Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score

BMJ Open - Tập 4 Số 2 - Trang e004425 - 2014
Keith A.A. Fox1, Gordon FitzGerald2, Étienne Puymirat3,4,5,6, Wei Huang2, Kathryn F. Carruthers1, Tabassome Simon7,8,9,10,11, Pierre Coste12, Jacques Monségu13, Philippe Gabríel Steg14,15,16, Nicolas Danchin3,4,5,6, Fred Anderson2
1Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
2University of Massachusetts Medical School, Worcester, Massachusetts, USA;
3Assistance publique des hôpitaux de Paris, AP-HP, Paris, France
4Department of Cardiology, European Hospital of Georges Pompidou, Paris, France
5INSERM U-970 Paris, France
6University Paris Descartes, Paris, France
7Department of Pharmacology, Assistance Publique-Hôpitaux de Paris, Hôpital St Antoine, Unité de Recherche Clinique (URCEST), Paris, France
8Hôpital du Haut Levêque, Pessac, Paris, France
9INSERM U698, Paris, France
10Université Bordeaux Segalen, Bordeaux, France
11Université Pierre et Marie Curie-Paris 06, Paris, France
12Hôpital d'Instruction des Armées du Val de Grâce (74 Bld de Port Royal BP 1 00446 Armées - France)
13Department of Cardiology, Hôpital du Val de Grâce, Paris, France
14Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
15INSERM U 698, Paris, France
16Université Paris Diderot, Paris, France

Tóm tắt

ObjectivesRisk scores are recommended in guidelines to facilitate the management of patients who present with acute coronary syndromes (ACS). Internationally, such scores are not systematically used because they are not easy to apply and some risk indicators are not available at first presentation. We aimed to derive and externally validate a more accurate version of the Global Registry of Acute Coronary Events (GRACE) risk score for predicting the risk of death or death/myocardial infarction (MI) both acutely and over the longer term. The risk score was designed to be suitable for acute and emergency clinical settings and usable in electronic devices.Design and settingThe GRACE risk score (2.0) was derived in 32 037 patients from the GRACE registry (14 countries, 94 hospitals) and validated externally in the French registry of Acute ST-elevation and non-ST-elevation MI (FAST-MI) 2005.ParticipantsPatients presenting with ST-elevation and non-ST elevation ACS and with long-term outcomes.Outcome measuresThe GRACE Score (2.0) predicts the risk of short-term and long-term mortality, and death/MI, overall and in hospital survivors.ResultsFor key independent risk predictors of death (1 year), non-linear associations (vs linear) were found for age (p<0.0005), systolic blood pressure (p<0.0001), pulse (p<0.0001) and creatinine (p<0.0001). By employing non-linear algorithms, there was improved model discrimination, validated externally. Using the FAST-MI 2005 cohort, the c indices for death exceeded 0.82 for the overall population at 1 year and also at 3 years. Discrimination for death or MI was slightly lower than for death alone (c=0.78). Similar results were obtained for hospital survivors, and with substitutions for creatinine and Killip class, the model performed nearly as well.ConclusionsThe updated GRACE risk score has better discrimination and is easier to use than the previous score based on linear associations. GRACE Risk (2.0) performed equally well acutely and over the longer term and can be used in a variety of clinical settings to aid management decisions.

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BMJ Open

Tập 4 Số 2

e004425

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