GRACE Risk Score Research Articles

Relation of GRACE Risk Score to Coronary Lipid Core Plaques in Patients with Acute Coronary Syndrome.

The GRACE risk score is established to predict thrombotic events in patients with acute coronary syndrome (ACS). Although thrombotic events including myocardial infarction after ACS are mainly attributable to vulnerable plaque formation, whether the GRACE score correlates with coronary lipid-rich plaque is unclear. A total of 54 patients with ACS undergoing primary percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were included in a prospective manner. Patients were divided into two groups according to the median of the GRACE risk score. Coronary lipid plaques in the target vessel were assessed by NIRS-IVUS with lipid core burden index (LCBI) and a maximum LCBI in 4 mm (maxLCBI4mm). The receiver operating characteristics (ROC) curve analysis was performed based on the major adverse cardiovascular events as an exploratory analysis. The GRACE risk score was significantly and positively correlated with LCBI (r = 0.31, p = 0.03) and maxLCBI4mm (r = 0.38, p = 0.006). LCBI (111.7 ± 85.7 vs. 169.0 ± 83.5, p = 0.02) and maxLCBI4mm (428.5 ± 227.1 vs. 600.6 ± 227.7, p = 0.009) in the target vessel were significantly higher in the high GRACE risk score group than their counterpart. In the ROC curve analysis, LCBI and maxLCBI4mm were predictive for clinical events. In conclusion, the higher GRACE risk score may serve as a discriminator of risk comprising more lipid-rich plaques as an underlying mechanism of an increased risk of thrombotic events after ACS. In patients with ACS, the higher GRACE risk score was significantly and modestly associated with greater coronary lipid plaques in the target vessel.

Performance of GRACE risk score for predicting 5-year cardiovascular mortality in NSTE-ACS patients

Performance of GRACE risk score for predicting 5-year cardiovascular mortality in NSTE-ACS patients

High in-hospital mortality and prevalence of cardiogenic shock in patients with ST-segment elevation myocardial infarction and concomitant COVID-19.

Published data suggest worse outcomes in acute coronary syndrome (ACS) patients with concomitant coronavirus disease (COVID-19) due to delays in standard management caused by burdened healthcare. To report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ST-elevation myocardial infarction (STEMI) patients and to compare these with the non-COVID-19 cohort hospitalized during the same period with the same access to medical care. From October 23rd, 2020 to April 23rd, 2021 (exactly 6 months) data were collected into a prospective ACS Registry. STEMI patients underwent invasive coronary angiography and were tested for COVID-19. Outcomes were in-hospital mortality and prevalence of cardiogenic shock. 125 patients, of whom 25 were COVID-19 positive, were admitted to the cardiology ward, and completed their hospital stay (i.e. discharge or death). There were no differences with regard to the time from symptom onset to reperfusion (median (Q1-Q3); 165 (130-202) vs. 170 (123-210), p = 0.86) and door-to-balloon time between the compared groups (25 (21-35) vs. 29 (21-59), p = 0.26). There was a higher GRACE risk score and mortality in the COVID-19 positive patients (180 (154-226) vs. 155 (132-181) and 48% vs. 10%, respectively, both p < 0.0001). Cardiogenic shock occurred more often in this group (32% vs. 13%; p = 0.035). COVID-19 positive patients had elevated high-sensitivity C-reactive protein (hsCRP) (p < 0.0001) and D-dimer (p = 0.003) and reduced left ventricular ejection fraction (p = 0.037). Postprocedural TIMI 3 flow grade was observed less frequently in this group (p = 0.044). High in-hospital mortality in patients with STEMI and COVID-19 did not result from delays in standard management, and could be related to increased thrombogenicity.

The prognostic utility of GRACE risk score in predictive adverse cardiovascular outcomes in patients with NSTEMI and multivessel disease

BackgroundGRACE risk score models are capable of predicting all-cause mortality of non-ST elevation myocardial infarction (NSTEMI) patients. However, its utility for evaluating major adverse cardiovascular events (MACE) in NSTEMI patients with multivessel disease (MVD) remains unclear.Methods and resultsThis study was designed as a retrospective cohort study that recruited patients with NSTEMI and multivessel disease between September 2013 and December 2018 in Daping Hospital, Chongqing, China. The primary outcome was a composite outcome that included all-cause mortality, recurrent angina, non-fatal myocardial infarction, coronary re-vascularization, and non-fatal strokes. Of the 827 patients with NSTEMI, 32 did not complete follow-up and 430 were excluded because of single-vessel disease. The remaining 365 NSTEMI patients with MVD had a median follow-up of 3.0 (IQR 2.6–3.3) years, 78 patients experienced outcomes. The GRACE risk score predicted the MACE (hazard ratio 1.014, 95% CI 1.006–1.021, P < 0.001). The GRACE risk score performed well in predicting all-cause mortality (c-statistic 0.72, 95% CI 0.59–0.85, P = 0.001) in MVD but was less powerful in predicting MACE (c-statistic 0.69, 95% CI 0.62–0.75, P < 0.001). When combining the GRACE risk score with the SYNTAX score, and blood urea nitrogen for predicting all-cause mortality and MACE events, the c-statistic value increased to 0.82 and 0.81 (P < 0.001).ConclusionIn NSTEMI patients with MVD, the GRACE score showed an acceptable predictive value for all-cause mortality, but it was less powerful in predicting MACE. Blood urea nitrogen may be valuable in assessing long-term cardiovascular events in patients with MVD.

PMHnet-alpha: development and validation of a neural network based discrete-time survival model for mortality prediction in ischemic heart disease

Abstract Background Current risk prediction models in ischemic heart disease (IHD) use a small set of well-known risk factors, have limited predictive capabilities, and are largely the same as they were twenty years ago. We developed and externally validated PMHnet-alpha, a neural-network based survival model for risk-stratification in ischemic heart disease that leverages the multitude of clinical features available in modern electronical health records. Methods We included 39,746 IHD patients from the regional Heart Registry that had been subjected to a coronary angiography between 2006 and 2017 with confirmed coronary artery disease. Clinical data was extracted from the Danish National Patient Registry, and electronic health records. 595 different features, consisting of diagnosis codes, procedure codes, biochemical test results, and clinical measurements were used as model inputs. Prior to model development, patients were randomly divided into a training set (n=34,746) and a tesing set (n=5,000). The testing set was not used for model development. Model performance was evaluated at six months, one years, three-, and five years of follow-up using time-dependent ROC curve analysis and Harrels' C-index. Lastly, we also assessed the calibration of the model. We benchmarked the performance of PMHnet-alpha against the GRACE Risk Score 2.0, which is widely considered to the best-performing model in current clinical use. We explored the importance of individual features using SHAP values on the trained models. Findings PMHnet-alpha had very high model discrimination on the testing data with time-dependent AUCs of 0.88 (95% CI 0.86–0.90) at six months, 0.88 (95% CI 0.86–0.90) at one year, 0.84 (95% CI 0.82–0.86) at three years, and 0.82 (95% CI 0.80–0.84) at five years. The discrimination of the benchmark model GRACE2.0 on the same data was considerably lower, 0.77 (95% CI 0.73–0.80) at six months, 0.77 (95% CI 0.74–0.80) at one year, and 0.73 (95% CI 0.70–0.75) at three years. PMHnet-alpha is undergoing external validation in other nordic countries. We identified that on-average, age, coronary pathology and smoking status were the most impactful features. Interpretation Here we present a significant improvement of the state of the art in cardiac risk prediction. PMHnet-alpha supports better and optimized use of available healthcare data, signified by the vast improvement compared to GRACE2.0. This also signifies an important paradigm shift in which data-driven strategies are necessary to transform the increasing amount of data generated in the modern healthcare system into evidence-based clinical decision making. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation, NordForsk

A critical analysis of Discovery Health’s claims-based risk adjustment of mortality rates in South African private sector hospitals

In 2019, Discovery Health published a risk adjustment model to determine standardised mortality rates across South African private hospital systems, with the aim of contributing towards quality improvement in the private healthcare sector. However, the model suffers from limitations due to its design and its reliance on administrative data. The publication's aim of facilitating transparency is unfortunately undermined by shortcomings in reporting. When designing a risk prediction model, patient-proximate variables with a sound theoretical or proven association with the outcome of interest should be used. The addition of key condition-specific clinical data points at the time of hospital admission will dramatically improve model performance. Performance could be further improved by using summary risk prediction scores such as the EUROSCORE II for coronary artery bypass graft surgery or the GRACE risk score for acute coronary syndrome. In general, model reporting should conform to published reporting standards, and attempts should be made to test model validity by using sensitivity analyses. In particular, the limitations of machine learning prediction models should be understood, and these models should be appropriately developed, evaluated and reported.

Clinical Significance of Culprit Vessel Occlusion in Patients With Non–ST-Elevation Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

In patients with non-ST-elevation myocardial infarction (NSTEMI), total occlusion of the culprit coronary artery (OCA) is not uncommon. We sought to determine the frequency and clinical impact of OCA at presentation in a large population of patients presenting with NSTEMI and who underwent systematic early invasive management. We performed a post hoc analysis of the TAO (Treatment of Acute Coronary Syndrome with Otamixaban) randomized trial, which included patients with NSTEMI with systematic coronary angiography within 72hours. We compared the baseline characteristics and outcomes of patients according to whether the culprit vessel was occluded (thrombolysis in myocardial infarction flow grade [TFG] 0 to 1) or patent (TFG 2 to 3) at presentation. A total of 7,473 patients with NSTEMI with only 1 culprit lesion identified were enrolled, of whom 1,702 patients had OCA (22.8%). In the OCA group, coronary angiography was performed earlier (18 ± 15 vs 20 ± 16hours, p <0.01), the culprit lesion was less likely to be the left anterior descending artery (26.5% vs 41.4%, p <0.001) but with more frequent angiographic thrombus (49.9% vs 22.7%, p <0.01). Culprit artery percutaneous coronary intervention during the index procedure was also more frequent (88.5% vs 78.1%, p <0.001) but with a lower rate of TFG grade 3 after the procedure and higher subsequent peak troponin I levels (8.3 ± 13.6µg/L vs 5.6 ± 11.9µg/L, p <0.001). At day 7, patients with OCA had higher mortality, and this persisted after adjustment on gender, Grace risk score, cardiovascular risk factors, andculpritvessel location (0.9% vs 0.4%, p=0.02; adjusted odds ratio [OR]=2.55, 95% confidence interval [CI] 1.23 to 5.29, p=0.01). The absolute difference of mortality was maintained through 30days: 1.2% versus 0.8%, p=0.13; OR: 1.72, 95% CI 0.97 to 3.05, but mortality rates were similar by 180days: 1.5% versus 1.6%, p=0.8, adjusted OR=1.11, 95% CI 0.69 to 1.80, p=0.66. In conclusion, a significant proportion of patients with NSTEMI have a totally occluded culprit vessel at presentation. These patients are at higher risk of early mortality but not at 6months.

The role of Tei index added to the GRACE risk score for prediction of in-hospital MACE after acute myocardial infarction.

Introduction: The Global Registry of Acute Coronary Events (GRACE) risk score is widely recommended for risk assessment in patients with acute myocardial infarction (AMI). Variable degrees of impairment in left ventricular (LV) systolic and diastolic function might be found after AMI. Tei index is an echocardiography parameter that represents both systolic and diastolic LV performance. Previous studies demonstrate Tei index as an independent predictor of Major Adverse Cardiovascular Events (MACE) after AMI. This study investigates whether the addition of Tei index could improve the GRACE risk score performance to predict inhospital MACE after AMI. Methods: A prospective cohort study was conducted on 75 patients who presented with AMI. Total GRACE score was calculated on patient admission and echocardiography was conducted within 72 hours of hospitalization for measurement of MPI. All patients were observed for the incidence of MACE during hospitalization. The incremental predictive value of the GRACE risk score alone and combined with Tei index was assessed by the change in area under the curve (AUC) by DeLong's method, likelihood ratio test (LRT), and continuous net reclassification improvement (cNRI). Results: The addition of Tei index to the GRACE risk score significantly improves the predictive value of the GRACE risk score (increase in AUC from 0.753 for the GRACE risk score to 0.801 for the GRACE score combine with Tei index, p=0.354; LRT=4.65, p=0.030; cNRI=0.515, p=0.046). Conclusions: Adjustment of Tei index to GRACE risk score might improve risk prediction of in-hospital MACE after AMI.

The relationship between body mass index, anthropometric measurements and GRACE risk score in acute coronary syndrome

PurposeThis study aims to determine the relationship between body mass index (BMI) and Global Registry of Acute Coronary Events (GRACE) risk score in patients diagnosed with acute coronary syndrome (ACS) and to evaluate the results in this context.Design/methodology/approachThis was a prospective cohort study of ACS patients admitted to a cardiac care unit in high specialization hospital's cardiology service. The study included 140 men aged >35 years who were diagnosed with ACS.FindingsThe mean age of the individuals participating in the study was 61.4 ± 10.9 years old. The mean BMI of the individuals was 25.3 ± 6.6 kg/m2, and the mean value of the waist/hip ratio was 0.85 ± 0.01. Individuals were divided into four quarters according to the GRACE score. It was determined that individuals with the highest GRACE score were very underweight or morbidly obese according to their BMI values (p = 0.04).Originality/valueIt has been observed that there is a U-shaped relationship between the GRACE score and the BMI in individuals diagnosed with ACS. The risk of death of ACS patients with very high or very low BMI values was found to be close to each other. Although there is a relationship between BMI and GRACE score, it is concluded that it is insufficient to determine the risk in coronary disease alone, and body fat distribution should be examined together with BMI.

The Prognostic Value of Echocardiographic Wall Motion Score Index in ST-Segment Elevation Myocardial Infarction

When compared to left ventricular ejection fraction (LVEF), previous studies have suggested the superiority of wall motion score index (WMSI) in predicting cardiac events in patients who have suffered acute myocardial infarction. However, there are limited studies assessing WMSI and mortality in ST-segment elevation myocardial infarction (STEMI). We aimed to compare the prognostic value of WMSI in a cohort of STEMI patients treated with primary percutaneous coronary intervention (PCI). A comparison of WMSI, LVEF, and all-cause mortality in STEMI patients treated with primary PCI between January 2008 and December 2020 was performed. The prognostic value of WMSI, LVEF, and traditional risk scores (TIMI, GRACE) were compared using multivariable logistic regression modelling. Among 1181 patients, 27 died within 30-days (2.3%) and 49 died within 12 months (4.2%). WMSI ≥1.8 was associated with poorer survival at 12-months (9.2% vs 1.5%; p < 0.001). When used as the only classifier for predicting 12-month mortality, the discriminatory ability of WMSI (area under the curve (AUC): 0.77; 95% CI: 0.68-0.84) was significantly better than LVEF (AUC: 0.71; 95% CI: 0.61-0.79; p=0.034). After multivariable modelling, the AUC was comparable between models with either WMSI (AUC: 0.89; 95% CI: 0.85-0.94) or LVEF (AUC: 0.87; 95% CI: 0.83-0.92; p < 0.08) yet performed significantly better than TIMI (AUC: 0.71; 95% CI: 0.62-0.79; p < 0.001), or GRACE (AUC: 0.63; 95% CI: 0.54-0.71; p < 0.001) risk scores. When examined individually, WMSI is a superior predictor of 12-month mortality over LVEF in STEMI patients treated with primary PCI. When examined in multivariable predictive models, WMSI and LVEF perform very well at predicting 12-month mortality, especially when compared to existing STEMI risk scores.

Abstract 9896: Living Alone is a Poor Prognostic Factor of Mortality Among Patients With Acute Myocardial Infarction

Introduction: Acute myocardial infarction (AMI) has been a major cause of death worldwide. Recently, living alone as a proxy for social isolation has been considered to increase the risk of cardiovascular disease. We thus investigated the impact of living alone on mortality in AMI patients. Methods: Subjects comprised 277 AMI patients who underwent percutaneous coronary intervention (PCI). Associations between all-cause death after PCI and baseline characteristics including living alone and Global Registry of Acute Coronary Events (GRACE) risk score, which is widely used for estimating mortality in AMI patients, were assessed. Results: Eighty-three patients (30%) were living alone and 194 patients (70%) were not. Median duration of follow-up was 1153 days (interquartile range, 560-1566 days). Thirty patients died after PCI including 20 cardiac deaths. Patients living alone showed higher incidences of both all-cause and cardiac deaths compared with patients not living alone (18% vs. 8%, p = 0.019 and 14% vs. 4%, p = 0.004, respectively). Multivariate Cox proportional hazards regression analysis modeling using relevant factors from univariate analysis showed living alone [hazard ratio (HR), 2.60; 95% confidence interval (CI), 1.20-5.62; p = 0.016] and GRACE risk score (HR, 1.02; 95%CI, 1.01-1.03; p = 0.003) correlated significantly with all-cause death. The interaction of GRACE risk score and living alone showed a value of p = 0.25. The optimal cut-off on the receiver-operating characteristic curve of GRACE risk score for predicting all-cause death was 162. Cox proportional hazards modeling using GRACE risk score and living alone revealed that patients living alone with GRACE risk score ≥162 showed a significantly greater risk of all-cause death than patients not living alone with GRACE risk score &lt;162 (HR 11.50; 95%CI 5.59-23.67; p &lt; 0.001). Conclusions: Among AMI patients, living alone represents an independent risk factor for all-cause death after PCI, separate from GRACE risk score. In addition, AMI patients living alone with high GRACE risk scores may experience an additively increased risk of mortality after PCI.

Abstract 14648: Can GRACE Risk Score Predict Mortality in Pulmonary Embolism?

Introduction Risk stratifying of pulmonary embolism (PE) patients and treatment for normotensive patients is still challenging. We aimed to assess the utility of GRACE risk score for 30-day mortality. Methods All consecutive patients hospitalized with a diagnosis of PE between2016 -2021 were included in this retrospective study. GRACE and PESI scores were calculated online. Results A total of 197 patients were enrolled. Mean age was 63.98±15.51. 56 of patients died by the end of the 30-day. When patients divided into 2 groups according to 30-day mortality, both groups were similar in terms of gender, hypertension, diabetes mellitus, coronary artery disease, heart failure and chronic obstructive pulmonary disease. Troponin level (212.4± 24.6 vs. 850.8±231.1; p&lt;0.0001), PESI (122.3±27.2 vs. 170.1±49.1; p&lt;0.0001) and GRACE (127.1±28.8 vs. 182±21.3; p&lt;0.0001) were significantly higher in non-survivor group. The correlation analysis we observed strong positive correlation between PESİ and GRACE (r=0.732; p&lt;0.0001). Regression analysis revealed that only GRACE score [p=0.021, β: 1.146, OR (95% CI): 1.021-1.286] was an independent risk factor associated with 30-day mortality. ROC curve for accuracy of GRACE score for predicting 30-day mortality in PE patients is shown in figure 1. Area under curve (AUC) for GRACE score was 0.969 [%95 CI: 0.948-0.990]. A cut off value of 161.5 for GRACE score was associated with 90.0% sensitivity and 89.7% specificity in prediction of 30-day mortality. Conclusion In this study, the relation between GRACE score and the clinical course of PE patients evaluated and we found GRACE risk score as an independent risk factor associated with 30-day mortality and strong correlation between GRACE and PESİ risk scores. To predict the mortality of high-risk normotensive and hypotensive PE patients,GRACE risk score exhibited high specificity and positive probability.

Abstract 13104: Prognostic Value of a Progressive Decrease in Apoj-Glyc Levels in Patients Attending A&amp;E Departments With Suspected Acute Coronary Syndrome or Angina-Like Pain

Introduction: Reduced serum levels of glycosylated apolipoprotein J (ApoJ-Glyc) have been proposed as a marker for the early detection of myocardial ischemia with a potential prognostic value. Objective: The EDICA clinical trial assessed the performance of ApoJ-Glyc as a biomarker for the early detection of myocardial ischemia in patients attending the A&amp;E department with chest pain suggestive of acute coronary syndrome (ACS) and investigated -as a secondary pilot objective- its prognostic value. Methods: EDICA -a multi-centre, international, diagnostic study (NCT04119882) assessed 404 patients. Based on clinical variables and diagnostic tests, 291 patients were considered to have had a “non-ischemic” event and 113 an “ischemic” event. Blood samples were obtained for the assessment of high-sensitivity troponin and ApoJ-Glyc at admission and at 1h and 3h thereafter. GRACE Risk Score was calculated in all ischemic patients. Patients were followed up for 6 months after presentation and the occurrence of MACE (cardiac death, recovered cardiac arrest, re-infarction, cardiac failure, new admission for ACS after discharge, or unplanned revascularization for cardiac ischemia after discharge) was recorded. ApoJ-Glyc serum levels were analyzed with a novel ELISA targeting a specific glycosylated variant of ApoJ (ApoJ-GlycA2). Results: Among the patients in the ischemic group, 8.8% had MACE at 6-months and these showed a 26% mean reduction in ApoJ-GlycA2 levels 3h post-admission compared with levels at presentation. This reduction was not observed in patients without MACE. Patients in the highest GRACE Risk Score tertile (&gt;118 points) showed a progressive decrease in ApoJ-GlycA2 levels after presentation compared with patients in the lower risk tertiles (mean decrease: 41% at 1h, P=0.01 and 35% at 3h, P=0.02 when compared with admission levels). Conclusions: A progressive decrease in ApoJ-Glyc levels after A&amp;E admission appears to not only identify patients with ischemic events but also those at higher risk of suffering serious recurrent cardiovascular events at 6-months’ follow-up. Further studies in larger cohorts of patients are warranted to validate the potential role of ApoJ-Glyc in risk stratification in the context of cardiac ischemic events.

A novel clinical and cardiac magnetic resonance risk score for early risk prediction after ST-segment elevation myocardial infarction

Abstract Background Cardiac magnetic resonance (CMR) performed early after ST-segment elevation myocardial infarction (STEMI) can improve major adverse cardiac event (MACE) risk prediction. However, predictive models including clinical and CMR variables are scarce and not routinely implemented in clinical practice. Purpose We aimed to create a simple clinical-CMR risk score for early MACE risk stratification in STEMI patients. Methods We performed a multicenter prospective registry in three Spanish university hospitals of reperfused STEMI patients (n=1118) in whom early (1-week) CMR-derived left ventricular ejection fraction (LVEF), infarct size and microvascular obstruction (MVO) were quantified. MACE was defined as a combined clinical endpoint of cardiovascular (CV) death, non-fatal myocardial infarction (NF-MI) or re-admission for acute decompensated heart failure (HF), whichever occurred first. Univariate and multivariate analyses were performed and a risk score was computed using the variables which independently predicted the risk of MACE. Results During a median follow-up of 5.52 [2.63–7.44] years, 216 first MACE (58 CV deaths, 71 NF-MI and 87 HF) were registered. Mean age was 59.3±12.3 years and most patients (82.8%) were male. Based on the four variables independently associated with MACE, we computed an 8-point risk score: time to reperfusion &amp;gt;4.15h (1 point), GRACE risk score &amp;gt;155 (3 points), CMR-LVEF &amp;lt;40% (3 points), and MVO &amp;gt;1.5 segments (1 point). This score permitted MACE risk stratification: MACE per 100 person-years was 1.96 in the low-risk category (0–2 points), 5.44 in the intermediate-risk category (3–5 points), and 19.7 in the high-risk category (6–8 points): p&amp;lt;0.001 in multivariable Cox survival analysis. Conclusions A novel risk score including clinical (time to reperfusion &amp;gt;4.15h and GRACE risk score &amp;gt;155) and CMR (LVEF &amp;lt;40% and MVO &amp;gt;1.5 segments) variables allows for simple and straightforward MACE risk stratification early after STEMI. External validation should confirm the applicability of the risk score. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional (FEDER) and Sociedad Española de Cardiología.

Sex inequities in the performance of the GRACE 2.0 score in non-ST-segment elevation acute coronary syndromes: a multinational observational study in contemporary cohorts from four European countries

Abstract Background The Global Registry of Acute Coronary Events (GRACE) score was developed and validated in predominantly male patient populations. Growing evidence indicates distinct pathophysiologic and clinical characteristics of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) in women and men. Purpose We aimed to assess sex differences in the performance of the GRACE score in NSTE-ACS in contemporary populations. Methods We calculated GRACE 2.0 risk estimates for patients with NSTE-ACS in contemporary nation-wide ACS cohorts from England, Wales, and Northern Ireland (MINAP, 2005–2017, n=400,054) and from Switzerland (AMIS Plus, 2005–2020, n=20,727; SPUM-ACS, 2009–2017, n=2,239). Sex disaggregated analyses were stratified according to the mortality endpoint of the score (in-hospital death, death at 6 months, death at 1 year), the clinical setting (calculated at admission and calculated for hospital survivors, respectively), the geographic region (United Kingdom and Switzerland, respectively) and the level of care (all hospitals and PCI-capable university hospitals, respectively). The area under the receiver operating characteristic curve (AUC), the average prediction error (APE), and the misclassification rate (MCR) were compared between women and men. Results The discriminatory performance of GRACE 2.0 for in-hospital death was lower and the APE and MCR were higher in women as compared to men in the United Kingdom (AUC female: 80.4%, 95% confidence interval [CI], 80.0 to 80.8, AUC male: 84.7%, 95% CI, 84.4 to 85.1, p&amp;lt;0.001; APE female: 0.0512, 95% CI, 0.0501–0.0522, APE male: 0.0357, 95% CI, 0.0351 to 0.0363; MCR female: 5.81%, 95% CI, 5.68 to 5.94, MCR male: 3.96, 95% CI, 3.89 to 4.03) and in Switzerland (AUC female: 84.2%, 95% CI, 81.4 to 86.8, AUC male: 88.5%, 95% CI 87.1–89.7, p=0.003; APE female: 0.0420, 95% CI 0.0376 to 0.0465, APE male: 0.0312, 95% CI 0.0289 to 0.0335; MCR female: 4.98%, 95% CI 4.39 to 5.56, MCR male: 3.69%, 95% CI, 3.39 to 4.00). Similar results were obtained for 6-month death and 1-year death endpoints across clinical settings, geographic regions, and levels of care. The risk of in-hospital death relative to males was increased in females that GRACE 2.0 classified as low-to-intermediate risk (suggesting no early invasive management strategy) in the United Kingdom (relative risk [RR]: 1.61, 95% CI, 1.50 to 1.74, p&amp;lt;0.001) and in Switzerland (RR: 1.84, 95% CI, 1.28 to 2.64, p&amp;lt;0.001). Conclusion Thus far, this is the largest investigation on the GRACE risk score. We confirmed good overall score performance and found decreased performance in contemporary female patients with NSTE-ACS irrespective of the mortality endpoint, the clinical setting, the geographic region, and the level of care. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation

Time to coronary angiography in a real-life cohort of NSTEACS patients: are guidelines too optimistic?

Abstract Background and purpose In 2020, new recommendations against routine use of pretreatment in NSTEACS have been established, especially if an early invasive strategy (within first 24 hours) is planned [1]. These recommendations are mainly based on evidence from clinical trials that have included short intervals of time to coronary angiography (CA) [2,3]. However, this timing seems hard to achieve in daily clinical practice, above all, when high-risk NSTEACS patients are now advised for an early invasive strategy. We aimed to assess the feasibility of these recommendations in real-world clinical practice. Methods We performed a retrospective analysis of a real-life cohort of NSTEACS patients referred to CA in a tertiary-level hospital between January and December 2020. Results We analysed 347 consecutive NSTEACS patients referred to CA (21.7% unstable angina, 78.3% NSTEMI). Percutaneous coronary intervention was performed in 60.5% and the radial or cubital artery access were exclusively used in 86.7%. Median time from hospital admission to CA was 39.4 hours (IQR: 20.7–67.0 hours) and 31.4% patients had the CA performed within first 24 hours (Figure 1). Main differences regarding clinical and risk-related variables among those patients who underwent CA before and after first 24 hours are shown in Table 1. More patients with NSTEMI and dynamic changes in ECG tended to be referred earlier to CA, while those with impaired renal function were more likely to receive a delayed strategy. There were 282 patients (82.7%) who met the high-risk criteria from current ESC guidelines on NSTEACS (GRACE risk score &amp;gt;140, ST transient elevation or depression in ECG, raise of cardiac troponin levels above the 99th percentile of the upper reference limit, cardiogenic shock or cardiac arrest at presentation); of whom, only 95 (33.7%) were referred to CA in the first 24 hours. No differences were found according to patients being admitted to PCI or non-PCI centres (32.1% vs. 30.9% had the CA performed within first 24 hours, p=0.81) or receiving pretreatment with a P2Y12 receptor inhibitor or not (31.7% vs. 31.0% of the CA ≤24 hours group; p=0.87). Conclusion Evidence from this real-life registry shows that median time from admission to CA is far from current recommendations for high-risk NSTEACS patients. This might represent an important limitation at the moment of translating guidelines to daily clinical practice, especially those who presume patients to have a CA performed within first 24 hours. Funding Acknowledgement Type of funding sources: None.

PMHnet-alpha: development and validation of a neural network based discrete-time survival model for mortality prediction in ischemic heart disease

Abstract Background Current risk prediction models in ischemic heart disease (IHD) use a small set of well-known risk factors, have limited predictive capabilities, and are largely the same as they were twenty years ago. We developed and externally validated PMHnet-alpha, a neural-network based survival model for risk-stratification in ischemic heart disease that leverages the multitude of clinical features available in modern electronical health records. Methods We included 39,746 IHD patients from the regional Heart Registry that had been subjected to a coronary angiography between 2006 and 2017 with confirmed coronary artery disease. Clinical data was extracted from the Danish National Patient Registry, and electronic health records. 595 different features, consisting of diagnosis codes, procedure codes, biochemical test results, and clinical measurements were used as model inputs. Prior to model development, patients were randomly divided into a training set (n=34,746) and a tesing set (n=5,000). The testing set was not used for model development. Model performance was evaluated at six months, one years, three-, and five years of follow-up using time-dependent ROC curve analysis and Harrels' C-index. Lastly, we also assessed the calibration of the model. We benchmarked the performance of PMHnet-alpha against the GRACE Risk Score 2.0, which is widely considered to the best-performing model in current clinical use. We explored the importance of individual features using SHAP values on the trained models. Findings PMHnet-alpha had very high model discrimination on the testing data with time-dependent AUCs of 0.88 (95% CI 0.86–0.90) at six months, 0.88 (95% CI 0.86–0.90) at one year, 0.84 (95% CI 0.82–0.86) at three years, and 0.82 (95% CI 0.80–0.84) at five years. The discrimination of the benchmark model GRACE2.0 on the same data was considerably lower, 0.77 (95% CI 0.73–0.80) at six months, 0.77 (95% CI 0.74–0.80) at one year, and 0.73 (95% CI 0.70–0.75) at three years. PMHnet-alpha is undergoing external validation in other nordic countries. We identified that on-average, age, coronary pathology and smoking status were the most impactful features. Interpretation Here we present a significant improvement of the state of the art in cardiac risk prediction. PMHnet-alpha supports better and optimized use of available healthcare data, signified by the vast improvement compared to GRACE2.0. This also signifies an important paradigm shift in which data-driven strategies are necessary to transform the increasing amount of data generated in the modern healthcare system into evidence-based clinical decision making. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation, NordForsk

Safety of intravenous cangrelor infusion during percutaneous coronary intervention in a real-world cohort of non-pretreated NSTEACS patients

Abstract Background and purpose Since publication of latest ESC guidelines in 2020, pretreatment with an oral P2Y12 receptor inhibitor (P2Y12i) is no longer systematically recommended in patients with non-ST elevation acute coronary syndrome (NSTEACS) [1]. Therefore, from now on, NSTEACS patients will arrive to the cathlab to a larger extent without having a loading dose of an oral P2Y12i administered. Cangrelor, a potent intravenous P2Y12i, is an emerging option that provides a rapid onset of platelet inhibition, but it has not been widely used yet [2]. We aimed to evaluate safety of cangrelor real-world use in NSTEACS patients who had not received an oral P2Y12i before percutaneous coronary intervention (PCI). Methods Development of periprocedural thrombotic complications, ischaemic and bleeding events at 30 days was retrospectively evaluated in a cohort of non-pretreated NSTEACS patients referred to PCI. Comparison among those who underwent intravenous infusion of cangrelor and those who received a loading dose of an oral P2Y12i (ticagrelor, prasugrel or clopidogrel) at the moment of PCI was performed. Results Between January and December of 2020, 155 non-pretreated NSTEACS patients were referred to our cathlab; of whom, 89 underwent PCI and were included in the analysis (18.0% with unstable angina, 82.0% with NSTEMI). Mean age was 66.0±14.3 years, 21 (23.6%) were female and the mean GRACE risk score was 112±34. PCI was performed ad-hoc (immediately after diagnostic catheterization) in 81 patients (91.0%), whereas 15 patients (16.9%) required PCI to be done in more than two times. Procedure was performed exclusively by radial or cubital artery access in 78 patients (87.6%). Regarding antiplatelet drug administration, cangrelor was used in 14 patients (15.7%), prasugrel in 35 (39.3%), ticagrelor in 29 (32.6%) and clopidogrel in 11 (12.4%). No significant differences were found among patients in terms of development of ischaemic events at 30 days (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or stent thrombosis) or periprocedural thrombotic events (no-reflow, bailout use of anti-IIb/IIIb or intraprocedural stent thrombosis). The use of cangrelor did not raise the incidence of bleeding events at 30 days (7.1% vs. 15.1%, p=0.682) [Table 1]. Cangrelor tended to be more frequently used in high-risk NSTEMI patients (20.8% vs. 12.9%, p=0.357) and in case of complex PCI (26.3% vs. 7.8%, p=0.018) [Figure 1]. After controlling by both variables, cangrelor did not significantly increase the risk of bleeding or ischaemic events at 30 days either. Conclusions Intravenous infusion of cangrelor during PCI in non-pretreated NSTEACS patients shows no differences in terms of thrombotic or bleeding events in comparison to the administration of a loading dose of an oral P2Y12i. Our results also suggest that cangrelor could be a safe option in patients with high thrombus burden who require complex PCI. Funding Acknowledgement Type of funding sources: None.

Novel scoring system based on clinical examination for prediction of in-hospital mortality in acute coronary syndrome patients: a retrospective cohort study

BackgroundThis study aims to develop PADjadjaran Mortality in Acute coronary syndrome (PADMA) Score to predict in-hospital mortality in acute coronary syndrome (ACS) patients based on clinical examination only. Additionally, we...

Combination of TyG Index and GRACE Risk Score as Long-Term Prognostic Marker in Patients with ACS Complicated with T2DM Undergoing PCI.

ObjectiveWe aimed to investigate the prognostic value of the triglyceride-glucose (TyG) index combined the with Global Registry of Acute Coronary Events (GRACE) score in adult acute coronary syndrome (ACS) patients with type 2 diabetes mellitus (T2DM) who underwent percutaneous coronary intervention (PCI).MethodsThe study enrolled total 899 ACS patients with T2DM who underwent PCI. TyG index and the GRACE risk score were calculated and assessed by median. The correlation was analyzed by Spearman’s rank correlation coefficient. The cumulative major adverse cardiovascular event (MACE) curve was generated using the Kaplan–Meier method. Multivariate Cox regression was used to identify predictors of MACEs. Additionally, the receiver operating characteristic curve (ROC), net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) were applied to analyze the performance of each single factor index and combined multivariate index in predicting MACE.ResultsIn the ACS patients with T2DM after PCI, there were significant differences in the TyG index and GRACE risk score between the MACE group and the MACE-free group (P < 0.001). Kaplan–Meier analysis showed that the TyG index combined with the GRACE risk score was positively correlated with the occurrence of MACEs (log rank P < 0.001). Multivariate Cox regression analyses showed that the TyG index, the GRACE risk score, and the TyG index combined with the GRACE risk score were independent predictors of long-term MACEs (adjusted HR: 1.805; 95% CI: 1.479–2.203, P < 0.001; adjusted HR: 1.012; 95% CI: 1.009–1.016, P < 0.001; and adjusted HR: 2.337; 95% CI: 1.805–3.025, P < 0.001, respectively). Correlation analysis indicated that the TyG index was positively correlated with the GRACE risk score (R = 0.140, P < 0.001). The analysis of AUC, NRI and IDI revealed that the combined multivariate index performed better prognostic role than each single factor index in predicting the occurrence of MACE.ConclusionBoth the GRACE risk score and the TyG index could be significant and independent predictors of clinical outcomes in ACS patients with T2DM after PCI. A combination of them could be enhanced predictions of clinical outcomes in these patients.