Registry Of Events Research Articles

Comparison of Mortality Prediction by the GRACE Score, Multiple Biomarkers, and Their Combination in All-comer Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

Objective This study examined the ability of a combination of biomarkers, including N-terminal pro-B-type natriuretic peptide (N-BNP) and high-sensitivity C-reactive protein (hs-CRP), to better predict mortality than the Global Registry of Acute Coronary Events (GRACE) score in acute myocardial infarction (AMI) patients who received primary percutaneous coronary intervention (PPCI). Methods The in-hospital mortality in 754 all-comer patients with AMI who underwent successful PPCI over 8 years was examined. A receiver operating characteristic (ROC) analysis was performed to determine the in-hospital mortality in a single center. A logistic regression analysis was used to compare the predictive accuracy of the GRACE score and biomarkers. The incremental predictive value of those biomarkers beyond the GRACE score was also examined. Results The mean age was 66±13 years old, and 609 patients with ST-elevated AMI (80.8%) were included. The in-hospital mortality was 6.8%. The GRACE score (in-hospital survivor/non-survivor: 106±33/161±32; p<0.05,) and N-BNP (in-hospital survivor/non-survivor: 2,458±7,058/8,880±1,1331 pg/mL; p<0.05) were significantly lower in survivors than in non-survivors. The area under the ROC curve (AUC) of in-hospital mortality of the GRACE score was significantly higher than that of the dual-biomarker combination (0.868/0.720; p<0.05). The AUC of the combination of the GRACE score and dual-biomarkers was not significantly higher than that of the GRACE score alone (0.870/0.868; p=0.747). Conclusion The measurement of representative cardiovascular biomarkers did not provide any additional benefit for mortality prediction beyond the GRACE score in AMI patients who received PPCI.

Combined nutritional and frailty screening improves assessment of short-term prognosis in older adults following percutaneous coronary intervention.

Frailty and malnutrition are well-known factors influencing outcomes of myocardial infarction (MI) in older adults. Due to considerable overlap between both entities, whether the simultaneous assessment of frailty and nutrition adds nonredundant value to risk assessment is unknown. We performed a prospective cohort study on 402 patients aged at least 65 years diagnosed with ST-elevation MI that underwent percutaneous coronary intervention. Nutritional status was assessed by Controlling Nutritional Status score (CONUT), Prognostic Nutritional Index, and Geriatric Nutritional Response Index. Frailty was assessed by Clinical Frailty Scale (CFS), Derby frailty index, and acute frailty network. Primary outcome was major adverse cardiac events (MACE), comprising all-cause mortality, non-fatal MI, and unplanned repeat revascularization during 28-day follow-up. Increment in Global Registry of Acute Coronary Events (GRACE) score performance following the addition of nutrition and frailty was assessed. The incidence of MACE was 8.02 (6.38-9.95) per 1000 person-days. The CONUT score and CFS were the best predictors of MACE and independent predictors in the multivariate Cox-regression models [hazard ratios, 2.80 (1.54-5.09) and 2.54 (1.50-4.29)]. CONUT score classified 151 (37.6%) patients as malnourished, and CFS classified 131 (32.6%) as frail. The addition of both CONUT and CFS to the GRACE score led to better model discrimination and calibration through improved c-statistic (+0.165) ( P < 0.0001) and Akaike and Bayesian information criteria. Combining CONUT and CFS provides nonredundant prognostic value despite their overlapping nature. Combined nutritional and frailty screening may improve risk prognostication in older adults following MI.

Utilization and Outcomes of Clinically Indicated Invasive Cardiac Care in Veterans with Acute Coronary Syndrome and Chronic Kidney Disease.

Of studies reporting an association of CKD with lower use of invasive cardiac care to treat acute coronary syndrome (ACS), just one accounted for the appropriateness of such care. However, its findings in patients hospitalized nearly 30 years ago may not apply to current practice. In a more recent cohort of 64,695 veterans hospitalized with ACS, CKD was associated with a 32% lower likelihood of receiving invasive care determined to be clinically indicated. Among patients with CKD, not receiving such care was associated with a 1.39-fold higher risk of 6-month mortality. Efforts to elucidate the reasons for this disparity in invasive care in patients with ACS and CKD and implement tailored interventions to enhance its use in this population may offer the potential to improve clinical outcomes. Previous studies have shown that patients with CKD are less likely than those without CKD to receive invasive care to treat acute coronary syndrome (ACS). However, few studies have accounted for whether such care was clinically indicated or assessed whether nonuse of such care was associated with adverse health outcomes. We conducted a retrospective cohort study of US veterans who were hospitalized at Veterans Affairs Medical Centers from January 2013 through December 2017 and received a discharge diagnosis of ACS. We used multivariable logistic regression to investigate the association of CKD with use of invasive care (coronary angiography, with or without revascularization; coronary artery bypass graft surgery; or both) deemed clinically indicated based on Global Registry of Acute Coronary Events 2.0 risk scores that denoted a 6-month predicted all-cause mortality ≥5%. Using propensity scoring and inverse probability weighting, we examined the association of nonuse of clinically indicated invasive care with 6-month all-cause mortality. Among 34,430 patients with a clinical indication for invasive care, the 18,780 patients with CKD were less likely than the 15,650 without CKD to receive such care (adjusted odds ratio, 0.68; 95% confidence interval, 0.65 to 0.72). Among patients with CKD, nonuse of invasive care was associated with higher risk of 6-month all-cause mortality (absolute risk, 21.5% versus 15.5%; absolute risk difference 6.0%; adjusted risk ratio, 1.39; 95% confidence interval, 1.29 to 1.49). Findings were consistent across multiple sensitivity analyses. In contemporary practice, veterans with CKD who experience ACS are less likely than those without CKD to receive clinically indicated invasive cardiac care. Nonuse of such care is associated with increased mortality.

Combination of the Barthel Index at Discharge with GRACE Leads to Improved One-Year Mortality Prediction in Older Patients with Acute Myocardial Infarction.

Many older patients with acute myocardial infarction (AMI) have impaired ability for activities of daily living (ADL). Impaired ADL leads to poor prognosis in elderly patients. The Global Registry of Acute Coronary Events (GRACE) score is widely used for risk stratification in AMI patients but does not consider physical performance, which is an important prognosis predictor for older adults. This study assessed whether the Barthel Index (BI) score combine the GRACE score would achieve improved one-year mortality prediction in older AMI patients. This single-center retrospective study included 688 AMI patients aged ≥65 years who were divided into an impaired ADL group (BI ≤60, n = 102) and a normal ADL group (BI >60, n = 586) based on BI scores at discharge. The participants were followed up for one year. Cox survival models were constructed for BI score, GRACE score, and BI score combined GRACE score for one-year mortality prediction. Patients had a mean age of 76.29 ± 7.42 years, and 399 were men (58%). A lower BI score was associated with more years of hypertension and diabetes, less revascularization, longer hospital stays, and higher one-year mortality after discharge. Multivariable Cox regression analysis identified BI as a significant risk factor for one-year mortality in older AMI patients (HR 0.977, 95% CI, 0.963-0.992, P = 0.002). BI (0.774, 95% CI: 0.731-0.818) and GRACE (0.758, 95% CI: 0.704-0.812) scores had similar predictive power, but their combination outperformed either score alone (0.810, 95% CI: 0.770-0.851). BI at discharge is a significant risk factor for one-year mortality in older AMI patients, which can be better predicted by the combination of BI and GRACE scores.

Improving Risk Stratification for Patients With Type 2 Myocardial Infarction

BackgroundDespite poor cardiovascular outcomes, there are no dedicated, validated risk stratification tools to guide investigation or treatment in type 2 myocardial infarction. ObjectivesThe goal of this study was to derive and validate a risk stratification tool for the prediction of death or future myocardial infarction in patients with type 2 myocardial infarction. MethodsThe T2-risk score was developed in a prospective multicenter cohort of consecutive patients with type 2 myocardial infarction. Cox proportional hazards models were constructed for the primary outcome of myocardial infarction or death at 1 year using variables selected a priori based on clinical importance. Discrimination was assessed by area under the receiving-operating characteristic curve (AUC). Calibration was investigated graphically. The tool was validated in a single-center cohort of consecutive patients and in a multicenter cohort study from sites across Europe. ResultsThere were 1,121, 250, and 253 patients in the derivation, single-center, and multicenter validation cohorts, with the primary outcome occurring in 27% (297 of 1,121), 26% (66 of 250), and 14% (35 of 253) of patients, respectively. The T2-risk score incorporating age, ischemic heart disease, heart failure, diabetes mellitus, myocardial ischemia on electrocardiogram, heart rate, anemia, estimated glomerular filtration rate, and maximal cardiac troponin concentration had good discrimination (AUC: 0.76; 95% CI: 0.73-0.79) for the primary outcome and was well calibrated. Discrimination was similar in the consecutive patient (AUC: 0.83; 95% CI: 0.77-0.88) and multicenter (AUC: 0.74; 95% CI: 0.64-0.83) cohorts. T2-risk provided improved discrimination over the Global Registry of Acute Coronary Events 2.0 risk score in all cohorts. ConclusionsThe T2-risk score performed well in different health care settings and could help clinicians to prognosticate, as well as target investigation and preventative therapies more effectively. (High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome [High-STEACS]; NCT01852123)

Myocardial Mechanical Dispersion Predicts Adverse Cardiac Remodeling in Patients with ST Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention.

The aim of the study was to investigate whether increased left ventricular mechanical dispersion is an early predictor for adverse cardiac remodeling in ST-segment elevation myocardial infarction patients who had post-percutaneous coronary intervention thrombolysis in myocardial infarction (TIMI) flow grade > 2. A total of 119 post-percutaneous coronary intervention ST elevation myocardial infarction patients with TIMI flow grade >2 were prospectively included in the study. Left ventricular global longitudinal strain was quantified by 2-dimensional speckletracking echocardiography, and left ventricular mechanical dispersion was determined at baseline and after 1 year to assess adverse cardiac remodeling. The levels of circulating biomarkers were measured at the baseline. TIMI score and the Global Registry of Acute Coronary Events score systems were used to evaluate the prognosis of patients. Patients with high quartile versus low quartile of left ventricular mechanical dispersion exerted higher Global Registry of Acute Coronary Events and TIMI score grades, left ventricular endsystolic volume, global longitudinal strain, and levels of the N-terminal fragment of brain natriuretic peptide and lower left ventricular ejection fraction. Multivariate log regression showed that N-terminal fragment of brain natriuretic peptide > 953 pg/mL, global longitudinal strain > -8%, and high quartile of left ventricular mechanical dispersion remained independent predictors for adverse cardiac remodeling. Addition of left ventricular mechanical dispersion to the N-terminal fragment of brain natriuretic peptide improved the discriminative potency of the whole model. Measurement of left ventricular mechanical dispersion might be useful in determining the risk of adverse cardiac remodeling in post-percutaneous coronary intervention ST elevation myocardial infarction patients.

HEART versus GRACE Score in Predicting the Outcomes of Patients with Acute Coronary Syndrome; a Systematic Review and Meta-Analysis.

Several scoring systems have been proposed to predict the outcomes of patients with ischemic heart disease. Global Registry of Acute Coronary Events (GRACE) and History, ECG, Age, Risk Factors, and Troponin (HEART) scores are two of the more widely used risk prediction tools in patients with acute coronary syndrome (ACS). The present systematic review and meta-analysis aimed to compare the value of GRACE and HEART scores in the outcome prediction of ACS patient. The online databases of Medline, Embase, Web of Science, and Scopus were search until September 2022 for articles directly comparing GRACE and HEART scores value in prediction of outcome in patients with ACS. GRACE score cut-offs were categorized into two groups of less than and equal to 100 and more than 100, and HEART score cut-offs were categorized into three groups of less than 4, equal to 4, and more than 4. Investigated outcomes were major adverse cardiovascular events (MACE), acute myocardial infraction (AMI) and all-cause mortality. 25 articles were included. The sensitivity and specificity of the GRACE score for prediction of MACE were 0.96 and 0.26 for cut-offs of ≤ 100, and 0.58 and 0.69 for cut-offs of >100, respectively. The sensitivity and specificity of the HEART score for prediction of MACE were 0.99 and 0.16 for cut-offs less than 4, 0.93 and 0.47 for equal to 4, and 0.77 and 0.78 for cut-offs greater than 4. GRACE score was shown to be predictive of AMI with sensitivity and specificity of 0.95 and 0.29, respectively. The analysis for the value of HEART score in the prediction of AMI a sensitivity and specificity of 0.94 and 0.48, respectively. The risk scores were not found to be suitable predictors of all-cause mortality. The results demonstrated the low specificity of GRACE and HEART scores in predicting the MACE, AMI and all-cause mortality, irrespective of the utilized cut-off. Considering the acceptable sensitivity of two scores in predicting the MACE and AMI, these scores were more suitable to be used as a rule-out tool for identification of ACS patients with low risk of developing adverse outcomes.

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

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

Use of machine learning models to predict in‐hospital mortality in patients with acute coronary syndrome

Cardiovascular diseases are a significant health burden with the prevalence increasing worldwide. Thus, a highly accurate assessment and prediction of death risk are crucial to meet the clinical demand. This study sought to develop and validate a model to predict in-hospital mortality among patients with the acute coronary syndrome(ACS) using nonlinear algorithms. A total of 2414 ACS patients were enrolled in this study. All samples were divided into five groups for cross-validation. The logistic regression (LR) model and XGboost model were applied to predict in-hospital mortality. The results of two models were compared between the variable set by the global registry of acute coronary events (GRACE) score and the selected variable set. The in-hospital mortality rate was 3.5% in the dataset. Model performance on the selected variable set was better than that on GRACE variables: a 3% increase in area under the receiver operating characteristic (ROC) curve(AUC) for LR and 1.3% for XGBoost. The AUC of XGBoost is 0.913 (95% confidence interval [CI]: 0.910-0.916), demonstrating a better discrimination ability than LR (AUC = 0.904, 95% CI: 0.902-0.905) on the selected variable set. Almost perfect calibration was found in XGBoost (slope of predicted to observed events, 1.08; intercept, -0.103; p < .001). XGboost modeling, an advanced machine learning algorithm, identifies new variables and provides high accuracy for the prediction of in-hospital mortality in ACS patients.

Independent Predictors of Mortality in COVID-19 Myocardial Injury: The Role of Troponin Levels, GRACE Score, SOFA Score, and TIMI Score.

Background Coronavirus disease 2019 (COVID-19) infection is associated with troponin elevation, which is associated with increased mortality. However, it is not clear if troponin elevation is independently linked to increased mortality in COVID-19 patients. Although there is considerable literature on risk factors for mortality in COVID-19-associated myocardial injury, the Global Registry of Acute Coronary Events (GRACE), Thrombolysis in Myocardial Infarction(TIMI), and Sequential Organ Failure Assessment(SOFA) scores have not been studied in COVID-19-related myocardial injury. This data is important in risk-stratifying COVID-19 myocardial injury patients. Methodology Of the 1,500 COVID-19 patients admitted to our hospitals, 217 patients who had troponin levels measuredwere included. Key variables were collected manually, and univariate and multivariate cox regression analysis was done to determine the predictors of mortality in COVID-19-associated myocardial injury. The differences in clinical profiles and outcomes of COVID-19 patients with and without troponin elevation were compared. Results Mortality was 26.5% in the normal troponin group and 54.6% in the elevated troponin group. Patients with elevated troponins had increased frequency of hypotension (p = 0.01), oxygen support (p < 0.01), low absolute lymphocyte(p < 0.01), elevated blood urea nitrogen (p < 0.01), higher C-reactive protein (p < 0.01), higher D-dimer (p < 0.01), higher lactic acid (p < 0.01), and higher Quick SOFA (qSOFA), SOFA, TIMI, and GRACE (all scores p < 0.01). On univariate cox regression, troponin elevation (hazard ratio (HR) = 1.85, 95% confidence interval (CI) = 1.18-2.88, p < 0.01), TIMI score >3 (HRv = 1.79, 95% CI = 1.11-2.75, p = 0.01), and GRACE score >140 (HR = 2.27, 95% CI = 1.45-3.55, p < 0.01) were highly associated with mortality, whereas cardiovascular disease (HR = 1.40, 95% CI = 0.89-2.21, p = 0.129) and cardiovascular risk factors (HR = 1.15, 95% CI = 0.73-1.81, p = 0.52) were not. After adjusting for age, use of a non-rebreather or high-flow nasal cannula, hemoglobin <8.5 g/dL, suspected or confirmed source of infection, and qSOFA and SOFA scores (HR = 1.18, 95% CI = 1.07-1.29, p < 0.01) were independently associated with mortality, whereas troponin (HR = 1.08, 95% CI = 0.63-1.85, p = 0.76), TIMI score (HR = 1.02, 95% CI = 0.99-1.06, p = 0.12) and GRACE scores (HR = 1.01, 95% CI = 0.99-1.02, p = 0.10) were not associated with mortality. Conclusions Our study shows that troponin, GRACE score, and TIMI score are not independent predictors of mortality in COVID-19 myocardial injury. This may be because troponin elevation in COVID-19 patients may be related to demand ischemia rather than acute coronary syndrome-related. This was shown by the association of troponin with a higher degree of systemic inflammation and end-organ dysfunction. Therefore, we recommend SOFA scoresin risk-stratifying COVID-19 patients with myocardial injury.

The "obesity paradox" in patients with atrial fibrillation: Insights from the Gulf SAFE registry.

The prognostic impact of obesity on patients with atrial fibrillation (AF) remains under-evaluated and controversial. Patients with AF from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) registry were included, who were recruited from six countries in the Middle East Gulf region and followed for 12 months. A multivariable model was established to investigate the association of obesity with clinical outcomes, including stroke or systemic embolism (SE), bleeding, admission for heart failure (HF) or AF, all-cause mortality, and a composite outcome. Restricted cubic splines were depicted to illustrate the relationship between body mass index (BMI) and outcomes. Sensitivity analysis was also conducted. A total of 1,804 patients with AF and recorded BMI entered the final analysis (mean age 56.2 ± 16.1 years, 47.0% female); 559 (31.0%) were obese (BMI over 30 kg/m2). In multivariable analysis, obesity was associated with reduced risks of stroke/systematic embolism [adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI), 0.18-0.89], bleeding [aOR 0.44, 95%CI, 0.26-0.74], HF admission (aOR 0.61, 95%CI, 0.41-0.90) and the composite outcome (aOR 0.65, 95%CI, 0.50-0.84). As a continuous variable, higher BMI was associated with lower risks for stroke/SE, bleeding, HF admission, all-cause mortality, and the composite outcome as demonstrated by the accumulated incidence of events and restricted cubic splines. This "protective effect" of obesity was more prominent in some subgroups of patients. Among patients with AF, obesity and higher BMI were associated with a more favorable prognosis in the Gulf SAFE registry. The underlying mechanisms for this obesity "paradox" merit further exploration.

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.

Plasma desmosine for prediction of outcomes after acute myocardial infarction.

Elastin degradation is implicated in the pathology of vulnerable plaque. Recent studies show promising results for plasma desmosine (pDES), an elastin-specific degradation product, as a marker of cardiovascular disease (CVD) outcomes. The aim of this study was to investigate the potential role of pDES as a marker of clinical outcome in patients with acute myocardial infarction (AMI). In this case-control study, we studied 236 AMI patients: 79 patients who had death and/or myocardial infarction (MI) at 2 years, and 157 patients who did not have an event at 2 years. pDES was measured using a validated liquid chromatography-tandem mass spectrometry method. Association of pDES with adverse outcomes, and the incremental value of pDES to global registry of acute coronary events (GRACE) score for risk stratification was assessed. pDES levels were elevated in patients with the composite outcome of death/MI at 2 years (p = 0.002). Logistic regression analyses showed pDES to be associated with death/MI at 2 years [Odds ratio (OR) 5.99 (95% CI 1.81-19.86) p = 0.003]. pDES remained a significant predictor of death/MI at 2 years even after adjustment for age, sex, history of CVD, revascularisation, blood pressure, medications on discharge, Troponin I, and NT-proBNP levels.[OR 5.60 (95% CI 1.04-30.04) p = 0.044]. In another multivariable model including adjustment for eGFR, pDES was significantly associated with the composite outcome at 6 months, but not at 2 years follow up. DES was also able to reclassify risk stratification for death/MI at 6 months, when added to the GRACE risk model [Net Reclassification Index (NRI) 41.2 (95% CI 12.0-70.4) p = 0.006]. pDES concentrations predict clinical outcomes in patients with AMI, demonstrating its potential role as a prognostic marker in AMI.

Admission lactate level and the GRACE 2.0 score are independent and additive predictors of 30-day mortality of STEMI patients treated with primary PCI-Results of a real-world registry.

In many of the risk estimation algorithms for patients with ST-elevation myocardial infarction (STEMI), heart rate and systolic blood pressure are key predictors. Yet, these parameters may also be altered by the applied medical treatment / circulatory support without concomitant improvement in microcirculation. Therefore, we aimed to investigate whether venous lactate level, a well-known marker of microcirculatory failure, may have an added prognostic value on top of the conventional variables of the "Global Registry of Acute Coronary Events" (GRACE) 2.0 model for predicting 30-day all-cause mortality of STEMI patients treated with primary percutaneous coronary intervention (PCI). In a prospective single-center registry study conducted from May 2020 through April 2021, we analyzed data of 323 cases. Venous blood gas analysis was performed in all patients at admission. Nested logistic regression models were built using the GRACE 2.0 score alone (base model) and with the addition of venous lactate level (expanded model) with 30-day all-cause mortality as primary outcome measure. Difference in model performance was analyzed by the likelihood ratio (LR) test and the integrated discrimination improvement (IDI). Independence of the predictors was evaluated by the variance inflation factor (VIF). Discrimination and calibration was characterized by the c-statistic and calibration intercept / slope, respectively. Addition of lactate level to the GRACE 2.0 score improved the predictions of 30-day mortality significantly as assessed by both LR test (LR Chi-square = 8.7967, p = 0.0030) and IDI (IDI = 0.0685, p = 0.0402), suggesting that the expanded model may have better predictive ability than the GRACE 2.0 score. Furthermore, the VIF was 1.1203, indicating that the measured lactate values were independent of the calculated GRACE 2.0 scores. Our results suggest that admission venous lactate level and the GRACE 2.0 score may be independent and additive predictors of 30-day all-cause mortality of STEMI patients treated with primary PCI.

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.

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 12743: Patient Satisfaction and Determinants of 1-Year Mortality Following Acute Coronary Syndrome

Introduction: The association of patient satisfaction with hospital ACS care and risk for long-term outcomes is incompletely described. This is particularly relevant to the Gulf region, where the ACS burden is high and literature on patient satisfaction and outcomes is lacking. The aim was to compare determinants of 1-year mortality based on patient satisfaction with ACS care in the Gulf region. Methods: In a prospective registry of 3566 ACS patients from Bahrain, Kuwait, Oman, and UAE (Gulf COAST registry), we grouped patients by their self-reported overall satisfaction with ACS care reported at 1-month following ACS (low satisfaction [n=1654] vs. high satisfaction [n=1912]; Table). We examined associations of baseline characteristics and risk for 1-year mortality in logistic regression models adjusted for Global Registry of Acute Coronary Events (GRACE) score. Results: Mortality at 1-year following ACS was higher in patients reporting low satisfaction (8.8%; n=146/1654) vs. high satisfaction (5.4%; n=103/1912) ( P &lt;.0001). Women, compared with men, had higher 1-year mortality risk in both satisfaction groups, and statistically significant risk in the low satisfaction group (aOR 1.45 [1.01–2.07]; P &lt;.05). Lack of employment (vs. any employment) was associated with higher 1-year mortality risk in both the low satisfaction (aOR 6.44 [2.58–16.03]) and high satisfaction (aOR 2.58 [1.35–4.93]) groups with borderline significant interaction ( P interaction = .08). In both satisfaction groups, lack of education, hypertension and prior angina were associated with higher 1-year mortality risk, whereas dyslipidemia and diabetes showed no association. Conclusions: Low patient satisfaction with ACS care was associated with higher 1-year mortality risk. Socioeconomic factors such as employment and education were associated with higher 1-year mortality, independent of patient satisfaction, and may guide mortality reduction interventions.

GRACE PLUS: A data fusion-based approach to improve GRACE score in the risk assessment of Acute Coronary Syndrome

Cardiovascular Diseases (CVDs) are the world’s leading cause of morbidity and mortality, being responsible for almost 17 million deaths each year. In Europe, let alone it is estimated that 20% of all citizens suffer from one form of CVD, namely cerebrovascular disease or heart failure and Coronary Artery Disease (CAD). Among the latter, Acute Coronary Syndrome (ACS) is of particular importance since it is deadly and, hence, requires a prompt diagnosis and immediate medical attention. Aiming to deal with prognostication and promote consistency in managing patients with ACS, the Global Registry of Acute Coronary Events (GRACE) risk score has been proposed. This tool is based on eight independent risk factors roughly accounting for 89.9% of prognostic information. Nevertheless, as some other risk factors, not included in GRACE, are also known to be important vectors in the stratification of patients, namely haemoglobin at admission, it is expected that by embedding additional risk factors information into GRACE it will lead to a better characterisation of a patient’s risk. Making use of data-fusion techniques, the present work proposes a generalisable framework to improve the classification performance of GRACE in predicting the risk of death in the course of six months after an ACS event, while preserving its interpretability and applicability. Considering haemoglobin concentration at admission, as an additional risk factor, it is shown that the discrimination performance of new GRACE Plus score outperformed that of GRACE in a database of cohorts comprising 1506 patients admitted with ACS, showing a F-1 score of 0.6033 for GRACE Plus against 0.5828 for GRACE, which is corroborated by one-tailed t-test in terms of correct stratification of death and survival endpoints, namely, t=−9.1876 and p<0.001.

Towards survival prediction of cancer patients using medical images.

Survival prediction of a patient is a critical task in clinical medicine for physicians and patients to make an informed decision. Several survival and risk scoring methods have been developed to estimate the survival score of patients using clinical information. For instance, the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk scores are developed for the survival prediction of heart patients. Recently, state-of-the-art medical imaging and analysis techniques have paved the way for survival prediction of cancer patients by understanding key features extracted from Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scanned images with the help of image processing and machine learning techniques. However, survival prediction is a challenging task due to the complexity in benchmarking of image features, feature selection methods, and machine learning models. In this article, we evaluate the performance of 156 visual features from radiomic and hand-crafted feature classes, six feature selection methods, and 10 machine learning models to benchmark their performance. In addition, MRI scanned Brain Tumor Segmentation (BraTS) and CT scanned non-small cell lung cancer (NSCLC) datasets are used to train classification and regression models. Our results highlight that logistic regression outperforms for the classification with 66 and 54% accuracy for BraTS and NSCLC datasets, respectively. Moreover, our analysis of best-performing features shows that age is a common and significant feature for survival prediction. Also, gray level and shape-based features play a vital role in regression. We believe that the study can be helpful for oncologists, radiologists, and medical imaging researchers to understand and automate the procedure of decision-making and prognosis of cancer patients.

Prognostic value of pulmonary hemodynamic parameters for predicting survival in acute coronary syndrome

Objective: To explore the characteristics and prognostic value of pulmonary hemodynamics in patients with acute coronary syndrome (ACS). Methods: From a prospective multicenter registry study of pulmonary hypertension due to left heart disease, consecutive ACS patients who underwent coronary angiography in combination with left and right heart catheterization during hospitalization between January 2013 and November 2016 were involved. The primary endpoint was all-cause mortality. The prognostic variables identified by the Lasso analysis were included in the Global Registry of Acute Coronary Events (GRACE) score. Model performance was evaluated before and after the addition of hemodynamic parameters. Results: A total of 251 patients were enrolled, with age of (63.7±11.5) years. A total of 198 males (78.9%) and 53 females (21.1%) were recruited, and the median follow-up time was 34.7 months. Right heart catheterization-assessed mean pulmonary arterial pressure (mPAP), systolic pulmonary arterial pressure (sPAP) and diastolic pressure gradient (DPG) were found to be significant predictors for survival in ACS. Adjusted for age and sex, the adjusted HR (95%CI) of mPAP, sPAP and DPG were 1.068 (1.015-1.123), 1.033 (1.002-1.065) and 1.094 (1.008-1.187), respectively (P<0.05). Applied to the present cohort of 251 patients, the median of the GRACE score was 123 points, with a C-index of 0.703 (95%CI: 0.615-0.791) for predicting mortality. After the addition of mPAP or DPG to the GRACE score, the C-index increased to 0.715 (95%CI: 0.629-0.801) or 0.711 (95%CI: 0.625-0.797), respectively. When comparing two models before and after the addition of mPAP or DPG, the integrated discriminatory index (IDI) was 4.3% (95%CI: 0.2%-13.5%, P=0.030) and 3.0% (95%CI: 0.2%-11.1%, P=0.020), respectively. Conclusion: Pulmonary hemodynamics can be predictive for survival in ACS patients, providing incremental prognostic value to risk assessment in ACS.