Global Registry Of Acute Cardiac Events Research Articles

Comparison of Different Risk Scores for Prediction of In-Hospital Mortality in STEMI Patients Treated with PPCI.

Several risk scores have been developed to predict and analyze in-hospital mortality and short- and long-term outcomes of ST-elevation myocardial infarction (STEMI) patients after primary percutaneous coronary intervention (PPCI); these can classify patients as having a high or low risk of death or complications. To compare the prognostic precision of four risk scores for predicting in-hospital mortality in patients with STEMI treated with PPCI. We performed a retrospective cohort analysis of patients with STEMI who underwent PPCI between 2012 and 2019 (N = 1346). GRACE (Global Registry of Acute Cardiac Events), CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications), Zwolle, and TIMI (Thrombolysis in Myocardial Infarction) risk scores were calculated for each patient according to different variables. We evaluated the predictive accuracy of these scores for in-hospital mortality using the C statistic, which was obtained using logistic regression and receiver operating characteristic curves. The GRACE, CADILLAC, Zwolle, and TIMI risk scores all had good predictive precision for in-hospital mortality, with C statistics ranging from 0.842 to 0.923. The GRACE and CADILLAC risk scores were found to be superior. All GRACE, CADILLAC, Zwolle, and TIMI risk scores showed a high predictive value for in-hospital mortality due to all causes in patients with STEMI treated with PPCI. The GRACE and CADILLAC risk scores revealed a better accuracy for predicting in-hospital mortality than the Zwolle and TIMI risk scores.

Comparative assessment of short-term prognosis in patients with ST-segment elevation acute coronary syndrome without percutaneous coronary intervention based on the GRACE, TIMI, RECORD, PREDICT scales

Aim. To conduct a comparative assessment of the short-term prognosis in patients with ST-segment elevation acute coronary syndrome (STE-ACS) without percutaneous coronary intervention (PCI) based on the Global Registry of Acute Cardiac Events (GRACE), Thrombolysis In Myocardial Infarction (TIMI), RECORD, PREdicting risk of Death In Cardiac disease Tool (PREDICT) scales and to ident ify the most significant markers of fatal and non-fatal complications.Material and methods. Eighty-two STE-ACS patients without PCI were examined. Risk assessment was carried out using the GRACE, TIMI, RECORD, and PREDICT scales. Outcomes were assessed 30 days after markers. To assess the predictive value of above scales, sensitivity (Se) and specificity (Sp), as well as relative risk with a 95% confidence interval, were calculated.Results. Comparative analysis of the prognosis of developing fatal complications in STE-ACS patients without PCI revealed the following predictive characteristics of scales: GRAСE — Se=1,000, Sp=0,54, χ2=25,763 (p<0,001); PREDICT — Se=0,281, Sp=0,96, χ2=20,297 (p<0,001); TIMI — Se=0,75, Sp=0,94, χ2=51,985 (p<0,001); RECORD — Se=1,000, Sp=0,48, χ2=21,716 (p<0,001). Regarding the development of non-fatal complications, the following data was obtained: GRACE — Se=0,680, Sp=0,760, χ2=9,970 (p<0,01); PREDICT — Se=0,080, Sp=1,000, χ2=4,167 (р>0,05); TIMI — Se=0,120, Sp=1,000, χ2=8,171 (р<0,05); RECORD — Se=0,680, Sp=0,640, χ2=5,128 (р<0,05). The most significant criteria for developing fatal and non-fatal complications were identified as follows: Killip class II acute heart failure, systolic blood pressure <100 mm Hg, age >65 years, stage ≥II A chronic heart failure, ST elevation ≥1 mm at admission, ejection fraction ≤<40%.Conclusion. A comparative evaluation of the 30-day prognostic significance of short-term scales (GRACE, RECORD, TIMI, PREDICT) in STE-ACS patients without PCI showed an ambiguous prognosis for developing both fatal and non-fatal complications. High sensitivity rates for predicting fatal complications were revealed in the GRACE and RECORD scales (100 and 100%, respectively) relative to the TIMI and PREDICT (75 and 28,1%, respectively), as well as for non-fatal complications in the GRACE and RECORD (68% for both) scales relative to the TIMI and PREDICT (12 and 8%, respectively).

Predicting 30-day mortality after ST elevation myocardial infarction: Machine learning- based random forest and its external validation using two independent nationwide datasets

BackgroundVarious prognostic models for mortality prediction following ST-segment elevation myocardial infarction (STEMI) have been developed over the past two decades. Our group has previously demonstrated that machine learning (ML)-based models can outperform known risk scores for 30-day mortality post-STEMI. The study aimed to redevelop an ML-based random forest prediction model for 30-day mortality post-STEMI and externally validate it on a large cohort. MethodsThis was a retrospective, supervised learning, data mining study developed on the Acute Coronary Syndrome Israeli Survey (ACSIS) registry and the Myocardial Ischemia National Audit Project (MINAP) for external validation. Patients included received reperfusion therapy for STEMI between 2006 and 2016. Discrimination and calibration performances were assessed for two developed models and compared with the Global Registry of Acute Cardiac Events (GRACE) score. ResultsThe ACSIS cohort (2,782 included /15,212 total) and MINAP cohort (22,693 included/735,000 total) were significantly different in most variables, yet similar in 30-day mortality rate (4.3–4.4%). Random forest models were developed on the ACSIS cohort with a full model including all 32 variables and a simple model including the 10 most important ones. Features’ importance was calculated using the varImp function measuring how much each feature contributes to the data's homogeneity. Applying the optimized models on the MINAP validation cohort showed high discrimination of area under the curve (AUC) = 0.804 (0.786–0.822) for the full model, and AUC = 0.787 (0.748–0.780) using the simple model, compared with the GRACE risk score discrimination of AUC = 0.764 (0.748–0.780). All models were not well calibrated for the MINAP data. Following Platt scaling on 20% of the MINAP data, the random forest models calibration improved while the GRACE calibration did not change. ConclusionsThe random forest predictive model for 30-day mortality post STEMI, developed on the ACSIS national registry, has been validated in the MINAP large external cohort and can be applied early at admission for risk stratification. The model performed better than the commonly used GRACE score. Furthermore, to the best of our knowledge, this is the first externally validated ML-based model for STEMI.

In-hospital mortality in patients with NON-ST segment elevation myocardial infarction in relation to high risk global registry of acute cardiac events score.

Objectives: Presage for early risk stratification is consequential for long term clinical outcomes in patients with non-ST elevation acute coronary syndrome. Thrombolysis in Myocardial Infarction risk scores (TIMI) and Global Registry of Acute Cardiac Events (GRACE) have been most extensively investigated risk scores till date for risk stratification in patients admitted with Cardiovascular disease. Study Design: Descriptive Case Series. Setting: Department of Cardiology Ayub Teaching Hospital, Abbottabad. Period: 4th August 2016 to 4th April 2017. Material & Methods: 199 patients diagnosed with NSTEMI were included in the study after obtaining an apprised consent. Risk stratification of each patient was done according to GRACE score. Patients were followed up during their hospital stay and their outcome was recorded on a pre-designed pro forma. The outcome was described as either death or discharge. Results: Mean±SD GRACE score was 156.12±20.65. The overall mortality in the study population was 11.6% (n=23). When the outcome variable was stratified according to age, gender, diabetes mellitus, obesity and hypertension, results were found in case of hypertension (p< 0.05), and statistically no significant in the case of other variables. Conclusion: A high risk GRACE score is associated with increased in-hospital mortality in patients with NSTEMI.

The role of plateletcrit and red blood cell distribution width as a predictor of in-hospital mortality in patients with acute coronary syndrome

Abstract Introduction Red Blood Cell Distribution Width (RDW CV) and Plateletcrit (PCT) are part of complete blood count (CBC) examination. There are few studies have been reported the use of these parameters to predict clinical outcome including mortality, but none of them conducted in Asian population. We seek to investigate the role of PCT and RDW CV as a potential objective biomarker to predict in hospital mortality coincide with Global Registry of Acute Cardiac Events (GRACE) score in Acute Coronary Syndrome (ACS). Methods We respectively analysed patients with ACS who were admitted to the coronary care unit between June 2018 and December 2019. The GRACE and CBC were taken consecutively. Results A total of 1053 patients with ACS (46% non-ST elevated ACS (NSTE-ACS) and 54% ST elevated myocardial infarction (STEMI)] were enrolled in this study. PCT and RDW-CV was found to be significantly correlated with mortality (p<0.001). Further analysis showed significant higher level of PCT in patients with event compared to the other group (0.32 vs 0.24, p<0.001). Similar result was found for RDW (14.1 vs 13.2, p<0.001). ROC curve analysis for PCT and RDW-CV levels showed an AUC of 0.65, (cut off value: 0.25. p<0.001) and 0.69 (cut off value 13.05, p<0.001), respectively. High PCT and RDW-CV level were found to be a good predictor of mortality in ACS patients. (OR 2.6 and OR 3.4 respectively, p<0.001) In patients with high risk GRACE risk categories, we found a significantly higher levels of PCT (0.27 vs 0.24, p<0.001) and RDW-CV (13.8 vs 13.2, p<0.001) compared to low-intermediate risk group. Conclusion(s) We found that both PCT and RDW-CV may act as novel and promising tool to predict in hospital mortality directly proportional with GRACE Score among ACS patient. Figure 1. ROC curve for PCT and RDW-CV. Funding Acknowledgement Type of funding source: None

The effect of prehospital telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction patients undergoing primary percutaneous coronary intervention: A cross-sectional study.

OBJECTIVES:The sooner the primary percutaneous coronary intervention (PPCI) is performed, the better prognosis is expected in patients with acute myocardial infarction. The objective is to evaluate the effect of prehospital triage based on electrocardiogram (ECG) and telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction (STEMI) patients undergoing PPCI.METHODS:This cross-sectional study was conducted based on the data extracted from the hospital information system (HIS) of one general hospital, which had the capability of performing PPCI 24 h a day, 7 days a week. All patients with STEMI who undergone PPCI during 1 year, transferred by emergency medical service (EMS) and their data were registered in the HIS were eligible. Besides the baseline characteristics, first medical contact (FMC)-to-balloon time was recorded. Morbidity based on predischarge left ventricular ejection fraction (LVEF) and mortality based on Global Registry of Acute Cardiac Events (GRACE) score were also recorded. Patients who were referred to the hospital by EMS with prehospital ECG and telecardiology were compared with those without prehospital ECG.RESULTS:Totally, 298 patients with STEMI were enrolled, of whom 183 patients (61.4%) had prehospital ECG (telecardiology), and 115 patients (38.6%) had not. The means of predischarge LVEF of the patients in the first and the second groups were 40.7 ± 10.4 and 40.6 ± 11.2, respectively (P = 0.946). The mean of the probability of 6-month mortality based on GRACE score in the first group was significantly less than that of the second group (P = 0.004). Analyses of multivariable ordinal logistic regression showed that 6-month mortality severity risk in the second group was 1.5 times more than the first group (95% confidence interval 0.8–2.6), although this difference was not statistically significant (P = 0.199).CONCLUSIONS:It is likely that prehospital telecardiology, with shortening FMC to balloon time result in reducing probability 6-month mortality in STEMI patients who undergone PPCI. However, the process of telecardiology had no effect on predischarge LVEF in the current study.

Real-world use of ticagrelor versus clopidogrel in percutaneous coronary intervention-treated ST-elevation myocardial infarction patients: A single-center registry study

ObjectivesThe primary aim was to investigate the efficacy and safety of dual antiplatelet therapy (DAPT) using ticagrelor (T-DAPT) versus clopidogrel (C-DAPT) in a real-world ST-elevation myocardial infarction (STEMI) population. MethodsWe retrospectively analyzed 655 consecutive patients having primary percutaneous coronary intervention (PCI) for STEMI at Liverpool Hospital, Sydney, Australia (from January 2013 to April 2016). Medical and procedural therapies were at clinician discretion. Patient data were retrieved from hospital records and primary clinicians. ResultsT-DAPT (65%) was used more frequently, and in patients with lower mean CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) score, than C-DAPT (24.6 vs. 32.2; p < 0.0001, respectively). All-cause mortality was 9.0% at 2.7 years follow-up, with fewer deaths for T-DAPT (4.5% vs. 17.2%; p < 0.0001). T-DAPT incurred less BARC (Bleeding Academic Research Consortium) 3–5 major bleeding (5.0% vs. 12.4%; p < 0.0001). Multivariate regression showed that C-DAPT, GRACE (Global Registry of Acute Cardiac Events) score, and renal insufficiency were independently associated with mortality. Intra-aortic balloon pump (IABP) and GRACE score independently predicted BARC 3–5 bleeding. Early DAPT discontinuation (1.7%) and ticagrelor intolerance (7.6%) was rare. Switching DAPT regimen was infrequent (21.7%) and mostly attributed to clinician preference (73.2%). Independent determinants of C-DAPT selection were older age, diabetes, prior PCI, IABP, and higher CRUSADE score. ConclusionTicagrelor was preferred in low bleeding risk patients, which may have contributed to less BARC 3–5 bleeding and lower mortality for T-DAPT. Thus, bleeding mitigation is a clinical priority when selecting DAPT for PCI-treated STEMI patients. Continuation of initial DAPT regimen was typical, but early switching from clopidogrel to ticagrelor shows willingness to optimize DAPT. Patients with very low CRUSADE scores (<21.5) may be appropriate for switching to a potent P2Y12 inhibitor.

TIMI and GRACE Risk Scores Predict Both Short-Term and Long-Term Outcomes in Chinese Patients with Acute Myocardial Infarction.

Little is known about the long-term prognostic values of both thrombolysis in myocardial infarction (TIMI) and Global Registry of Acute Cardiac Events (GRACE) risk scores (RSs) to the Asian ethnicity. The purpose of this study is to compare the usefulness of these two scores in risk stratification and prediction of long-term (up to 3 years) outcomes for Chinese patients with myocardial infarction (MI). We calculated the TIMI and GRACE RSs for 726 consecutive patients with MI [55.6% with ST-segment elevation (STEMI) and 44.4% with non-ST-segment elevation (NSTEMI)]. Although the risk profile of our population (median TIMI score = 5 for STEMI, 4 for NSTEMI, and median GRACE score = 164) was higher, the in-hospital mortality (7.1% for NSTEMI and 6.7% for STEMI) was comparable to that predicted by GRACE RS. The GRACE RS worked well in predicting short-term and long-term death (C-statistics range 0.710 to 0.789) and triple (death, MI, and stroke) endpoints (C-statistics range 0.695 to 0.764) in both subsets of MI. GRACE RS performed significantly better than the TIMIRS in predicting 3-year mortality in NSTEMI (p = 0.035) and 1-year and 3-year mortality in STEMI (p = 0.028 and 0.009, respectively). Stratification by tertiles of GRACERS furnished greater prognostic information versus risk assessment by the TIMI RS. The use of RSs revealed a fair to good discriminatory accuracy in predicting both short-term and long-term major adverse cardiac events in Asian patients with MI. Compared with the simpler TIMI RS, the GRACERS was more accurate in predicting long-term mortality.

Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assays

We compare the ability of 5 established risk scores to identify patients with suspected acute coronary syndromes who are suitable for discharge after a modified single-presentation high-sensitivity troponin result. This was a prospective observational study conducted in a UK district general hospital emergency department. Consecutive adults recruited with suspected acute coronary syndrome for whom attending physicians determined evaluation with serial troponin testing was required. Index tests were definitions of low risk applied to modified Goldman, Thrombolysis in Myocardial Infarction (TIMI), Global Registry of Acute Cardiac Events (GRACE), History, ECG, Age, Risk Factors, Troponin (HEART), and Vancouver Chest Pain Rule risk scores, incorporating either high-sensitivity troponin T or I results. The endpoint was acute myocardial infarction within 30 days. A test sensitivity threshold for acute myocardial infarction of 98% was chosen. Clinical utility was defined as a negative predictive value greater than or equal to 99.5% and identification of greater than 30% suitable for discharge. Nine hundred fifty-nine patients underwent high-sensitivity troponin T analysis and 867 underwent high-sensitivity troponin I analysis. In the high-sensitivity troponin T group, 79 of 959 (8.2%) had an acute myocardial infarction and 66 of 867 (7.6%) in the high-sensitivity troponin I group. Two risk scores (GRACE <80 and HEART ≤3) did not have the potential to achieve a sensitivity of 98% with high-sensitivity troponin T, and 3 scores (Goldman ≤1, TIMI ≤1, and GRACE <80) with high-sensitivity troponin I. A TIMI score of 0 or less than or equal to 1 and modified Goldman score less than or equal to 1 with high-sensitivity troponin T, and TIMI score of 0 and HEART score of less than or equal to 3 with high-sensitivity troponin I had the potential to achieve a negative predictive value greater than or equal to 99.5% while identifying greater than 30% of patients as suitable for immediate discharge. With established risk scores, it may be possible to identify greater than 30% of patients suitable for discharge, with a negative predictive value greater than or equal to 99.5% for the diagnosis of acute myocardial infarction, using a single high-sensitivity troponin test result at presentation. There is variation in high-sensitivity troponin assays, which may have implications in introducing rapid rule-out protocols.

Predictors and outcomes of early coronary angiography in patients with prior coronary artery bypass surgery presenting with non-ST elevation myocardial infarction

IntroductionThe best strategy in patients with prior coronary artery bypass graft surgery (CABG) who present with non-ST elevation myocardial infarction (NSTEMI) remains less well defined. We compare the characteristics, therapeutic...

The effect of referral for cardiac rehabilitation on survival following acute myocardial infarction: a comparison survival in two cohorts collected in 1995 and 2003

International guidelines recommend referral for cardiac rehabilitation (CR) after acute myocardial infarction (AMI). However, the impact on long-term survival after CR referral has not been adjusted by time-variance. We compared the effects of CR referral after hospitalization for AMI in two consecutive decades. A total of 2196 and 2055 patients were recruited in the prospective observational studies of the Evaluation of the Methods and Management of Acute Coronary Events (EMMACE) -1 and 2 in 1995 and 2003, (1995: median age 72 years, 39% women, 74% referred vs 2003: median age 71 years, 36% women, 64% referred) and followed up through September 2010. Survival functions showed CR referral to be an independent predictor for survival in 2003, but not in 1995 (hazard ratio (HR), 0.90; 95% confidence interval [CI]; 0.70 to 1.17, p = 0.44 in 1995 vs HR, 0.80; 95% CI, 0.66 to 0.96, p = 0.02 in 2003) when patients entered the model at three months after discharge and had a common exit at 90 months. Significant positive and negative predictors for CR referral were beta-blocker prescription (+), reperfusion (+) and age (-) in 1995, and reperfusion (+), revascularization (+), heart failure (HF) (+), antiplatelets (+), angiotensin-converting-enzyme inhibitor (ACE-I) (+), statins (+), diabetes (-), and the modified Global Registry of Acute Cardiac Events (GRACE) risk score (-) in 2003. CR referral was associated with improved survival in 2003, but not in 1995 in patients admitted with acute MI.

Depression is associated with longer emergency department length of stay in acute coronary syndrome patients

BackgroundPatient demographic characteristics have been associated with longer emergency department (ED) treatment times, but the influence of psychosocial characteristics has not been assessed. We evaluated whether depression was associated with greater ED length of stay (LOS) in non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) patients presenting to a large metropolitan academic medical center.MethodsWe calculated ED LOS for NSTEMI or UA patients enrolled an observational cohort study by taking the difference between ED triage time in the medical record and time of transfer to an inpatient bed from standardized transfer documentation forms. Depression status was defined as current, past, or never by clinical interview and also by self-report on the Beck Depression Inventory.ResultsParticipants were 120 NSTEMI/UA patients [mean age= 62, 36% women, 56% Hispanic, 26% Black/African American, 40% NSTEMI, mean global registry of acute cardiac events (GRACE) score= 93.9]. Mean ED LOS was 11.6 hours, SD= 8.3. A multiple linear regression model that included the above demographic and clinical variables, and time of presentation to ED, explained 11% of the variance in ED LOS, F (11, 108)= 2.35, p= .01, R2 adj.= .11. Currently depressed patients spent 5.4 more hours (95% CI= .40, 10.4 hours) in the ED on average than patients who had never been depressed.ConclusionsCurrently depressed NSTEMI/UA patients are in the ED for an average of 5 hours longer than those who have never been depressed. Further research is needed to identify the reasons for this difference.

Cardiac catheterisation in nonagenarians: Single center experience.

ObjectiveTo explore the treatment, procedure related risks, and outcomes of patients older than 90 years of age undergoing cardiac catheterization.MethodsWe retrospectively studied 32 patients ≥ 90 years (93.0 ± 1.2 years) who underwent cardiac catheterisation in a tertiary specialist hospital (0.2% of 14,892 procedures during three years). The results were compared to a patient cohort younger than 90 years of age.ResultsBaseline characteristics revealed a higher prevalence of diabetes (P < 0.001), chronic obstructive pulmonary disease (P < 0.04), previous myocardial infarction (P < 0.02), and complex coronary anatomy (SYNTAX score 33 vs. 19) in nonagenarians. Patients < 90 years of age showed more hyperlipidemia (P < 0.01) and previous percutaneous coronary interventions (P < 0.015). Nonagenarians underwent coronary angiography more often for acute coronary syndrome (ACS) (P < 0.003), were presented more often in cardiogenic shock (P < 0.003), and were transferred faster to coronary angiography in cases of ACS (P < 0.0001). The observed in-hospital mortality rate (13% study group vs. 1% control group; P < 0.003) in nonagenarians was lower than the calculated rate of thrombolysis in myocardial infarction (TIMI) and global registry of acute cardiac events (GRACE) mortality and strongly influenced by the severity of clinical presentation and the presence of co-morbidities.ConclusionDespite the common scepticism that cardiac catheterisation exposes patients ≥ 90 years to an unwarranted risk, our data demonstrate an acceptable incidence of complications and mortality in this group of patients.

Cortisol levels and history of depression in acute coronary syndrome patients

Depressed mood following an acute coronary syndrome (ACS) is a risk factor for future cardiac morbidity. Hypothalamic-pituitary-adrenal (HPA) axis dysregulation is associated with depression, and may be a process through which depressive symptoms influence later cardiac health. Additionally, a history of depression predicts depressive symptoms in the weeks following ACS. The purpose of this study was to determine whether a history of depression and/or current depression are associated with the HPA axis dysregulation following ACS. A total of 152 cardiac patients completed a structured diagnostic interview, a standardized depression questionnaire and a cortisol profile over the day, 3 weeks after an ACS. Cortisol was analysed using: the cortisol awakening response (CAR), total cortisol output estimated using the area under the curve method, and the slope of cortisol decline over the day. Total cortisol output was positively associated with history of depression, after adjustment for age, gender, marital status, ethnicity, smoking status, body mass index (BMI), Global Registry of Acute Cardiac Events (GRACE) risk score, days in hospital, medication with statins and antiplatelet compounds, and current depression score. Men with clinically diagnosed depression after ACS showed a blunted CAR, but the CAR was not related to a history of depression. Patients with a history of depression showed increased total cortisol output, but this is unlikely to be responsible for associations between depression after ACS and later cardiac morbidity. However, the blunted CAR in patients with severe depression following ACS indicates that HPA dysregulation is present.

Anaemia and the development of depressive symptoms following acute coronary syndrome: longitudinal clinical observational study

ObjectiveDepressive symptoms are common following acute coronary syndrome (ACS) and predict subsequent cardiovascular morbidity. Depression in acute cardiac patients appears to be independent of clinical disease severity and other cardiovascular...

Evaluation of Global Registry of Acute Cardiac Events and Thrombolysis in Myocardial Infarction scores in patients with suspected acute coronary syndrome

Purposes We aimed to evaluate the Global Registry of Acute Cardiac Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores in patients with suspected but not proven acute coronary syndrome (ACS). Basic procedures We conducted a secondary analysis of data from the RATPAC trial. Standardized data were collected from 2263 patients presenting to 6 emergency departments with suspected but not proven ACS. Patients were followed up by record review and postal questionnaire at 30 and 90 days after recruitment to identify major adverse events, defined as death, emergency revascularization, life-threatening arrhythmia, hospitalization for ACS, or nonfatal acute myocardial infarction (AMI). Main findings Data were available for 2243 patients (mean age, 54.5 years; 58% male). The major adverse event rate was 43 (2%) of 2243 after 30 days and 62 (3%) of 2243 after 90 days. The c statistics for 30-day events were 0.717 (95% confidence interval [CI], 0.698-0.735) for GRACE and 0.682 (95% CI, 0.662-0.701) for TIMI. The corresponding 90-day c statistics were 0.726 (95% CI, 0.707-0.745) for GRACE and 0.693 (95% CI, 0.674-0.712) for TIMI. The c statistic for patient age alone was 0.656 for 30-day events and 0.689 for 90-day events. Principal conclusions The GRACE and TIMI scores are little better than age alone as predictors of major adverse events in patients with suspected but not proven ACS, and thus add little to prognostic assessment of such patients.

C-reactive protein improves risk prediction in patients with acute coronary syndrome, or does it?

Patients with acute coronary syndrome (ACS) represent a heterogeneous population. Both the severity of coronary artery disease and the extent of myocardial damage can differ markedly among patients presenting with ACS and these differences—in addition to age, left ventricular dysfunction, and the presence of co-morbidities—are likely to be responsible for different clinical outcomes in different patients. Accurate risk stratification of ACS patients continues to represent a major challenge to the managing physician.1,2 Established cardiovascular risk factors have been incorporated into algorithms for risk assessment in ACS patients and several clinical risk scores have been proposed in the past decade, which are promoted by International guidelines for management of patients with ACS.1,3 The Platelet glycoprotein IIb/IIIa in Unstable Angina: Receptor suppression Using Integrilin Therapy (PURSUIT),4 the Thrombolysis in Myocardial Infartion (TIMI),5 and the Global Registry of Acute Cardiac Events (GRACE)6 risk scores appear to be efficient prognostic indicators. However, they have limitations and physicians do not appear to have fully embraced the use of these scores in clinical practice.7,8 There is interest in the use of newer biomarkers, particularly those that have been shown to have independent prognostic value in different patient subgroups with coronary artery disease.9,10 The advent of biomarkers of inflammation, in particular high-sensitivity C-reactive protein, raised new hopes regarding improved prognostic algorithms in ACS.11 It has been speculated that the addition of C-reactive protein to other clinical variables encompassed by different risk scores can increase the prognostic ability of these clinical risk scores. In the general population, the use of a multimarker approach in different studies resulted in better risk prediction compared with single markers ( Figure 1 ).12 In the Wang et al. study12 in over 3000 people attending the … *Corresponding author. Tel: +44 208 725 2628, Fax: +44 208 725 3328, Email: jkaski{at}sgul.ac.uk

Understanding Physicians' Risk Stratification of Acute Coronary Syndromes

An important treatment-risk paradox exists in the management of acute coronary syndromes (ACSs). However, the process of risk stratification by physicians and its relationship to the management of ACS have not been well studied. Our objective was to examine patient risk assessment by physicians in relation to treatment and objective risk score evaluation and the underlying patient characteristics that physicians consider to indicate high risk. The prospective Canadian ACS 2 Registry recruited 1956 patients admitted for non-ST-segment elevation ACS in 36 hospitals in October 2002 to December 2003. We recorded patient risk assessment by the treating physician and case management on standardized case report forms and calculated the Thrombolysis in Myocardial Infarction (TIMI), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT), and Global Registry of Acute Cardiac Events (GRACE) risk scores. Of the 1956 patients with ACS, 347 (17.8%) were classified as low risk, 822 (42.0%) as intermediate risk, and 787 (40.2%) as high risk by their treating physicians. Patients considered as high risk were more likely to receive aggressive medical therapies and to undergo coronary angiography and revascularization. However, there were only weak correlations between risk assessment by physicians and all 3 validated risk scores. In multivariable analysis, history of stroke, worse Killip class, presence of ST-segment deviation, T-wave inversion, and positive cardiac biomarker status were all independently associated with high-risk categorization by the treating physician, while advanced age and previous coronary bypass surgery were independent negative predictors. There was no significant association between the high-risk category and several established prognosticators, such as history of heart failure, hemodynamic variables, and creatinine level. Contemporary risk stratification of ACS appears suboptimal and may perpetuate the treatment-risk paradox. Physicians may not recognize and incorporate the most powerful adverse prognosticators into overall patient risk assessment. Routine use of validated risk score may enhance risk stratification and facilitate more appropriate tailoring of intensive therapies toward high-risk patients.

Quantitative troponin elevation does not provide incremental prognostic value beyond comprehensive risk stratification in patients with non–ST-segment elevation acute coronary syndromes

The aim of this study was to evaluate whether quantitative cardiac troponin (cTn) assessment can improve risk stratification in a spectrum of patients with non-ST-segment elevation (NSTE) acute coronary syndrome (ACS) using the validated Global Registry of Acute Cardiac Events (GRACE) risk model. The Canadian ACS Registry II is a prospective, multicenter study that enrolled patients admitted to hospital with a suspected NSTE ACS within 24 hours of symptom onset. Of the total 2297 patients, those with elevated cTn (n = 1013) were further stratified into tertiles of cTn ranges. Our primary end point was death and our secondary end point was a composite of death or/and recurrent myocardial infarction at 1-year follow-up. Multivariable analysis adjusting for validated predictors of death confirmed the independent prognostic value of any abnormal cTn (vs normal) for death (adjusted odds ratio 2.28, 95% CI 1.49-3.49, P < .001) and for the composite outcome (adjusted odds ratio 2.18, 95% CI 1.61-2.95, P < .001) at 1 year. With quantitative assessment, the gradient of mortality risk with increasing cTn level was not evident after adjusting for other prognosticators. Quantitative (compared to qualitative) assessment of cTn level did not improve either the GRACE risk model discrimination for 1-year death. Any cTn elevation is associated with higher rate of death at 1 year, but its quantitative assessment did not prove as important as its mere presence as an independent long-term prognosticator in a nonclinical trial, "real-world" NSTE ACS population.

ST-segment depression in non–ST elevation acute coronary syndromes: Quantitative analysis may not provide incremental prognostic value beyond comprehensive risk stratification

It is unclear whether quantitative ST-segment assessment can improve risk stratification of unselected acute coronary syndrome (ACS) patients using the validated Global Registry of Acute Cardiac Events (GRACE) risk model. In the prospective, multicenter, Canadian ACS Registry, the admission electrocardiogram was evaluated centrally at a blinded core laboratory. Patients with ST-elevation myocardial infarction and other electrocardiogram confounders were excluded. ST depression (ST down) was measured and summed in all leads except aVR. Patients with ST down were divided into 3 groups based on tertiles of cumulative ST down. A multivariable model was developed to examine the independent prognostic value of ST down severity after adjusting for other known prognosticators in the GRACE risk model. Among 2590 patients with non-ST-elevation ACS, more severe ST down was associated with advanced age, higher heart rate and Killip class, elevated creatinine, abnormal biomarkers, higher GRACE risk score, and higher 1-year mortality (all P < .001). After adjusting for these confounding prognosticators, the presence of any ST down remained independently associated with higher 1-year mortality (odds ratio 1.78, 95% CI 1.21-2.63, P = .004). However, the gradient of risk with increasing magnitude of ST down was no longer evident (adjusted odds ratios 1.77, 1.77, 1.81, for ascending tertiles of cumulative ST down, respectively). Moreover, quantitative ST down did not improve the model discrimination for 1-year mortality. The results were similar when the number of leads with ST down or the maximum magnitude of ST down was analyzed, after adjusting for tertiles of GRACE risk score or inhospital revascularization, or using the composite end point of death or myocardial (re)infarction at 1 year. Greater ST down is associated with other adverse prognosticators across the broad spectrum of non-ST-elevation ACS. Although the presence of any ST down is an independent predictor of 1-year mortality, its quantitative assessment is not as important as its mere presence when studied on the background of comprehensive clinical and biomarker evaluation in a nonclinical trial-based ACS population.