-ACS, and TRI. However, the TRI can be of good value in clinical practice due to its simplicity and high sensitivity in detecting patients at higher risk of CI-AKI after primary PCI.

Validation and comparison of six risk scores for post acute myocardial infarction infection

Abstract Background Various risk scores have been proven to predict outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, few of them were validated and compared the difference of the prediction of infection during hospitalization in such patients. Aim We aimed to validate and compare the discriminatory value of different risk scores for predicting infection. Methods Patients who were diagnosed with STEMI treated with PCI were enrolled from January 2010 to May 2018. The six risk scores included the Age, Serum Creatinine (SCr), or Glomerular Filtration Rate, and Ejection Fraction (ACEF or AGEF) score, Canada Acute Coronary Syndrome Risk Score (CACS score), CHADS2 score, Global Registry for Acute Coronary Events (GRACE) score and Mehran score. The primary end point was infection during hospitalization. The secondary endpoint was major adverse clinical events including all cause death, stroke and any bleeding. The prognostic accuracy of the six scores was assessed using the c statistic for discrimination and the Hosmer-Lemeshow test for calibration. Results A total of 2260 eligible patients were enrolled (62.32±12.36 year, 81.3% of males). A significant gradient of risk with respect to infection and in hospital major adverse clinical events (MACE) was observed with increasing all six risk scores. Other than the CHADS2 score (AUC: 0.682; 95% CI, 0.652–0.712), other five risk scores showed the good discrimination for predicting infection, with the GRACE score being the best (AUC: 0.791; 95% CI, 0.765–0.817). In addition, all risk scores showed best calibration for infection, but good calibration for CACS risk score (calibration slope: 0.77, 95% CI: 0.18–1.35) (Figure 1). Furthermore, each score showed a best discrimination for in hospital MACE, with AUCs ranging from 0.761 to 0.786, other than CACS risk score and CHADS2 risk score with AUC of 0.700 and 0.696, respectively. All risk scores showed best calibration for in hospital MACE. Conclusions In patients with STEMI undergoing PCI, these risk scores (ACEF, AGEF, CACS, GRACE and Mehran) showed good discrimination and calibration to predict infection and MACE. The CACS score was recommended for clinical use as its clinical variables were simple and practical. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): National Science Foundation for Young Scientists of China

Differential leukocyte counts and cardiovascular mortality in very old patients with acute myocardial infarction: a Chinese cohort study

BackgroundTotal leukocyte and differential Leukocyte counts are prognostic indictors in patients with coronary artery disease (CAD). However, there is no data available regarding their prognostic utility in very old patients with acute myocardial infarction (AMI). The aim of this study is to investigate the potential role of different leukocyte parameters in predicting the mortality among very old patients with AMI.MethodsA total of 523 patients aged over 80 years with AMI were consecutively enrolled into this study. Leukocyte and its subtypes were obtained at admission in each patient. The primary study endpoint was cardiovascular mortality. Patients were followed up for an average of 2.2 years and 153 patients died. The associations of leukocyte parameters with mortality were assessed using Cox regression analyses. The concordance index was calculated to test the model efficiency.ResultsIn multivariable regression analysis, neutrophils-plus-monocytes-to-lymphocytes ratio (NMLR) and neutrophils-to-lymphocytes ratio (NLR) were two most significant predictors of mortality among all the leukocyte parameters (HR = 3.21, 95% CI 1.75–5.35; HR = 2.79, 95% CI 1.59–4.88, respectively, all p < 0.001, adjusted for age, male gender, body mass index, family history of CAD, smoking, hypertension, diabetes mellitus, high-density lipoprotein cholesterol (HDL-C), non-HDL-C, high sensitivity C-reactive protein, creatinine, left ventricular ejection fraction, troponin I, use of statin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and percutaneous coronary intervention). Furthermore, adding NMLR and NLR into the Cox model increased the C-statistic by 0.038 and 0.037 respectively, which were more significant than that of other leukocyte parameters. Besides, addition of NMLR and NLR to the Canada Acute Coronary Syndrome Risk Score model also increased the C-statistic by 0.079 and 0.077 respectively.ConclusionOur data firstly indicated that most leukocyte subtypes were independent markers for the mortality in very old patients with AMI, while NMLR and NLR appeared to be more effective.

Prognostic relevance of GRACE risk score in Takotsubo syndrome.

Takotsubo syndrome is an increasingly recognised cardiac condition that clinically mimics an acute coronary syndrome, but data regarding its prognosis remain controversial. It is currently unknown whether acute coronary syndrome risk scores could effectively be applied to Takotsubo syndrome patients. This study aims to assess whether the Global Registry of Acute Coronary Events (GRACE) score can predict clinical outcome in Takotsubo syndrome and to compare the prognosis with matched acute coronary syndrome patients. A total of 561 Takotsubo syndrome patients was included in this prospective registry. According to the GRACE score, the population was divided into quartiles. The primary endpoint was all-cause mortality and the secondary endpoints were cardiocerebrovascular events (a composite of all-cause mortality, cardiovascular death, recurrence of Takotsubo syndrome and stroke). The median GRACE risk score was 139±27. Takotsubo syndrome patients with a higher GRACE risk score mostly have a higher rate of physical triggers and lower left ventricular ejection fraction on admission. During long-term follow-up, all-cause mortality rates were 5%, 11%, 12% and 22%, respectively, in the first, second, third and fourth quartile (P<0.001). After multivariate analysis, the GRACE risk score was found to be a strong predictor of all-cause mortality (odds ratio (OR) 1.68, 95% confidence interval (CI) 1.28-2.20; P=0.001) and cardiocerebrovascular events (OR 1.63, 95% CI 1.26-2.11; P=0.001). Moreover, all-cause mortality in Takotsubo syndrome patients was comparable with the matched acute coronary syndrome cohort. In Takotsubo syndrome, the GRACE risk score allows us to predict all-cause mortality and cardiocerebrovascular events at long-term follow-up.

Predictive value of the Canada Acute Coronary Syndrome risk score for post-acute myocardial infarction infection

BackgroundAlthough rare, infection in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) significantly increases mortality. Therefore, it is important to identify patients at high risk of infection. We aimed to validate the value of the Canada Acute Coronary Syndrome (C-ACS) risk score for predicting infection in such patients. MethodsWe conducted a prospective cohort study. Consecutive patients with STEMI undergoing PCI at our hospital from January 2010 to June 2016 were enrolled . C-ACS risk score was calculated based on the following clinical parameters (1 point for each): age ≥ 75 years, Killip class >1, systolic blood pressure <100 mmHg, and heart rate > 100 beats/min. The primary outcome was development of post-acute myocardial infarction (P-AMI) infection. ResultsA total of 2198 patients were enrolled, of whom 424 (18.5%) developed infection. The incidence of infection, in-hospital mortality, and major adverse clinical events (MACE) were significantly higher in those with a C-ACS risk score ≥2. After adjusting for potential risk factors, C-ACS risk score remained a significant predictor of P-AMI infection (odds ratio [OR] = 2.27, 95% confidence interval [CI] = 1.92–2.67, p < 0.001), in-hospital mortality, and MACE. Receiver operating characteristic curves demonstrated the C-ACS risk score had good predictive value for P-AMI infection (area under the curve = 0.783, 95% CI = 0.759–0.806, P < 0.001), in-hospital mortality and MACE. ConclusionsThe C-ACS risk score was a good predictor of P-AMI infection, and other clinical outcomes.

Accuracy of the Canadian new risk score as in hospital prognostic score for the Egyptian patients with acute coronary syndrome

ObjectivesPatients with acute coronary syndrome (ACS) need to be risk stratified to deliver the most appropriate therapy. There is no appropriate score for early-risk stratification at the time of the first medical contact with ACS patients. Canada Acute Coronary Syndrome Risk Score (Canadian-ACS) is a new risk score for early prognostication in acute coronary syndromes. The aim of our study is to evaluate the accuracy and validity of Canadian-ACS risk score as a prognostic score for in-hospital risk stratification of patients with ACS, as compared to TIMI AND GRACE risk scores in the Egyptian patients. MethodsOur study included 79 patients having acute coronary syndrome admitted to CCU. Calculations of The Canada Acute Coronary Syndrome Risk Score (Canadian-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of: age ≥75 years, Killip class >1, systolic blood pressure <100mm Hg, and heart rate >100 beats/min. ResultsIn our study, there is a strong association between Canadian-ACS and TIMI risk score with sensitivity 85.7% and specificity 100.0% and Grace risk score with sensitivity 78.1%% and specificity 85.1%. The negative predictive value of a Canadian-ACS score ≥1 is ≥84.4% for short-term in hospital morbidity and mortality, and for score ≥2 at ≥98%. Conclusionthe Canadian-ACS is a valid accurate and simple prognostic risk score for short-term risk stratification in patients with ACS independent of hypertension, diabetes, smoking and troponin level.

N-terminal pro-brain natriuretic peptide improves the C-ACS risk score prediction of clinical outcomes in patients with ST-elevation myocardial infarction.

BackgroundIt remained unclear whether the combination of the Canada Acute Coronary Syndrome Risk Score (CACS-RS) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) could have a better performance in predicting clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention.MethodsA total of 589 consecutive STEMI patients were enrolled. The potential additional predictive value of NT-pro-BNP with the CACS-RS was estimated. Primary endpoint was in-hospital mortality and long-term poor outcomes.ResultsThe incidence of in-hospital death was 3.1%. Patients with higher NT-pro-BNP and CACS-RS had a greater incidence of in hospital death. After adjustment for the CACS-RS, elevated NT-pro-BNP (defined as the best cutoff point based on the Youden’s index) was significantly associated with in hospital death (odd ratio = 4.55, 95%CI = 1.52–13.65, p = 0.007). Elevated NT-pro-BNP added to CACS-RS significantly improved the C-statistics for in-hospital death, as compared with the original score (0.762 vs. 0.683, p = 0.032). Furthermore, the addition of NT-pro-BNP to CACS-RS enhanced net reclassification improvement (0.901, p < 0.001) and integrated discrimination improvement (0.021, p = 0.033), suggesting effective discrimination and reclassification. In addition, the similar result was also demonstrated for in-hospital major adverse clinical events (C-statistics: 0.736 vs. 0.695, p = 0.017) or 3-year mortality (0.699 vs. 0.604, p = 0.004).ConclusionsBoth NT-pro-BNP and CACS-RS are risk predictors for in hospital poor outcomes in patients with STEMI. A combination of them could derive a more accurate prediction for clinical outcome s in these patients.

External validation of the ProACS score for risk stratification of patients with acute coronary syndromes

IntroductionThe ProACS risk score is an early and simple risk stratification score developed for all-cause in-hospital mortality in acute coronary syndromes (ACS) from a Portuguese nationwide ACS registry. Our center only recently participated in the registry and was not included in the cohort used for developing the score. Our objective was to perform an external validation of this risk score for short- and long-term follow-up. MethodsConsecutive patients admitted to our center with ACS were included. Demographic and admission characteristics, as well as treatment and outcome data were collected. The ProACS risk score variables are age (≥72 years), systolic blood pressure (≤116 mmHg), Killip class (2/3 or 4) and ST-segment elevation. We calculated ProACS, Global Registry of Acute Coronary Events (GRACE) and Canada Acute Coronary Syndrome risk score (C-ACS) risk scores for each patient. ResultsA total of 3170 patients were included, with a mean age of 64±13 years, 62% with ST-segment elevation myocardial infarction. All-cause in-hospital mortality was 5.7% and 10.3% at one-year follow-up. The ProACS risk score showed good discriminative ability for all considered outcomes (area under the receiver operating characteristic curve >0.75) and a good fit, similar to C-ACS, but lower than the GRACE risk score and slightly lower than in the original development cohort. The ProACS risk score provided good differentiation between patients at low, intermediate and high mortality risk in both short- and long-term follow-up (p<0.001 for all comparisons). ConclusionsThe ProACS score is valid in external cohorts for risk stratification for ACS. It can be applied very early, at the first medical contact, but should subsequently be complemented by the GRACE risk score.

Validação externa do score de risco ProACS para estratificação de risco de doentes com síndrome coronária aguda

IntroductionThe ProACS risk score is an early and simple risk stratification score developed for all‐cause in‐hospital mortality in acute coronary syndromes (ACS) from a Portuguese nationwide ACS registry. Our center only recently participated in the registry and was not included in the cohort used for developing the score. Our objective was to perform an external validation of this risk score for short‐ and long‐term follow‐up. MethodsConsecutive patients admitted to our center with ACS were included. Demographic and admission characteristics, as well as treatment and outcome data were collected. The ProACS risk score variables are age (≥72 years), systolic blood pressure (≤116 mmHg), Killip class (2/3 or 4) and ST‐segment elevation. We calculated ProACS, Global Registry of Acute Coronary Events (GRACE) and Canada Acute Coronary Syndrome risk score (C‐ACS) risk scores for each patient. ResultsA total of 3170 patients were included, with a mean age of 64±13 years, 62% with ST‐segment elevation myocardial infarction. All‐cause in‐hospital mortality was 5.7% and 10.3% at one‐year follow‐up. The ProACS risk score showed good discriminative ability for all considered outcomes (area under the receiver operating characteristic curve >0.75) and a good fit, similar to C‐ACS, but lower than the GRACE risk score and slightly lower than in the original development cohort. The ProACS risk score provided good differentiation between patients at low, intermediate and high mortality risk in both short‐ and long‐term follow‐up (p<0.001 for all comparisons). ConclusionsThe ProACS score is valid in external cohorts for risk stratification for ACS. It can be applied very early, at the first medical contact, but should subsequently be complemented by the GRACE risk score.

Validation of the Canada Acute Coronary Syndrome Risk Score for Hospital Mortality in the Gulf Registry of Acute Coronary Events-2.

Several risk scores have been developed for acute coronary syndrome (ACS) patients, but their use is limited by their complexity. The new Canada Acute Coronary Syndrome (C-ACS) risk score is a simple risk-assessment tool for ACS patients. This study assessed the performance of the C-ACS risk score in predicting hospital mortality in a contemporary Middle Eastern ACS cohort. The C-ACS score accurately predicts hospital mortality in ACS patients. The baseline risk of 7929 patients from 6 Arab countries who were enrolled in the Gulf RACE-2 registry was assessed using the C-ACS risk score. The score ranged from 0 to 4, with 1 point assigned for the presence of each of the following variables: age ≥75 years, Killip class >1, systolic blood pressure <100 mm Hg, and heart rate >100 bpm. The discriminative ability and calibration of the score were assessed using C statistics and goodness-of-fit tests, respectively. The C-ACS score demonstrated good predictive values for hospital mortality in all ACS patients with a C statistic of 0.77 (95% confidence interval [CI]: 0.74-0.80) and in ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome patients (C statistic: 0.76, 95% CI: 0.73-0.79; and C statistic: 0.80, 95% CI: 0.75-0.84, respectively). The discriminative ability of the score was moderate regardless of age category, nationality, and diabetic status. Overall, calibration was optimal in all subgroups. The new C-ACS score performed well in predicting hospital mortality in a contemporary ACS population outside North America.

GRACE score predicts heart failure admission following acute coronary syndrome

Congestive heart failure (CHF) is a common and preventable complication of acute coronary syndrome (ACS). Nevertheless, ACS risk scores have not been shown to predict CHF risk. We investigated whether the at-discharge Global Registry of Acute Coronary Events (GRACE) score predicts heart failure admission following ACS. Five-year mortality and hospitalization data were obtained for patients admitted with ACS from June 1999 to September 2009 to a single centre of the GRACE registry. CHF was defined as any admission assigned WHO International Classification of Diseases 10 diagnostic code I50. The hazard ratio (HR) for CHF according to GRACE score was estimated in Cox models adjusting for age, gender and the presence of CHF on index admission. Among 1,956 patients, CHF was recorded on index admission in 141 patients (7%), and 243 (12%) were admitted with CHF over 3.8 median years of follow-up. Compared to the lowest quintile, patients in the highest GRACE score quintile had more CHF admissions (116 vs 17) and a shorter time to first admission (1.2 vs 2.0 years, HR 9.87, 95% CI 5.93-16.43). Per standard deviation increment in GRACE score, the instantaneous risk was more than two-fold higher (HR 2.28; 95% CI 2.02-2.57), including after adjustment for CHF on index admission, age and gender (HR 2.49; 95% CI 2.06-3.02). The C-statistic for CHF admission at 1-year was 0.74 (95% CI 0.70-0.79). The GRACE score predicts CHF admission, and may therefore be used to target ACS patients at high risk of CHF with clinical monitoring and therapies.

PM162 Short and intermediate-term prognostication of the Canada Acute Coronary Syndrome Risk Score in the Gulf RACE-2 registry

PM162 Short and intermediate-term prognostication of the Canada Acute Coronary Syndrome Risk Score in the Gulf RACE-2 registry

Could Epicardial Adipose Tissue Thickness by Echocardiography Be Correlated with Acute Coronary Syndrome Risk Scores

The aim of our study was, echocardiographic epicardial adipose tissue (EAT) thickness could show the severity and the prognosis of acute coronary syndromes (ACS). Sixty-five ACS patients (mean age 57.4±12.2years) who underwent coronary angiography were studied. EAT thickness on the free wall of right ventricle was measured at end-diastole from the parasternal long-axis views of 3 cardiac cycles. SYNTAX and Global Registry of Acute Coronary Events (GRACE) scoring considered for severity and the prognosis of ACS. The mean value of the EAT thickness were 5.5±0.5mm (range 1-12mm). EAT thickness had a positive correlation with high sensitive troponin T (r=0.712, P<0.001) and body mass index (r=0.522, P<0.001.) EAT thickness was significantly correlated patients with high SYNTAX score (r=0.690, P<0.001), but not correlated with GRACE score (r=0.224, P=0.072). Epicardial adipose tissue thickness was correlated with angiographic severity of ACS, but not correlated with clinical prognosis risk score.

Canada Acute Coronary Syndrome Risk Score: A new risk score for early prognostication in acute coronary syndromes

Despite the availability of several acute coronary syndrome (ACS) prognostic risk scores, there is no appropriate score for early-risk stratification at the time of the first medical contact with patients with ACS. The primary objective of this study is to develop a simple risk score that can be used for early-risk stratification of patients with ACS. We derived the risk score from the Acute Myocardial Infarction in Quebec and Canada ACS-1 registries and validated the risk score in 4 other large data sets of patients with ACS (Canada ACS-2 registry, Canada-GRACE, EFFECT-1, and the FAST-MI registries). The final risk score is named the Canada Acute Coronary Syndrome Risk Score (C-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of each of these variables: age ≥75 years, Killip >1, systolic blood pressure <100 mm Hg, and heart rate >100 beats/min. The primary end points were short-term (inhospital or 30-day) and long-term (1- or 5-year) all-cause mortality. The C-ACS has good predictive values for short- and long-term mortality of patients with ST-segment elevation myocardial infarction and non-ST-segment elevation ACS. The negative predictive value of a C-ACS score ≥1 is excellent at ≥98% (95% CI 0.97-0.99) for short-term mortality and ≥93% (95% CI 0.91-0.96) for long-term mortality. In other words, a C-ACS score of 0 can potentially identify correctly ≥97% short-term survivors and ≥91% long-term survivors. The C-ACS risk score permits rapid stratification of patients with ACS. Because this risk score is simple and easy to memorize and calculate, it can be rapidly applied by health care professionals without advanced medical training.

Ecological Studies and Cardiovascular Outcomes Research

Is it better to have a heart attack in the United States or Canada? Ecological studies are epidemiological evaluations in which the unit of analysis is populations, or groups of people, rather than individuals.1 They can answer important questions such as the question posed above that cannot easily be answered using any other form of study design. Ecological studies are conducted by researchers in a variety of disciplines, including outcomes researchers, to study potential causal associations between 1 or more exposure and outcome variables. They are frequently used where alternative study designs are not possible (eg, randomized control trials), such as when investigating the effect of geographical and temporal factors on disease incidence or the effect of a government policy change on health outcomes. In this overview, we provide an introduction to the use of ecological studies in cardiovascular outcomes research, drawing on published examples from our group and others. It is important for clinicians to be aware of both the potential strengths and weaknesses of this type of study design. Because ecological studies are ubiquitous in the medical literature, it is not possible to review all published cardiovascular ecological studies in a systematic manner. Individual-level variables are properties of each person whereas ecological variables are properties of groups, organizations, or places.1,2 All ecological studies are potentially prone to the so-called “ecological fallacy,” which is a term for the biases that may occur when the association that exists between variables at an aggregate level may not represent the true association that exists at an individual level.3 On the other hand, the ecological fallacy may be offset by avoidance of the “individualistic fallacy” whereby one assumes that individual patients are unaffected by the neighborhood in which they live or the setting in which they are treated.4 Complete …

TIMI, PURSUIT, and GRACE Risk Scores: Sustained Prognostic Value and Interaction With Revascularization in NSTE-ACS

Aims Regarding prognosis, patients with a non-ST elevation acute coronary syndrome (ACS) are a very heterogeneous population, with varying risks of early and long-term adverse events. Early risk stratification at admission seems to be essential for a tailored therapeutic strategy. We sought to compare the prognostic value of three ACS risk scores (RSs) and their ability to predict benefit from myocardial revascularization performed during initial hospitalization. Methods and results We studied 460 consecutive patients admitted to our coronary care unit with an ACS [age: 63±11 years, 21.5% female, 55% with myocardial infarction (MI)]. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Platelet glycoprotein IIb/IIIa in Unstable agina: Receptor Suppression Using Integrilin (PURSUIT), and Global Registry of Acute Coronary Events (GRACE) RSs were calculated using specific variables collected at admission. Their prognostic value was evaluated by the combined endpoint of death or MI at 1 year. The best cut-off value for each RS, calculated with receiver operating characteristic curves, was used to assess the impact of myocardial revascularization on the combined incidence of death or MI. Death or MI at 1 year was 15.4% (32 deaths/49 MIs). The best predictive accuracy for death or MI at 1 year was obtained by the GRACE RS (AUC) [area under the curve: 0.715; confidence interval (CI: 0.672–0.756)] but the performance of the PURSUIT RS (AUC: 0.630; CI: 0.584–0.674), and TIMI RS (AUC: 0.585; CI: 0.539–0.631) was also good. We found a statistically significant interaction between the risk stratified by the best cut-off value for the GRACE and PURSUIT RSs and myocardial revascularization, with a better prognosis for the high-risk patients. The high-risk patients represented 36.7, 28.7, and 57.8% of the population, for the GRACE, PURSUIT, and TIMI RSs, respectively. Conclusion The RSs studied demonstrated a good predictive accuracy for death or MI at 1 year and enabled the identification of high-risk subsets of patients who will benefit most from myocardial revascularization performed during initial hospital stay.