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Ethnicity-Dependent Performance of the GRACE Risk Score
Quick Takes
- This study reports that ethnic minority patients with NSTEMI were younger and exhibited increased cardiometabolic risk factor profiles.
- While the GRACE score had good discrimination for in-hospital mortality in both Whites and ethnic minorities, it was not well calibrated in ethnic minority patients with an overestimation of the risk of in-hospital mortality.
- This analysis highlights the potential to optimize the current risk scoring model for NSTEMI patients for risk prediction in different ethnic groups.
Study Questions:
What is the performance of the GRACE (Global Registry of Acute Coronary Events) score in a racially diverse non–ST-segment elevation myocardial infarction (NSTEMI) population, particularly its ability to predict all-cause in-hospital mortality in different racial groups of patients?
Methods:
The investigators identified 326,160 admissions with NSTEMI in the MINAP (Myocardial Infarction National Audit Project), 2010–2017, including White (n = 299,184) and ethnic minorities (excluding White minorities) (n = 26,976). The authors calculated the GRACE score for in-hospital mortality and assessed ethnic group baseline characteristics by low, intermediate, and high risk. The performance of the GRACE risk score was estimated by discrimination (area under the receiver operating characteristic curve [AUC]) and calibration (calibration plots). AUC was calculated separately in White and ethnic minority patients and GRACE model calibration was assessed in the two groups by running a regression model to predict death within the hospital from the GRACE score.
Results:
Ethnic minorities presented younger and had increased prevalence of cardiometabolic risk factors in all GRACE risk groups. The GRACE risk score for White (AUC, 0.87; 95% confidence interval [CI], 0.86-0.87) and ethnic minority (AUC, 0.87; 95% CI, 0.86-0.88) patients had good discrimination. However, while the GRACE risk model was well calibrated in White patients (expected to observed [E:O] in-hospital death rate ratio, 0.99; slope, 1.00), it overestimated risk in ethnic minority patients (E:O ratio, 1.29; slope, 0.94).
Conclusions:
The authors reported that the GRACE risk score provided good discrimination overall for in-hospital mortality, but was not well calibrated and overestimated risk for ethnic minorities with NSTEMI.
Perspective:
This study examined the performance of the GRACE risk score in predicting in-hospital mortality for NSTEMI patients across racially diverse groups in England and Wales and reports that ethnic minority patients were younger and exhibited increased cardiometabolic risk factor profiles with higher rates of prior MI, prior percutaneous coronary intervention, hypertension, hypercholesterolemia, and diabetes. While the GRACE score had good discrimination for in-hospital mortality in both cohorts, it was not well calibrated in ethnic minority patients with an overestimation of the risk of in-hospital mortality. This analysis highlights the potential to optimize the current risk scoring model for NSTEMI patients for risk prediction in different ethnic groups. Finally, while these data suggest that GRACE score may not be well calibrated for certain ethnic minority groups in the United Kingdom, we must be mindful prior to changing the score without looking at the performance in several ethnic minority groups worldwide.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Homozygous Familial Hypercholesterolemia, Interventions and ACS, Interventions and Vascular Medicine, Hypertension, Chronic Angina
Keywords: Acute Coronary Syndrome, Cardiometabolic Risk Factors, Diabetes Mellitus, Ethnic Groups, Hospital Mortality, Hypercholesterolemia, Hypertension, Minority Groups, Myocardial Infarction, Non-ST Elevated Myocardial Infarction, Percutaneous Coronary Intervention, Risk Factors, Secondary Prevention
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