Registry Of Acute Coronary Events Research Articles

Coronary Artery Calcium Scoring by Computed Tomography and the GRACE Risk Score as Predictors of Obstructive Coronary Artery Disease in Patients with Non-ST Segment Elevation Acute Coronary Syndrome: A Comparative Study

Abstract Aim and objectives The aim of our study is to enhance patient risk stratification which can potentially influence the treatment strategy. Our objective is to evaluate the correlation of the Global Registry of Acute Coronary Events (GRACE) risk score, the coronary artery calcium (CAC) score and their use combined with the extent and severity of obstructive coronary artery disease (CAD) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Patients and Methods This study included two hundred and two patients who presented with NSTE-ACS and were planned for coronary angiography in Ain Shams University hospitals during the period from September 2020 to February 2021. The GRACE score was calculated for all patients and they were divided into 3 groups according to the predicted in-hospital and post-discharge to 6 months mortality risk. Patients then underwent coronary artery calcium scoring (CACS) using computed tomography (CT) and were divided into 4 groups according to their Agatston score. Following invasive coronary angiography, patients were divided into 2 groups depending on whether or not there was at least one significant stenosis. Patients who had significant stenosis were then divided into 4 subgroups according to the number of vessels affected; one-vessel disease, two-vessel disease, multi-vessel disease and left main CAD. A receiveroperating characteristic (ROC) curve was plotted for the CAC score, the GRACE score and for the CAC score combined with the GRACE score. It was used to suggest a cut-off value for each score below which obstructive CAD can be excluded in patients presenting with NSTE-ACS. Results The CAC score and the GRACE score were significantly higher in patients with obstructive CAD detected on invasive coronary angiography. Both, the CAC score and the GRACE score positively correlated with the number of affected coronaries. It was also detected that a CAC score of zero had a highly significant relationship with the absence of significant stenosis on invasive coronary angiography (p value <0.001). A CAC score of zero had a negative predictive value of 84.8% [95% Confidence Interval (CI): 72.4% to 92.2%], a positive predictive value of 73.7(95% CI: 69.3% to 77.7%), a sensitivity of 94.3 %( 95% CI: 88.5% to 97.7 %), and a specificity of 48.8% (95% CI: 37.4% to 60.2%). In addition, tested the use of zero CAC to exclude obstructive CAD in patients with low inhospital and post discharge mortality risk had a higher sensitivity, specificity, positive and negative predictive values. From the ROC curve, it could be concluded that the use of CACS in combination with the GRACE score improves the sensitivity, specificity, positive and negative predictive value in comparison to the use of the GRACE score alone. Conclusion CAC score as detected by CT is predictive of obstructive CAD and correlates with its extent or in other words, the number of affected coronaries. The low radiation dose and absence of contrast exposure in CACS make it an attractive candidate for the on-going research regarding the noninvasive tools for prediction of CAD. In addition to the role of GRACE score in predicting the risk of mortality in ACS, it can be also used to predict the severity and extent of obstructive CAD. It can be hypothesized that its combination with CAC score improves its reliability as a predictor of obstructive CAD.

Trombosit Dağılım Genişliği Akut Koroner Sendrom Şiddeti ve Koroner Trombüs Yükü ile İlişkili mi?

Aim: Platelets play a pivotal role in the pathogenesis of acute coronary syndrome (ACS), and platelet distribution width (PDW) shows the activities of platelets in circulation. The purpose of this study was to determine the association of PDW with the ACS severity and angiographic intracoronary thrombus burden and Thrombolysis In Myocardial Infarction (TIMI) flow grade.
 Materials and Methods: One hundred forty-nine consecutive patients who were diagnosed as having ACS were retrospectively evaluated. Global Registry of Acute Coronary Events (GRACE) scores were calculated from the clinical and laboratory data for ACS severity. TIMI flow grades and thrombus grades of the culprit coronary arteries were calculated for each patient. Patients were grouped into two groups according to their PDW values: high PDW and low PDW. The SPSS 17.0 software was used for statistical analysis. 
 Results: PDW was found to be correlated with GRACE scores (P

A Study on the Assessment of Risk in the Management of Acute Coronary Syndrome using GRACE score

Aim: To assess the risk in the management of acute coronary syndrome by using GRACE score.
 Methods: This was an observational study conducted among 155 patients of cardiology department. Myocardial infarction patients of age above 20 years who were treated with fibronolytics were included in the study. Patients were assessed for the risk by using the GRACE (Global Registry of Acute Coronary Events) score criteria and was classified into low (?108 points), intermediate (109 to 140 points) and high (>140 points).
 Results: In this study, the severity of the LV dysfunction in most of the patients was observed to be mild followed moderate and severe. Majority of the patients were observed to be with high risk 61 (39.35%) followed by low risk 49 (31.61%) and intermediate risk 45 (29.04%). Most of the patients with high risk were observed to be in the age group 61-70 years (26.23%) whereas with intermediate risk were observed to be in the age group 41-50 years (35.55%).
 Conclusion: Among the mild, moderate and severe LV dysfunction, most of the patients were observed to be with high risk according to the GRACE score criteria.

Prevalence and prognostic value of malnutrition in patients with acute coronary syndrome and chronic kidney disease.

Malnutrition is a rising global health issue associated with unfavorable outcomes of a variety of disorders. Currently, the prevalence and prognostic significance of malnutrition to patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) remained largely unclear. A total of 705 patients diagnosed with ACS and CKD in the First Affiliated Hospital of Wenzhou Medical University between 2013 and 2021 were included in this retrospective cohort study. Malnutrition was assessed by the Controlling Nutritional Status (CONUT), the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI), respectively. The relationships between malnutrition and all-cause mortality and major cardiovascular events (MACEs) were analyzed. During a median follow-up of 31 months, 153 (21.7%) patients died, and 165 (23.4%) had MACEs. The prevalence of malnutrition was 29.8, 80.6, and 89.8% for the PNI, CONUT, and GNRI, respectively. All the malnutrition indexes were correlated with each other (r = 0.77 between GNRI and PNI, r = -0.72 between GNRI and CONUT, and r = -0.88 between PNI and CONUT, all p < 0.001). Compared with normal nutrition, malnutrition was independently associated with an increased risk for all-cause mortality (adjusted hazard ratio for moderate and severe degrees of malnutrition, respectively: 7.23 [95% confidence interval (CI): 2.69 to 19.49] and 17.56 [95% CI: 5.61 to 55.09] for the CONUT score, 2.18 [95% CI: 0.93 to 5.13] and 3.16 [95% CI: 1.28 to 7.79] for the GNRI, and 2.52 [95% CI: 1.62 to 3.94] and 3.46 [95% CI: 2.28 to 5.25] for the PNI score. p values were lower than 0.05 for all nutritional indexes, except for moderate GNRI p value = 0.075). As for MACEs, similar results were observed in the CONUT and PNI. All the risk scores could improve the predictive ability of the Global Registry of Acute Coronary Events (GRACE) risk score for both all-cause mortality and MACEs. Malnutrition was common in patients with ACS and CKD regardless of the screening tools used, and was independently associated with all-cause mortality and MACEs. Malnutrition scores could facilitate risk stratification and prognosis assessment.

Correlation of TIMI Risk Score and GRACE Risk Score with Lesion of Coronary Artery Disease in Patients with Non-ST Segment Elevation Acute Coronary Syndrome

Objective: To compare the correlation of “thrombolysis in myocardial infarction (TIMI)” and “Global Registry of Acute Coronary Events (GRACE)” risk score with lesion of coronary artery disease in patients with non-ST segment elevation acute coronary syndrome. Study Design: Cross-sectional study. Place and Duration: The Department of adult cardiology, “National Institute of Cardiovascular Diseases (NICVD)”, Karachi, Pakistan, from January 2021 to July 2021. Methodology: Demographics, weight, height, risk factors along with the required information needed for TIMI and GRACE score were obtained at the time of presentation in emergency department as per the scoring criteria. SYNTAX score was calculated after performing conventional angiography of the patients, using SYNTAX.com calculator. Results: In a total of 104 patients, the mean age was 57.21±12.22 years while 56 (53.8%) patients were male. Hypercholesterolemia was found in 33 (31.7%) patients. Mean score of TIMI was calculated as 4.680±2.064 while SYNTAX score was calculated as 26.45±12.94 and the correlation between TIMI risk score and SYNTAX score was noted as (r=0.109) and P value was found to be non-significant i.e. (P=0.270). Mean score of GRACE was noted as 135.38±90.88 while SYNTAX score was noted as 26.45±12.94 and the correlation between GRACE risk score and SYNTAX score was documented as (r=0.179) and P value was found to be non-significant i.e. (P=0.068). Practical Implications: Both TIMI and GRACE risk scoring systems showed weak correlations with SYNTAX scores. Conclusion: There is a weak correlation between TIMI risk score and SYNTAX score as well as GRACE risk score and SYNTAX score. Keywords: Acute coronary syndrome, coronary artery disease, GRACE score, myocardial infarction, thrombolysis.

Correlation between admission red cell distribution width and GRACE risk score as an early mortality marker in patients with acute myocardial infarction

Background: Red blood cell distribution width (RDW) is a measurement of the size variation of red blood cells in circulation. The Global Registry of Acute Coronary Events (GRACE) score is the most commonly used risk-stratification scoring system to predict mortality in acute coronary syndrome for both ST- elevated myocardial infarction (STEMI), non-ST elevated myocardial infarction (NSTEMI). The aim of this study was to assess the easily determinable red blood cell distribution width (RDW) as an early mortality marker of acute myocardial infarction (MI) mortality and the correlation of RDW-CV on admission with GRACE risk score in patients with acute myocardial infarction. Methods: This hospital-based, prospective observational study included 211 patients (mean age 58.15 +/- 12.45 years, male 176) admitted with acute MI (STEMI/NSTEMI) from January 2022 to June 2022. The study population was divided into two groups basing on the 50th percentile of the admission RDW-CV value -13.7. The GRACE score was calculated on admission to predict the GRACE in hospital mortality score within 24 hours of admission. Results: The study found that the higher RDW-CV values were associated with adverse prognostic factors in acute myocardial infarction like increased age, lower systolic blood pressure, heart failure, cardiac arrest, higher cardiac biomarker levels and higher in-hospital mortality (p = 0.049, level of significance p&lt; 0.05) and this correlated with a higher GRACE score (Pearson’s correlation coefficient R= 0.47, P&lt;0.05). Conclusion: Thus, RDW can be used as a useful parameter for predicting in-hospital mortality in acute MI patients.

Contemporary Use of Ticagrelor vs Clopidogrel in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A GRACE Risk Score Stratification–Based Analysis in a Large-Scale, Real-World Study From China

ObjectiveTo evaluate potential gains in outcomes from ticagrelor-based strategy according to risk stratification by Global Registry of Acute Coronary Events (GRACE) score. MethodsA total of 19,704 patients discharged alive post–acute coronary syndrome who underwent percutaneous coronary intervention and received ticagrelor or clopidogrel between March 2016 and March 2019 were included in the study. The primary endpoint was ischemic events at 12 months, composed of cardiac death, myocardial infarction, and/or stroke. Secondary outcomes included all-cause mortality and Bleeding Academic Research Consortium type 2 to 5 and 3 to 5 bleeding. ResultsThe ticagrelor group comprised 6432 (32.6%) patients and the clopidogrel group comprised 13,272 (67.4%) patients. During the follow-up period, there was a significant reduction in the incidence of ischemic events in patients treated using ticagrelor who had excessive risk of bleeding. According to the GRACE score, among low-risk patients, ticagrelor use compared with clopidogrel was not associated with decreased ischemic events (HR, 0.82; 95% CI, 0.57 to 1.17; P=.27) with excessive risk of Bleeding Academic Research Consortium type 3 to 5 bleeding (HR, 1.59; 95% CI, 1.16 to 2.17; P=.004). The risk of ischemic events (HR, 0.60; 95% CI, 0.41 to 0.89; P=.01) were lower in the intermediate- to high-risk patients treated with ticagrelor without significant difference in BARC type 3 to 5 bleeding risk (HR, 1.11; 95% CI, 0.75 to 1.65; P=.61). ConclusionThere was still a gap between guideline-indicated therapy and the clinical practice in a sizable subset of patients with acute coronary syndrome who underwent percutaneous coronary intervention. The GRACE risk score could identify patients who would derive benefit from the ticagrelor-based antiplatelet strategy.

The Impact of Gender and Race When Using the GRACE ACS Score to Predict Mortality.

Acute coronary syndrome (ACS) causes significant global morbidity and mortality and requires early risk stratification. The global registry of acute coronary events (GRACE) score is a well-known, validated risk stratification system that does not include race and gender. We aimed to assess whether the addition of gender and race could add to the predictability of the GRACE score model. We performed a retrospective cohort study of 46 764 ACS patients from the files of a national healthcare system. We compared the predictability of the GRACE score in conjunction with gender and race versus the original GRACE score. Different possible associations of predictability were investigated and statistically calculated. The accuracy of the prediction models was assessed using the receiver operating characteristic curve and its respective area under the curve (AUC). We compared the AUC of the 2 models, with the significance set at a P value of less than .05. Our comparison favored the original GRACE score over the modified prediction model with gender and race added (AUC = 0.838 and 0.839 respectively, P = .008). Although the P value comparing the AUC shows that the original GRACE was superior, due to our large dataset, the actual numbers are similar and may not be clinically significant. Gender and race were significantly associated with in-hospital mortality (P < .001, P = .002, respectively). However, this relationship disappeared in the multivariate analysis. Gender significantly predicted in-hospital mortality, with females 1.167 times more likely to die (P < .001). Non-white racial groups had lower in-hospital mortality than whites (OR: 0.823, P = .03). The GRACE score was valid in its original form and its ability to predict mortality was not substantially improved by including gender and race.

Normal thyroid stimulating hormone is associated with all-cause mortality in patients with acute myocardial infarction after percutaneous coronary intervention

BackgroundCirculating thyroid-stimulating hormone (TSH) levels within the normal reference range can affect the cardiovascular system. The present study investigated the prognostic value of normal TSH levels in patients presenting with acute myocardial infarction (AMI) following percutaneous coronary intervention (PCI).MethodsBetween January 2013 and July 2019, 1240 patients with AMI and normal thyroid function were enrolled and classified according to TSH tertile. The trial endpoint was all-cause mortality. The integrated discrimination index (IDI) and the net reclassification index (NRI) were used to assess the combined predictive values of the TSH levels and the Global Registry of Acute Coronary Events (GRACE) scores.ResultsAfter a median 44.25-month follow-up, 195 individuals died. Even after covariate adjustment by multivariate Cox regression (HR: 1.56; 95% CI 1.08–2.25; P = 0.017), the patients in the third TSH tertile were at the highest risk of all-cause mortality. A subgroup analysis revealed significant interactions between the TSH levels and the GRACE scores (high risk vs. low/medium risk) (P = 0.019). The addition of the TSH levels to the GRACE scores substantially improved the prediction of all-cause mortality, especially for high-risk patients (NRI = 0.239; IDI = 0.044; C-statistic value range 0.649–0.691; all significant).ConclusionsThe third TSH tertile is associated with a higher incidence of all-cause mortality than the first TSH tertile in high-risk patients presenting with AMI after PCI.

Independent and joint associations between the triglyceride-glucose index and NT-proBNP with the risk of adverse cardiovascular events in patients with diabetes and acute coronary syndrome: a prospective cohort study

BackgroundElevated triglyceride-glucose (TyG) index and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are independently associated with increased risk of major adverse cardio-cerebral events (MACCEs) in diabetic patients with the acute coronary syndrome (ACS), but have not been evaluated jointly. We sought to investigate the independent and joint association of the TyG index and NT-proBNP with MACCEs risk.MethodsData from 5046 patients with diabetes and ACS were recorded in the Cardiovascular Center Beijing Friendship Hospital Database Bank between 2013 and 2021, including measurements of fasting triglycerides, plasma glucose, and NT-proBNP. The TyG index was calculated as Ln (fasting triglycerides [mg/dL] × fasting plasma glucose [mg/dL]/2). Associations of the TyG index and NT-proBNP with MACCEs risk were assessed using flexible parametric survival models.ResultsDuring 13589.9 person-years of follow-up, 985 incident MACCEs of the 5046 patients (65.6 years of age and 62.0% men) were observed. Elevated TyG index (HR: 1.18; 95% CI 1.05‒1.32 per 1 unit increase) and NT-proBNP categories (HR: 1.95; 95% CI: 1.50‒2.54 for > 729 pg/ml compared to < 129 pg/ml) were independently associated with MACCEs risk in the fully adjusted model. According to the joint categories of the TyG index and NT-proBNP, patients with the TyG index > 9.336 and NT-proBNP > 729 pg/ml were at the highest risk of MACCEs (HR: 2.45; 95% CI 1.64‒3.65) than the ones with TyG index < 8.746 and NT-proBNP < 129 pg/ml. The test for interaction was not significant (Pinteraction = 0.49). Incorporating these two biomarkers into the established clinical model, the Global Registry of Acute Coronary Events (GRACE) risk score, resulted in a significant improvement in risk stratification.ConclusionsThe TyG index and NT-proBNP were independently and jointly associated with the risk of MACCEs in patients with diabetes and ACS, suggesting that patients with both markers elevated should be aware of the higher risk in the future.

Effectiveness of GRACE risk score in patients admitted to hospital with non-ST elevation acute coronary syndrome (UKGRIS): parallel group cluster randomised controlled trial

ObjectiveTo determine the effectiveness of risk stratification using the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) for patients presenting to hospital with suspected non-ST elevation acute coronary...

Corrected QT interval and GRACE score relationship in patients with non-ST segment elevation myocardial infarction

The Global Registry of Acute Coronary Events (GRACE) prediction model stratifies patients with non-ST-segment elevation myocardial infarction (NSTEMI). Corrected QT interval (QTc) is not considered in this model.To evaluate the relationship between the QTc interval and the GRACE score in patients with NSTEMI.An observational, retrospective study was carried between 2016 and 2019. We included patients with diagnosis of NSTEMI, QTc intervals were calculated with Bazett's formula, and they were classified into 2 groups: a normal QTc interval (<440 ms) and prolonged (≥440 ms). According to the GRACE score they were classified in three ranges: low risk (≤109 points), intermedium (110 - 139 points) and high (≥140 points), we determined if there were a correlation between QTc interval and the GRACE score.A total of 940 patients with a diagnosis of NSTEMI were admitted in our institution, 634 met the inclusion criteria, there were 390 patients with normal QTc interval and 244 with a prolonged QTc interval. Patients with prolonged QTc were older (65.5 vs 61, p=0.001) with a lower proportion of males (71.7% vs 82.8%, p=0.001). An association was found between the GRACE score and the QTC interval, subjects with a normal QTc had a greater proportion of low and intermediate risk than those with a prolonged QTc (p=0.001). Conclusions. In NSTEMI patients, a normal QTc interval (<440 ms) is associated with a GRACE risk score of low or intermediate risk.

Predictive Value of the Modified GRACE Scoring System for All-Cause Mortality in Patients with Acute Myocardial Infarction.

To establish a modified Global Registry of Acute Coronary Events (GRACE) scoring system with an improved predictive performance compared with the traditional GRACE scoring system. We identified 5512 patients who were hospitalized with a definite diagnosis of acute myocardial infarction (AMI) from January 1, 2015, to December 31, 2020, at the Heart Center of the First Affiliated Hospital of Xinjiang Medical University through the hospital's electronic medical record system. A total of 4561 patients were enrolled after the inclusion and exclusion criteria were applied. The mean follow-up was 51.8 23.4 months. The patients were divided into dead and alive groups by endpoint events. The differences between the two groups were compared using the two-sample t test and chi-square test. Adjusted traditional risk factors as well as LogBNP (B-type natriuretic peptide precursor, BNP) and the modified GRACE scoring system were included in a multifactorial COX regression model. The predictive performance of the traditional and modified GRACE scoring systems was compared by (Receiver Operating Characteristic) ROC curves. Significant differences in age, heart rate, creatinine, uric acid, LogBNP, traditional GRACE score, and modified GRACE score were found between the dead and alive groups by the two-sample t test. Comparison of the two groups by the chi-square test revealed that the dead group had a higher incidence of males; higher cardiac function class; a previous history of hypertension, diabetes, coronary artery disease (CAD), or cerebrovascular disease; a history of smoking; the need for intra-aortic balloon pump (IABP) support; and more patients taking aspirin, clopidogrel, ticagrelor, and -blockers. The results were analyzed by a multifactorial COX regression model, and after adjusting for confounders, age, cardiac function class, history of CAD, use of aspirin and -blockers, and the modified GRACE scoring system were found to be associated with all-cause mortality (ACM) in patients with AMI. The ROC curve was used to compare the predictive performance of the conventional GRACE scoring system with that of the modified GRACE scoring system, and it was found that the modified GRACE scoring system (Area Under Curve (AUC) = 0.809, p 0.001, 95% (Confidence Interval) CI (0.789-0.829)) was significantly better than the traditional GRACE scoring system (AUC = 0.786, p 0.001, 95% CI (0.764-0.808)), the comparison between the two scores was statistically significant (p 0.001). The change in the C statistic after 10-fold crossover internal validation of the modified GRACE score was not significant, and the integrated discrimination improvement (IDI) between the old and new models was calculated with IDI = 0.019 0, suggesting that the modified GRACE score has a positive improvement on the traditional GRACE score. The modified GRACE scoring system, established by combining B-type natriuretic peptide precursor (BNP) and the traditional GRACE scoring system, was independently associated with ACM in patients with AMI, with a larger AUC and higher predictive value than the traditional GRACE scoring system. NCT02737956.

Comparison of in hospital outcome of patients with and without distorted terminal portion of QRS complex on initial electrocardiogram in ST segment elevation myocardial infarction with GRACE scoring assessment

Distorted terminal portion of QRS complex on initial electrocardiogram in ST segment elevation myocardial infarction is a strong predictor of in hospital adverse outcome This observational prospective study was carried out in the department of cardiology, BSMMU, Dhaka from July 2014 to June 2015 to analyse admission ECG in patients of STEMI based on terminal portion of QRS complex and find out inhospital death, heart failure, cardiogenic shock and recurrent myocardial infarction, with GRACE scoring assessment. Total 60 patients with STEMI (age 54.33±10.37, 55M/5/F) were included in this study after analysing the selection criteria. We defined two ECG groups according to absence of distortion of terminal QRS (Group-I) and presence of distorted terminal QRS (Group-II) in two or more adjacent leads. Group-II further divided into pattern-A – J point originating at ³50% of height of R wave in leads with qR configuration and pattern B- S wave is absent in leads with RS configuration. Global Registry of Acute Coronary Events (GRACE) risk score was evaluated and compared in between two groups. Out of 60 patients of STEMI, 30 patients had distortion of QRS complex. There were 7 deaths, 16 heart failure, 3 cardigenic shock and no recurrent myocardial infarction. Hospital mortality and heart failure were found to be significantly higher in distorted QRS group (1 vs. 6 patients p=0.04; 4 vs. 12 patients p=0.02; respectively), cardiogenic shock of both groups did not show significant difference (0 vs. 3 patients p=0.075). Multiple logistic regression analysis using hospital mortality as dependable variable and all studied risk factors were independent variables, QRS distortion on admission ECG and Killip class were only variable found to be statistically significant (OR=7.25, p value &lt; 0.05 ; OR=16.25, p value&lt; 0.05 respectively). GRACE risk score was significantly high in distorted QRS group and low in without QRS distorted group (6 vs 15 patients p=0.014; 6 vs 16 patients p=0.007; respectively). Intermediate GRACE score did not show any statistically significant difference between two groups (p=0.77). Careful analysis of ECG which is simple, cheap, universally available bed side investigation may offer important prognostic information in patients with STEMI and would help in deciding which patients should go urgent myocardial revascularization procedure. Assessment of GRACE risk scoring is strongly encourage in everyday clinical practice as it provides reliable identification of STEMI patients who are at high risk of death. Bangladesh Medical Res Counc Bull 2022; 48(3): 211-218

Adding value of the Charlson comorbidity index to the Grace score for mortality risk prediction in patients with acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background The Global Registry of Acute Coronary Events (GRACE) risk score is widely recommended for risk assessment in patients with acute coronary syndrome (ACS). The Charlson Comorbidity Index (CCI) is a recognized measure of comorbid burden, and a useful tool for estimating prognosis in patients with multiple coexisting illnesses. Despite it has been validated in the context of ACS-related mortality, scarce and conflicting data still exist about the role of the CCI when added to the traditional GRACE risk score for outcome prediction in patients with acute coronary syndrome (ACS). Purpose The assessment of the potential predictive value of the CCI both for short, and long term all-cause mortality, in a contemporary ACS population, and its potential adding value beyond the GRACE risk score. Methods All consecutive admission due to ST-elevation myocardial infarction-STEMI, non ST elevated myocardial infarction-NSTEMI, and unstable angina-UA, from 01/01/2018 to 31/12/2020 were retrospectively reviewed from an internal database of a tertiary cardiac center in Italy. Logistic and Cox proportional regression analysis were performed in order to assess the contribution of the CCI on short and long term mortality. In order to specify the CCI adding value to the GRACE score, several measures of improvement in discrimination (increase in the area under the receiver-operating characteristic curve-AUC, the integrated discrimination improvement-IDI, and the continuous net reclassification improvement-cNRI&amp;gt;0) , were implemented. Robustness of the results were assessed through an internal validation procedure with bootstrapping. Results A total of 1310 patients (646 STEMI, 588 NSTEMI, and 76 UA) were identified. Almost 28% were female, and the median age was 68 (58-78). 97 (7,4%) and 136 (11,2%) deaths occurred, respectively, in hospital and during long term follow-up (median follow-up time: 12 months; IQR: 8-23). After multivariate logistic regression analysis the CCI was not associated with in-hospital death, while it was significantly and independently associated with the long-term mortality along with GRACE score (HR: 1,33, 95% CI: 1,22-1,43; p&amp;lt;0,001, Fig.1). An additive effect of CCI with the GRACE risk score was observed in predicting long-term mortality with an AUC from 0,762 to 0.821 (p &amp;lt; 0,001). The incremental predictive value of combining CCI and the GRACE risk score for the long term mortality was significantly improved, as shown by the net reclassification improvement (cNRI&amp;gt;0: 0.678, p &amp;lt; 0.001, Table 1) and integrated discrimination improvement (IDI: 0.08, p &amp;lt; 0.001). Conclusion The CCI is a predictor of long-term mortality and improves risk stratification of patients with ACS over the GRACE risk score.

The prediction of angiographic coronary thrombus burden using the admission GRACE 2.0 score in ST-elevation myocardial infarction patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Heavy coronary thrombus burden is associated with increased periprocedural complications in ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI (PPCI)[1]. The prediction of such a burden can help in planning the PPCI procedure in the best way. The Global Registry of Acute Coronary Events (GRACE) 2.0 score is a useful non-invasive tool to predict major adverse events in STEMI patients [2]. Purpose to assess the difference in coronary thrombus burden in STEMI patients with low and high risk GRACE 2.0 score on admission. Methods We retrospectively studied 210 STEMI patients who presented to a single PPCI centre over a period of 6 months. We consecutively included all the patients who were eligible for PPCI according to the European Society of Cardiology (ESC) guidelines [2]. We excluded the patients who received fibrinolysis, who had a previous PCI and presented with in-stent thrombosis and those who presented more than 24 hours from the onset of chest pain. All procedures were done according to the Helsinki declaration of research on human beings. The study protocol was approved by the local research ethics committee. The GRACE 2.0 score was calculated at the time of presentation to the emergency department using the online calculator [3]. We divided the patients according to their GRACE 2.0 score into a high-risk score (more than 140) and a non-high-risk score(up to 140) groups according to the ESC guidance.2 We compared the two groups regarding various cardiovascular risk factors and the angiographic thrombus burden during the PPCI procedure. Two experienced interventional cardiologists (blinded to the allocation group) assessed the thrombus burden using the TIMI thrombus grades [4]. A heavy thrombus burden was defined as a thrombus grade of 4 or 5. A professional statistician carried out the statistical analysis using IBM SPSS 21.0 software. Results The baseline characteristics of the studied groups are shown in figure 1. Multivariate regression analysis did not show an influence of the different cardiovascular risk factors on the thrombus burden in the studied groups. The percentage of patients with a heavy thrombus burden was higher in the high-risk score group; however, the difference between the two groups was not statistically significant (44.6% vs 35.3%, P=0.46) (figure 2). This study is the first to assess the ability of the GRACE 2.0 score to predict the coronary thrombus burden in STEMI patients undergoing PPCI. The study is limited by the small number of patients included and the small geographical scale. Conclusion Although the GRACE 2.0 is a well-validated tool to predict the clinical prognosis in STEMI patients, it could not identify those patients with a high coronary thrombus burden in our small study. Further larger-scale studies are required to find other non-invasive tools to identify this high-risk cohort.

Prognostic significance of serial N-terminal pro-B-type natriuretic peptide levels in patients with acute myocardial infarction: A prospective study

This study aimed to investigate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at different sampling times and prognosis in patients with acute myocardial infarction (AMI) undergoing emergency percutaneous coronary intervention (PCI). Between March 2017 and January 2020, 1,105 patients with AMI who underwent emergency PCI were included. NT-proBNP levels were measured on days 0, 1, 2, 3, and 7. A composite of all-cause death, MI recurrence (reMI), and rehospitalization due to heart failure, known as major adverse cardiovascular events (MACE), was recorded. During the 36.8-month follow-up, 175 patients (15.8%) experienced MACEs. When patients were grouped based on quartiles of NT-proBNP levels on days 0 and 7, the results demonstrated that patients in quartile 4 showed a substantially increased MACE risk compared to those in quartile 1 (hazard ratio [HR] 2.27, 95% confidence interval [CI]:1.27-4.08, P=.006; HR 2.20, 95%CI:1.23-3.94, P=.008). There were U-shaped relationships between the HR for MACE and NT-proBNP levels on days 2, 3, and 7, as well as peak NT-proBNP (P for nonlinearity=.007, .006, .004, and .009, respectively). A similar relationship was observed in the HR for reMI and NT-proBNP levels on days 2 and 3. For MACE at 3 years, serial NT-proBNP levels improved the predictive accuracy of the Global Registry of Acute Coronary Events (GRACE) risk score (concordance index [C-index]: 0.711; continuous net reclassification improvement [NRI]: 0.192, 95% CI: 0.022-0.445; integrated discrimination improvement [IDI]: 0.034, 95% CI: 0.016-0.064). For all-cause death at 3 years, the combination of NT-proBNP and GRACE score showed excellent performance, with C-index, continuous NRI, and IDI values of 0.801, 0.373 (95%CI: 0.072-0.853), and 0.051 (95%CI: 0.025-0.091), respectively. Early and sequential measurement of NT-proBNP levels could assist in predicting MACE risk. Moreover, the relationship between MACE risk and NT-proBNP levels was U-shaped. clinicaltrials.gov NCT: 03593928.

Social Determinants of Health and Mortality After Premature and Non-premature Acute Coronary Syndrome

ObjectiveTo describe and compare the determinants of 1-year mortality after premature vs non-premature acute coronary syndrome (ACS). Patients and MethodsParticipants presenting with ACS were enrolled in a prospective registry of 29 hospitals in 4 countries, from January 22, 2012 to January 22, 2013, with 1-year of follow-up data. The primary outcome was all-cause 1-year mortality after premature ACS (men aged <55 years and women aged <65 years) and non-premature ACS (men aged ≥55 years and women aged ≥65 years). The associations between the baseline patient characteristics and 1-year mortality were analyzed in models adjusting for the Global Registry of Acute Coronary Events (GRACE) score and reported as adjusted odds ratio (aOR) (95% CI). ResultsOf the 3868 patients, 43.3% presented with premature ACS that was associated with lower 1-year mortality (5.7%) than those with non-premature ACS. In adjusted models, women experienced higher mortality than men after premature (aOR, 2.14 [1.37-3.41]) vs non-premature ACS (aOR, 1.28 [0.99-1.65]) (Pinteraction=.047). Patients lacking formal education vs any education had higher mortality after both premature (aOR, 2.92 [1.87-4.61]) and non-premature ACS (aOR, 1.78 [1.36-2.34]) (Pinteraction=.06). Lack of employment vs any employment was associated with approximately 3-fold higher mortality after premature and non-premature ACS (Pinteraction=.72). Using stepwise logistic regression to predict 1-year mortality, a model with GRACE risk score and 4 characteristics (education, employment, body mass index [kg/m2], and statin use within 24 hours after admission) had higher discrimination than the GRACE risk score alone (area under the curve, 0.800 vs 0.773; Pcomparison=.003). ConclusionIn this study, women, compared with men, had higher 1-year mortality after premature ACS. The social determinants of health (no formal education or employment) were strongly associated with higher 1-year mortality after premature and non-premature ACS, improved mortality prediction, and should be routinely considered in risk assessment after ACS.

Timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome-an updated individual patient data meta-analysis.

The optimal timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome (NSTE-ACS) was subject of several randomized controlled trials (RCTs) since more than 20 years. American and European guidelines recommend an early invasive strategy <24 h for high-risk NSTE-ACS patients with a global registry of acute coronary events (GRACE) risk score >140 but without evidence for ongoing ischaemia or haemodynamic instability.1,2 However, scientific evidence supporting this recommendation is sparse. Butt et al.3 analysed the effect of the GRACE risk score on all-cause mortality in a post-hoc analysis of the very early versus deferred invasive evaluation using computerized tomography (VERDICT) trial. We combined the published VERDICT data with an existing database of our previous meta-analysis (Supplementary material online for further details, Table S1, Table S2, and Figure S1r).4 Consecutively, we updated our previous GRACE risk score subgroup analysis to synthetize up-to-date scientific evidence from the currently available data. The methodology is described in the Supplementary material online in detail. In short, we performed one-stage as well as two-stage meta-analyses. Both approaches led to the same result that an early invasive strategy does reduce the risk of all-cause mortality in patients with a GRACE risk score >140 but not in patients with a GRACE risk score ≤140 or the unselected population of NSTE-ACS patients (Figure 1). While some heterogeneity is present in the total population (I2 = 30%), it is absent in each subgroup stratum (I2 = 0%; Supplementary material online, Figure S2). The reported finding is driven by the addition of data from the VERDICT trial. Exclusion of this trial leads to a similar finding as reported in our previous meta-analysis (see Supplementary material online, Table S3 and Supplementary material online, Figure S3).4

Association Between Plasma Ceramides and One-Year Mortality in Patients with Acute Coronary Syndrome: Insight from the PEACP Study.

The plasma lipidome profile is likely to improve risk stratification in patients with acute coronary syndrome (ACS) and predict cardiovascular events for secondary disease prevention. Ceramides are involved in the initiation or acceleration of several key pathophysiological processes in atherosclerosis. This study evaluated whether plasma ceramide levels at admission was associated with one-year mortality in patients with ACS. In total, 826 patients with ACS from a prospective multicenter study for early evaluation of acute chest pain were enrolled. High-performance liquid chromatography with tandem mass spectrometry (LC/MS) was used to measure the plasma levels of eleven ceramides (C16-C26). The primary outcome was all-cause mortality, and the secondary outcome was cardiac mortality during the one-year follow-up. The relationship between the ceramide levels and mortality was evaluated by Cox regression analysis. The receiver operating characteristic (ROC) curve was established to evaluate discrimination of ceramides. Eighty-eight (10.7%) patients died after a 12-month follow-up. Five ceramides (C16:0, C18:0, C20:0, C24:1 and C24:2) and their ratios to Cer(d18:1/24:0) were independently associated with the risk of all-cause death and cardiac death. Combining the Global Registry of Acute Coronary Events (GRACE) score with ceramides and their ratios to Cer(d18:1/24:0) had areas under ROC curves ranging from 0.778-0.804 (P<0.001) for all-cause mortality, which was greater than that of the GRACE score alone. Measurements of long-chain ceramides and very-long-chain ceramides may help in identifying a high risk of mortality beyond traditional assessment tools in patients with ACS. clinicaltrials.gov, identifier: NCT04122573.