GRACE Risk Score Research Articles

Construction and Validation of a Predictive Model for Long-Term Major Adverse Cardiovascular Events in Patients with Acute Myocardial Infarction.

Current scoring systems used to predict major adverse cardiovascular events (MACE) in patients with acute myocardial infarction (AMI) lack some key components and their predictive ability needs improvement. This study aimed to develop a more effective scoring system for predicting 3-year MACE in patients with AMI. Our statistical analyses included data for 461 patients with AMI. Eighty percent of patients (n=369) were randomly assigned to the training set and the remaining patients (n=92) to the validation set. Independent risk factors for MACE were identified in univariate and multifactorial logistic regression analyses. A nomogram was used to create the scoring system, the predictive ability of which was assessed using calibration curve, decision curve analysis, receiver-operating characteristic curve, and survival analysis. The nomogram model included the following seven variables: age, diabetes, prior myocardial infarction, Killip class, chronic kidney disease, lipoprotein(a), and percutaneous coronary intervention during hospitalization. The predicted and observed values for the nomogram model were in good agreement based on the calibration curves. Decision curve analysis showed that the clinical nomogram model had good predictive ability. The area under the curve (AUC) for the scoring system was 0.775 (95% confidence interval [CI] 0.728-0.823) in the training set and 0.789 (95% CI 0.693-0.886) in the validation set. Risk stratification based on the scoring system found that the risk of MACE was 4.51-fold higher (95% CI 3.24-6.28) in the high-risk group than in the low-risk group. Notably, this scoring system demonstrated better predictive ability than the GRACE risk score (AUC 0.776 vs 0.731; P=0.007). The scoring system developed from the nomogram in this study showed favorable performance in prediction of MACE and risk stratification of patients with AMI.

Effectiveness of the GRACE risk score according to troponin elevation in patients admitted with non-ST elevation acute coronary syndrome: a post-hoc analysis of the UKGRIS cluster RCT

Abstract Background In the United Kingdom GRACE Risk Score (UKGRIS) phase 3 parallel group cluster randomised controlled trial, the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) did not improve adherence to guideline recommended management or reduce cardiovascular events at 12 months in patients admitted with suspected non ST elevation acute coronary syndrome (NSTEACS) compared with standard care.(1) Troponin elevation in the context of NSTEACS is associated with high risk of adverse clinical events, including myocardial infarction, heart failure and death,(2) and in this population the GRS may impact on outcomes. Purpose To investigate the effectiveness of the GRS compared with standard care according to troponin elevation in patients admitted with NSTEACS. Methods Post-hoc analysis of primary and secondary outcome measures according to troponin elevation on admission of the UKGRIS trial across 42 sites in England. Patients aged ≥18 years admitted with suspected NSTEACS and a minimum follow-up of 24 months were eligible. Primary outcome measures were use of guideline recommended management and time to the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospital admission, and readmission for cardiovascular event. Secondary measures included the duration of hospital stay, EQ-5D-5L (five domain, five level version of the EuroQoL index), and the composite endpoint components. Results A total of 3050 patients were randomised in UKGRIS, of whom 2602 had troponin elevation. The effect of GRS compared with standard care on the uptake of guideline recommended care was greater for participants with troponin elevation (odds ratio 1.34, 95% CI 0.84 to 2.13) compared to those without (0.88, 0.52 to 1.47) (Table 1). There was an interaction between troponin elevation and effect of GRS versus standard care on guideline uptake (relative odds ratio 1.52, 95% CI 1.16 to 2.00, P < 0.01). The time to the first composite event was not improved by the GRS among participants with (hazard ratio 0.86, 95% CI 0.67 to 1.12) or without troponin elevation (1.19, 0.80 to 1.77) (Figure 1), with no interaction (relative hazards ratio 0.73, 95% CI 0.51 to 1.03, P = 0.07), and none of the individual components of the composite outcome had a significant interaction between randomisation to GRACE and troponin elevation. Baseline adjusted EQ-5D-5L utility at 12 months and duration of hospital stay at 24 months were not statistically significantly different for the two trial arms among participants with or without troponin elevation. Conclusions For suspected NSTEACS, the effect of the GRS compared with standard care on uptake of recommended processes was greater in those with elevated troponin than in those without. However, this did not translate to a reduction in the composite primary outcomes or secondary outcomes at 24 months.

Comparison of GRACE and TIMI risk scores in the prediction of in hospital outcome among NSTEMI patients: a single centre study

Abstract Background Major component of ACS, Non-ST segment elevation myocardial infarction (NSTEMI), has more than twice the incidence compared to ST-segment elevation myocardial infarction (STEMI). GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) risk scores are the two most popular prediction models in ACS due to TIMI’s advantage in its simplicity in clinical application and GRACE’s favorable discriminating power. Nevertheless, limited evidence compared the usefulness of these two major risk scores and their association with in-hospital events. Purpose To compare between the predictive ability of GRACE & TIMI risk scores for In hospital outcomes among the NSTEMI patients . Methods This prospective observational study was carried out from 8th march 2020 to 7th March 2022. Total 2152 acute NSTEMI patients were included. Both GRACE & TIMI risk score were calculated. For GRACE score, patients who scored ≤108 points were low risk,109-139 points were medium risk, ≥140 points were high risk . For TIMI scores patients with 0-2 scores were low risk , 3-4 scores were medium risk and 5-7 score were High risk. In Hospital outcomes were defined as the in hospital composite events which includes acute left ventricular failure, cardiogenic shock, arrhythmia & mortality. Results Among the 2152 patients majority were male (73.5%) with mean age of the study population were 58.33 ± .25 years. Mean Grace score & TIMI score of the study population were 137.81±16.38& 3.29±.97 respectively. Most of the patients were categorized in to Medium risk groups by both GRACE & TIMI risk scores , 70% & 51.3% respectively. However, high risk group percentage were higher in GRACE score group(41.3%) in comparison to TIMI score group(10.3%). GRACE score showed better predictive ability than TIMI score for in-hospital outcomes as evaluated by ROC curve( AUC of GRACE vs TIMI, In hospital ALVF:0.89vs 0.59, P<0.001; Cardiogenic Shock 0.72 vs 0.57, P=0.002; Mortality: 0.75 vs 0.59, P=0.002; arrhythmia 0.72 vs0.63, P=0.003). Conclusion GRACE showed better predictive accuracy than TIMI in NSTEMI patients for in-hospital outcomes. The sequential use of TIMI and GRACE scores provide an easy and promising discriminative tool in predicting outcomes in NSTEMI patients , thus improve the identification of high-risk patients.Pic :ROC curve for prediction of ALVFPic: ROC curve for Mortality prediction

The sooner the better? What is the optimal timing for coronary angiography in high-risk non-ST-elevation acute coronary syndrome

Abstract Introduction current guidelines recommend an early invasive coronary angiography (ICA), in the first 24 hours, for high-risk non-ST elevation acute coronary syndrome (NSTE-ACS) patients. However, several studies have failed to demonstrate a significant improvement in all-cause mortality, with controversial results regarding recurrent ischemia and myocardial infarction. Purpose to evaluate the optimal timing of ICA in high-risk NSTE-ACS. Methods this was a national multicentre retrospective study of patients hospitalized for NSTE-ACS between October 2010 and October 2023. Patients presenting in Killip class IV, mechanical complications, life-threatening arrhythmias or cardiac arrest were excluded. Participants were divided into three groups, according to the timing of ICA: in the first 24 hours (D0), between 24 and 48 hours (D1) and between 48 and 72 hours (D2). The incidence of in-hospital complications and mortality, as well as 1-year mortality rate and cardiovascular rehospitalization, was compared for the three groups. Results a total of 9949 patients was included, 98.2% with non-ST elevation myocardial infarction (NSTEMI) and 1.8% with unstable angina with high-risk criteria (GRACE risk score >140 or transient ST-segment elevation). Most patients were submitted to early ICA (46.7%), with 26.7% and 26.6% in D1 and D2, respectively. Interestingly, patients in higher Killip class (II or III) were referred for ICA latter than patients in Killip class I (9.0% in D0 vs. 11.3% in D1 vs. 13.5% in D2, p<0.001). Regarding in-hospital complications, early ICA was associated with a lower incidence of acute heart failure (8.5% vs. 11.1% vs. 11.5%, p<0.001) and shorter length of stay (7 vs. 6 vs. 10 days, p=0.01). However, it did not reduce in-hospital mortality (1.2% vs. 0.7% vs. 0.8%, p=0.07), recurrent myocardial infarction (0.9% vs. 1.5% vs. 1.3%, p=0.09), cardiogenic shock (7.9% vs. 5.7% vs. 5.4%, p=0.19), mechanical complications (0.1% vs. 0.2% vs. 0.1%, p=0.50) or sustained ventricular tachycardia (0.8% vs. 0.6% vs. 0.4%, p=0.12). Left ventricular ejection fraction was also similar between groups (54%±12, p=0.97). There were also no significant differences between groups regarding 1-year mortality or cardiovascular rehospitalization (15.1% vs. 15.9% vs. 15.7%, p=0.89). Conclusion in high-risk NSTE-ACS patients, early ICA resulted in lower incidence of acute heart failure and shorter length of stay. However, timing of ICA didn’t show a significant impact on in-hospital mortality or complications, nor in 1-year mortality rate or cardiovascular rehospitalization.

Clinical decision-making in patients with non-ST-segment-elevation myocardial infarction: more than risk stratification.

This study aims to explore the association between risk stratification and total occlusion (TO) of the culprit artery and multivessel disease (MVD) in patients with non-ST-segment-elevation myocardial infarction (NSTEMI) and to obtain more data on clinical decision-making in addition to risk stratification. We retrospectively collected data from 835 patients with NSTEMI admitted to our hospital between 1 January 2016 and 1 August 2022. All patients underwent percutaneous coronary intervention (PCI) within 72 h of admission. We excluded patients with a history of cardiac arrest, myocardial infarction, coronary artery bypass grafting, or PCI. Univariate and multivariate regression analyses were performed to determine the predictors of acute TO and MVD. A total of 349 (41.8%) patients presented with a TO culprit vessel, whereas 486 (58.2%) had a patent culprit vessel. Thrombolysis in myocardial infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk stratifications were similar between the two groups of patients (P = 0.712 and 0.991, respectively). The TO infarct vessel was more commonly observed in the left circumflex artery. Patients with TO were more likely to develop MVD (P = 0.004). Univariate and multivariate linear regression analyses were performed to evaluate the role of variables in the presence of TO and MVD in patients with NSTEMI. Regional wall motion abnormalities (RWMAs) [odds ratio (OR) = 4.022; confidence interval (CI): 2.782-5.813; P < 0.001] were significantly linked to TO after adjusting for potentially related variables. Furthermore, age (OR = 1.032; CI: 1.018-1.047; P < 0.001), hypertension (OR = 1.499; CI: 1.048-2.144; P = 0.027), and diabetes mellitus (OR = 3.007; CI: 1.764-5.125; P < 0.001) were independent predictors of MVD in patients with NSTEMI. TIMI and GRACE risk scores were related to MVD prevalence in the multivariate logistic regression model. Patients with a TO culprit vessel had a higher risk of out-of-hospital cardiac death after a 2-year follow-up compared with those without a TO culprit vessel (P = 0.022). TIMI and GRACE risk scores were not associated with a TO of the culprit artery; however, they correlated with the prevalence of MVD in patients with NSTEMI. RWMA is an independent predictor of acute TO in patients with NSTEMI. Patients with a TO culprit vessel had worse clinical outcomes than those without a TO culprit vessel.

Potential of speckle tracking echocardiography with the assessment of left ventricle myocardial work in predicting coronary artery disease in non-ST-segment elevation acute coronary syndrome

Aim. The study aimed at evaluating the role of the left ventricular (LV) longitudinal strain (LS) measurement and the left ventricle myocardial work parameters in predicting coronary artery disease (CAD), and determining the indications for early invasive diagnosis and treatment in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).Materials and methods. The study included 51 patients aged from 41 to 93 years who were admitted at the Institute clinic with a diagnosis of NSTE-ACS. Upon admission, the risk of hospital mortality was assessed using GRACE risk score; standard echocardiography (EchoCG) and speckle tracking echocardiography (ST EchoCG) were performed to assess the LV longitudinal strain and the LV myocardial work parameters, and coronary angiography (CAG) was performed within 48 hours. The comparison group consisted of 20 volunteers without CAD.Results. According to the risk assessment with the GRACE score, the patients with low and moderate risk made 41 and 47 %, respectively. Local contractility disorders during standard EchoCG were detected in 15 patients (29 %). When analyzing regional parameters of longitudinal strain and myocardial work, the greatest prognostic value in identifying patients with hemodynamically significant changes in the coronary arteries (CAs) was demonstrated by the functional risk area (FRA) of 4 or more adjacent segments with a myocardial work index ≤1400 mmHg x% (sensitivity and specificity 84,2 and 78,1 %, AUC=0,83). In the dysfunctional segments of the risk zone in almost all patients, a paradoxical mechanism of deformation was detected in the form of post-systolic shortening with a post-systolic index (PSI) reaching a value of ≥20 % at least in one of the adjacent segments. The combination of a significant increase in PSI and the detection of FRA limited to 3 segments indicated the acuity of coronary insufficiency, hemodynamically significant stenosis (sensitivity and specificity 84 % and 79 %). When distributing patients, taking into account the data of standard EchoCG and ST EchoCG with the assessment of myocardial work, in the absence of significant disturbances in systolic function, the patients with intact main CAs or insignificant changes in the main CAs prevailed; among patients without visual impairment of contractility, the detected FRA indicated a hemodynamically significant damage of one of the main CAs; a combination of local contractility disorders and additional FRA was associated with multiple CA damage.Conclusion. The use of ST EchoCG with the assessment of myocardial work and identification of the functional risk area in NSTE-ACS patients makes it possible to predict CAD, detect patients at risk of an unfavorable outcome regardless of the GRACE risk level, determine indications for immediate invasive diagnostics, and choose the optimal method of revascularization.

The effect of hsCRP on TyG index-associated cardiovascular risk in patients with acute coronary syndrome undergoing PCI

The effect of systemic inflammation, represented by high-sensitivity C-reactive protein (hsCRP), on triglyceride glucose (TyG) index-associated cardiovascular risk in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) has not yet been determined. This study was a retrospective analysis of a single-center prospective registry and finally included 1701 patients (age, 60 ± 10 years; male, 76.7%). The primary endpoint was defined as major adverse cardiovascular events (MACE), including cardiovascular mortality, non-fatal stroke, and non-fatal myocardial infarction. In the multivariate COX regression model that included the GRACE risk score, higher TyG index was significantly associated with a greater incidence of MACE in patients with hsCRP levels less than 2 mg/L but not 2 mg/L or more (P for interaction = 0.039). Each unit increase in the TyG index was independently associated with a 52% increased risk of MACE only in patients with hsCRP levels less than 2 mg/L (P = 0.021). After adjustment for other confounding factors, including the GRACE risk score, compared with those in the group of TyG index < 8.62 and hsCRP < 2 mg/L, patients in the group of TyG index ≥ 8.62 and hsCRP ≥ 2 mg/L had a 3.9 times higher hazard ratio for developing MACE. The addition of both TyG index and hsCRP had an incremental effect on the predictive ability of the GRACE risk score-based prognostic model for MACE (C-statistic: increased from 0.631 to 0.661; cNRI: 0.146, P = 0.012; IDI: 0.009, P < 0.001). In conclusion, there was a significant interaction between the TyG index and hsCRP for the risk of MACE, and the TyG index was reliably and independently associated with MACE only when hsCRP levels were less than 2 mg/L. Furthermore, high TyG index and high hsCRP levels synergistically increased the risk of MACE, suggesting that the prognostic value of TyG index combined with hsCRP might be promising in patients with ACS undergoing PCI.

Enhanced predictive performance of the GRACE risk score by incorporating lipoprotein(a) for major adverse cardiac events in acute myocardial infarction patients undergoing PCI

BackgroundAs scientific research advances, the landscape of detection indicators and methodologies evolves continuously. Our current study aimed to identify some novel perioperative indicators that can enhance the predictive accuracy of the Global Registry of Acute Coronary Events (GRACE) score for the in-hospital major adverse cardiovascular events (MACEs) in patients with acute myocardial infarction. MethodsA total of 647 adult patients with AMI admitted to the emergency department were consecutively enrolled in the retrospective research starting from June 2016 to September 2019. The endpoint was in-hospital MACE. Stepwise regression analysis and multivariate logistic regression were performed to select the indicators for the union model established by nomogram. Bootstrap with 1000 replicates was chosen as the internal validation of the union model. The area under the receiver operating curve (AUC) and calibration plot were used to evaluate the discrimination and calibration. Decision curve analysis (DCA) was performed to evaluate the clinical sufficiency of the nomogram. Akaike's information criterion (AIC) and Bayesian Information Criterion (BIC) were used to evaluate the goodness of fit. ResultsLipoprotein(a) combined with serum uric acid, fasting blood glucose, and hemoglobin could improve the GRACE risk score. The AUC of the union model was 0.86, which indicated a better discriminative ability than the GRACE risk score alone (AUC, 0.81; P < 0.05). The calibration plots of the union model showed favorable consistency between the prediction of the model and actual observations, which was better than the GRACE risk score. DCA plots suggested that the union model had better clinical applicability than the GRACE risk score. ConclusionLipoprotein(a) has shown promise in augmenting the predictive capability of the GRACE risk score, however, it may be beneficial to integrate it with other commonly used indicators.

Correlation between the GRACE Risk Score and the SYNTAX Score in Patients with Non-ST-Segment Elevation Myocardial Infarction

Correlation between the GRACE Risk Score and the SYNTAX Score in Patients with Non-ST-Segment Elevation Myocardial Infarction

Prognostic Utility of Ratio of Systolic Blood Pressure to Left Ventricular End- Diastolic Pressure Post Successful Primary Percutaneous Coronary Intervention in Prediction of Major Adverse Cardiac Events in Patients with ST-segment Elevation Myocardial Infarction

Abstract Background Of all causes of Cardiovascular disease (CVD), ischemic heart disease (IHD) remains the major contributor, accounting for half of all CVD-associated morbidity and mortality. IHD as measured by the Global Burden of Disease project is driven predominantly by acute myocardial infarction (MI) and, to a lesser extent, angina. Aim of the Work To evaluate the prognostic utility of the ratio of SBP/LVEDP at the time of PPCI in prediction of MACE both in-hospital and during 3-months follow up in patients presented with STEMI with a single vessel disease. Patients and Methods This was a prospective study that was conducted on 153 patients presented with STEMI and underwent successful PPCI for a single vessel disease in Ain-Shams University Hospitals and Nasr City Health Insurance Hospital in the period from March 2019 to March 2021. Results Our results demonstrated, that SBP/LVEDP ratio can be used to predict MACE occurrence at a cutoff level of ≤ 3.9, and can be used to predict patients who are MACE-free at cutoff level of ≥ 9.2. The lower ratio of SBP/LVEDP (≤3.9) was detected at 27 patients (17.6%) from the whole study population (153 patients) with higher statistical significance difference of older age group. Different risk factors and positive family history showed no statistical significance difference with lower ratio. In this study, lower ratio showed higher statistical significant difference in anterior STEMI group, lower EF% “Simpson”, higher LVESV, DD grade II, higher WMSI, with the culprit lesion vessel when its LAD, with higher LVEDP, lower invasive SBP, and lower invasive DBP. This study found that lower ratio had a better prognostic ability with a higher AUC (0.880) when compared to the widely used GRACE and TIMI risk scores. Lower ratio ≤3.9 showed higher statistical significant difference with higher GRACE RS and higher TIMI RS when compared with higher ratio. Our ratio had a strong prognostic ability in prediction of MACE with lower ratio with higher statistical significant difference of occurrence of MACE in 26 patients (96.3%, P = 0.000) when compared with patients with the same ratio but without occurrence of MACE in 1 patient (3.7%). Conclusion Our study concluded that SBP/LVEDP is an easily rapidly determined ratio at the time of PPCI that can provide important prognostic information regarding risk stratification of STEMI patients, with a high predictive ability for occurrence of MACE at a cutoff point of ≤ 3.9, during hospital stay and short term follow up.

Right ventricular–pulmonary arterial coupling in patients with first acute myocardial infarction: an emerging post-revascularization triage tool

BackgroundThe tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio is a non-invasive surrogate for right ventricular–pulmonary arterial (RV-PA) coupling, studied in chronic RV pressure overload syndromes. However, its prognostic utility in patients with acute myocardial infarction (AMI), which may cause acute RV pressure overload, remains unexplored. ObjectiveThis study aimed to determine predictors of RV-PA uncoupling in patients with first AMI and examine whether it could improve risk stratification for cardiovascular in-hospital mortality after revascularization. MethodsThree-hundred consecutive patients with first AMI were prospectively studied (age 61.2 ± 11.8, 24% females). Echocardiography was performed 24 h after successful revascularization, and TAPSE/PASP was evaluated. Cardiovascular in-hospital mortality was recorded. ResultsThe optimal cutoff value of TAPSE/PASP to determine cardiovascular in-hospital mortality was 0.49 mm/mmHg. RV-PA uncoupling was considered for patients with TAPSE/PASP ≤0.49 mm/mmHg. Left ventricular ejection fraction (LVEF) was independently associated with RV-PA uncoupling. A total of 23 (7.7%) patients died in hospital despite successful revascularization. TAPSE/PASP was independently associated with in-hospital mortality after adjustment for Global Registry of Acute Coronary Events (GRACE) risk score and LVEF (odds ratio 0.14 [95% confidence interval 0.03–0.56], P = 0.007). The prognostic value of a baseline model including the GRACE risk score and NT-pro-BNP (χ2 26.55) was significantly improved by adding LVEF ≤40% (χ2 44.71, P < 0.001), TAPSE ≤ 17 mm (χ2 75.42, P < 0.001) and TAPSE/PASP ≤ 0.49 mm/mmHg (χ2 101.74, P < 0.001) for predicting cardiovascular in-hospital mortality. ConclusionRV-PA uncoupling, assessed by echocardiographic TAPSE/PASP ≤ 0.49 mm/mmHg 24 h after revascularization, may improve risk stratification for cardiovascular in-hospital mortality after first AMI.

In-Hospital Outcomes of Patients with Anterior Wall Myocardial Infarction and Right Bundle Branch Block in the Primary PCI Era: Impact and Prognostic Factors

Objective: This study investigates the in-hospital outcomes of patients presenting with Anterior Wall Myocardial Infarction (AWMI) and Right Bundle Branch Block (RBBB) during the primary Percutaneous Coronary Intervention (PCI) era. It aims to assess the impact of primary PCI on these patients and identify factors contributing to poor outcomes. Methodology: A prospective observational study was conducted at the Department of Cardiology, Hayatabad Medical Complex (HMC), Peshawar, Pakistan. The study enrolled 150 patients diagnosed with AWMI and RBBB, undergoing reperfusion therapy. Data on demographics, clinical characteristics, and treatment outcomes were collected and analyzed using IBM SPSS version 21.0. Results: Among the 150 patients included in the study, there was a balanced gender distribution with a mean age of 51.15 years. The majority of patients, 136 (90.7%), survived their hospital stay. Primary PCI was significantly associated with improved survival rates compared to medical management alone. Factors such as TIMI and GRACE risk scores were crucial for risk stratification, highlighting the need for personalized management strategies. Conclusion: The findings underscore the effectiveness of primary PCI in improving in-hospital outcomes for patients with AWMI and RBBB. This study highlights the necessity of timely reperfusion therapy and personalized risk stratification to enhance patient prognosis. By documenting the impact of primary PCI and identifying factors leading to poor outcomes, this research provides valuable insights that aid in the optimization of treatment protocols for this high-risk patient group.

Combined effect of inflammation and malnutrition for long-term prognosis in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a cohort study

BackgroundInflammation is a key driver of atherosclerotic diseases and is often accompanied by disease-related malnutrition. However, the long-term burden of dysregulated inflammation with superimposed undernutrition in patients with acute coronary syndrome (ACS) remains unclear. This study sought to investigate the double burden and interplay of inflammation and malnutrition in patients with ACS undergoing percutaneous Coronary Intervention (PCI).MethodsWe retrospectively included 1,743 ACS patients undergoing PCI from June 2016 through November 2017 and grouped them according to their baseline nutritional and inflammatory status. Malnutrition was determined using the nutritional risk index (NRI) with a score lower than 100 and a high-inflamed condition defined as hs-CRP over 2 mg/L. The primary outcome was major adverse cardiovascular events (MACEs), compositing of cardiac mortality, non-fatal myocardial infarction, non-fatal stroke, and unplanned revascularization. Long-term outcomes were examined using the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox proportional hazards regression analysis was applied to adjust for confounding. The reclassification index (NRI)/integrated discrimination index (IDI) statistics estimated the incremental prognostic impact of NRI and hs-CRP in addition to the Global Registry of Acute Coronary Events (GRACE) risk score.ResultsDuring a median follow-up of 30 months (ranges 30–36 months), 351 (20.1%) MACEs occurred. Compared with the nourished and uninflamed group, the malnourished and high-inflamed group displayed a significantly increased risk of MACEs with an adjusted hazard ratio of 2.446 (95% CI: 1.464–4.089; P < 0.001). The prognostic implications of NRI were influenced by patients’ baseline inflammatory status, as it was only associated with MACEs among those high-inflamed (P for interaction = 0.005). Incorporating NRI and hs-CRP into the GRACE risk score significantly improved its predictive ability for MACEs (NRI: 0.210, P < 0.001; integrated discrimination index; IDI: 0.010, P < 0.001) and cardiac death (NRI: 0.666, P < 0.001; IDI: 0.023, P = 0.002).ConclusionsAmong patients with ACS undergoing PCI, the double burden of inflammation and malnutrition signifies poorer outcomes. Their prognostic implications may be amplified by each other and jointly improve the GRACE risk score’s risk prediction performance.

Study of GRACE and TIMI Risk Scores’ Application in the Risk Stratification in Patients with Acute Coronary Syndrome in Qinghai

Study of GRACE and TIMI Risk Scores’ Application in the Risk Stratification in Patients with Acute Coronary Syndrome in Qinghai

A CASE REPORT OF AN ASYMPTOMATIC PATIENT WITH TYPE 2 WELLENS’ SYNDROME AND RENAL CARCINOMA

Abstract A 65–year–old male with renal cell carcinoma, previously treated with nephrectomy and recently diagnosed with lung metastases, presented to the cardiology clinic for investigations before starting chemotherapy. He reported a history of ischemic heart disease, a non–ST–elevation myocardial infarction for which he refused coronary angiography in 2005, and a negative maximal stress test for ischemia in 2017. Additionally, the patient reported insulin–dependent type 2 diabetes mellitus and well–controlled arterial hypertension. The patient was referred for a cardiological evaluation due to a reported short–term rhythmic heartbeat without other cardiological symptoms. Cardiological parameters were stable (blood pressure: 140/95 mmHg; heart rate: 42 bpm, and oxygen saturation without oxygen supplementation: 98%). Physical examination was normal. Laboratory investigations did not show elevated levels of high–sensitivity troponin I, and only signs of mild chronic kidney disease were observed. The initial ECG showed sinus bradycardia with deeply inverted T–waves in the extended anterior area (Fig. 1), which were not present in an ECG performed one month earlier. There was no reported chest pain. An echocardiogram examination demonstrated hypertensive heart disease with marked hypokinesia of the mid–apical portion of the anterior wall and anterior interventricular septum, together with a moderate reduction in global systolic function (LV ejection fraction: 40%). The patient was hospitalized, and underwent coronary angiography the following day. He had a low–risk score (GRACE: 95 pts) As shown in Fig. 2, there was evidence of long sub–occlusive stenosis of the proximal part of the anterior descending coronary artery that was treated with angioplasty and a single drug–eluted stent placement, resulting in a good angiographic result. After the procedure, there was a rapid recovery of regional kinetics but a slower normalization of the electrocardiographic morphology (Fig. 3). Comment Wellens‘ syndrome identifies a particular subtype of unstable angina characterized by the appearance of ischemic changes on the ECG,. The clinical risk assessment of this subgroup of patients with ACS, apparently having a more benign prognosis due to their definition as unstable angina with a low GRACE risk score, potentially has an evolution toward a large myocardial infarction if not promptly diagnosed.

Impact of clinical frailty scale on short and long term outcome in patients with acute coronary syndrome

Abstract Funding Acknowledgements None. Background As recently outlined in the European Society of Cardiology (ESC) guidelines on acute coronary syndrome (ACS), scarce data still exits about the prognostic role of frailty to guide clinical decision-making for patients with ACS. Purpose To assess the potential predictive value of frailty both for short, and long term all-cause mortality, in a contemporary ACS population. Methods All consecutive admissions due to ACS, from 01/01/2019 to 31/12/2021, were retrospectively reviewed from an internal database of a tertiary cardiac center in Salerno (Italy). Logistic and Cox proportional regression analysis were performed in order to assess the contribution of frailty on 30-days and long term mortality. Frailty was assessed using the Clinical Frailty Scale (CFS) and patients were classified as non frail (CFS 1-4), and frail (CFS 5-9). Both logistic and Cox regression analysis were adjusted for age, gender, GRACE risk score, comorbidity burden, defined by the Charlson comorbidity score (CCS), and all other relevant covariates associated with outcomes of interest in the univariate analysis. In order to estimate the survival rates during the follow-up, a Kaplan Meyer analysis was carried out and differences between the CFS groups were assessed using the log-rank test. Robustness of the results were assessed through an internal validation procedure with bootstrapping. All statistical analyses were performed using SPSS software version 25.0 (SPPS Inc., Chicago, Illinois) and R version 4.0.5 (R Foundation for Statistical Computing, Vienna, Austria). A p-value of less than 0.05 was considered significant. Results 1366 patients were identified. The median age was 68 (58-77). Of these patients, 1087 (79,6%) were classified as non-frail (CFS 1-4), and 279 (20,4%) as frail (CFS 5-9). 120 (8,8%) and 140 (11,2%) deaths occurred, respectively, during the first 30 days from admission, and during long term follow-up (median follow-up time: 15 months; IQR: 10-24). After multivariate regression analysis the CFS was associated with both short and long-term mortality (OR: 1,6, 95% CI: 1,34-1,91; p&amp;lt;0,001 and HR: 1,37, 95% CI: 1,18-1,58; p&amp;lt;0,001, Fig. 1). Patients with CFS ≥ 5 showed significant higher mortality rate during long term follow-up (p&amp;lt;0.001; Fig.2). Conclusions The CFS is a strong predictor of both short and long-term mortality in patients affected by ACS also after comprehensive adjustment for baseline differences in other risk factors.Fig. 2

A simple angio-based coronary flow assessment of culprit vessels in primary percutaneous coronary intervention is associated with long-term prognosis after ST-segment-elevation myocardial infarction

BackgroundDespite prompt reperfusion, the risk of adverse clinical outcomes following ST-segment-elevation myocardial infarction (STEMI) remains pronounced, owing partly to suboptimal reperfusion. However, coronary functional evaluation is seldom feasible during primary percutaneous coronary intervention (PPCI). We aimed to examine the clinical implication of a simple coronary assessment based on single-angiographic view (μQFR) during PPCI in discriminating impaired coronary flow and adverse outcomes for STEMI. MethodsSTEMI Patients undergoing successful PPCI were enrolled and followed up prospectively from 4 medical centers in China. Post-PPCI μQFR of culprit vessels were analyzed. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of cardiac death, non-fatal MI, ischemia-driven target-vessel revascularization and readmission for heart failure. ResultsA total of 570 patients with STEMI were enrolled, and post-PCI μQFR was analyzable in 557 (97.7%) patients, with a median of 0.94. Patients with low post-PCI μQFR showed higher incidence of adverse outcomes than those with high μQFR, showing a 2.5-fold increase in the risk for MACE (hazard ratio: 2.51, 95% confidence intervals: 1.33 to 4.72; P = 0.004). Moreover, post-PCI μQFR significantly increased discriminant ability for the occurrence of MACE when added to traditional GRACE risk score for STEMI (integrated discrimination improvement: 0.029; net reclassification index: 0.229; P < 0.05). ConclusionsA low μQFR of culprit vessel in PPCI is independently associated with worse clinical outcomes in patients with STEMI. The single-angiographic-view-based coronary evaluation is a feasible tool for discriminating poor prognosis and could serve as a valuable complement in risk stratification for STEMI.

Unstable Angina Risk Stratification Using High-Sensitivity Cardiac Troponin and Coronary Angiography

Patients formerly diagnosed with unstable angina (UA) are being reclassified as non-ST-elevation myocardial infarction (NSTEMI) with the widespread adoption of sensitive troponin assays (hsTn), leading to significant changes in the incidence and prognosis of UA. The main purpose of this study was to evaluate the value of hsTn and the presence of significant obstructive CAD in the risk stratification of patients with unstable angina. We conducted a retrospective, single-centre study of 742 patients hospitalized for UA between 2016-2021. The primary endpoint of this study was all-cause mortality. The secondary outcome (MACE) was defined as a composite of nonfatal myocardial infarction (MI), hospitalization for heart failure (hHF), and repeated coronary angiography due to recurring UA (rUA) after the index event. Outcomes were assessed within one month, one year, and up to 5 years of follow-up. The average follow-up duration was 45±24 months, and 37.2% (N=276) of patients completed a 5-year follow-up. No in-hospital death was observed, and 6.9% of patients died during follow-up, which was more commonly a late event (>12 months). The composite secondary endpoint (MI+hHF+rUA) was observed in 16.7% of the patients. There was 3.2% nonfatal MI, 2.3% hHF, and 11.6% rUA during follow-up. We developed a risk model (UA Mortality Risk) using variables with the highest discriminatory power: age, hsTn, and ST-segment deviation. Our model performed well against the GRACE and TIMI risk scores in predicting death during follow-up. Obstructive CAD on coronary angiography was the only independent predictor of MACE during follow-up. In conclusion, a contemporary cohort of patients with UA presented with favourable prognosis, particularly within the first year after the index event. Non-significant increases in HsTn levels add to the risk stratification of UA patients, and the presence of obstructive CAD was the only independent predictor of MACE, highlighting the potential importance of assessing coronary anatomy.

Diagnostic and prognostic role of serum interleukin-6 and carotid ultrasonography to detect subclinical atherosclerosis in patients with RA and ANCA-associated vasculitis.

ANCA-associated vasculitis (AAV) can affect multiple organs with severe life-threatening manifestations. Disease monitoring is difficult due to a lack of defined biomarkers. We aimed to assess the diagnostic role of serum interleukin-6 and vascular ultrasonography in AAV and subclinical atherosclerosis. The study included 20 AAV patients and two control groups of 34 patients with rheumatoid arthritis (RA) and 35 healthy controls. The levels of Il-6, carotid intima-media thickness test (CIMT), atherosclerotic plaque, and degree of stenosis were investigated. A GRACE-risk score was calculated for AAV and RA patients. The AAV patients had elevated levels of IL-6 (115 ± 23.96) compared to the RA patients (91.25 ± 42.63) and the healthy controls (15.65 ± 3.30), p < 0.001. IL-6 showed a diagnostic accuracy of 73% in distinguishing AAV from RA patients (AUC = 0.730; 95% CI 0.591 to 0834). In the AAV group, CIMT was 1.09, above the upper reference value of 0.90, p < 0.001. The AAV patients had a higher median GRACE risk score, and 60% of them had a high risk of cardiovascular events as compared to 35% of the RA patients. Sonography of extracranial vessels and serum levels of IL-6 can be used in daily clinical practice to diagnose and monitor patients with AAV.

The possible utility of global longitudinal strain in the risk-stratifying process of non-ST elevation-acute coronary syndrome.

There are various ways that coronary artery disease (CAD) might present itself. Individual risk stratification for non ST-elevation-acute coronary syndrome (NSTE-ACS) patients should determine whether invasive coronary angiography and revascularization should be scheduled. To assess the possible utility of left ventricular global longitudinal strain in the risk-stratifying process of NSTE-ACS. The cardiology department of Zagazig University in Egypt organized and oversaw this cross-sectional study. The practical portion was carried out on 90 patients with NSTE-ACS based on European society of cardiology (ESC) guidelines (and they agreed for invasive strategy) between May 2019 and December 2020 at Salalah Heart Center in Sultanate of Oman. All patients underwent a full clinical examination, 12-lead ECG, and serial high-sensitivity troponin T (hs-TnT) in addition to a thorough history taking process. On patient's admission, the GRACE risk score was assessed. All patients who were suspected of having NSTE-ACS upon admission underwent transthoracic echocardiography, including two-dimensional speckle tracking (2D-ST). Left ventricular global longitudinal strain (LV-GLS %) was measured and analyzed using 2D speckle tracking. SYNTAX Score was determined for all patients. By analysis of the performance of LV-GLS% in prediction of high risk by GRACE score, we found that with cutoff (≥-13.8), the AUC was (0.944) with sensitivity, specificity, PPV, NPV, and accuracy (0.944, 93.3%, 84%, 53.8%, 98.4%, 85.6%), respectively. Global longitudinal strain can predict accurately high-risk NSTE-ACS patients by GRACE score.