Saving GRACE—Upgrade Offers ‘Less Clunky’ Risk Assessment Tool

ACCEL | There are more options for treating high-risk patients with more intensive long-term treatment after ACS. Newer antithrombotic and anticoagulant therapies reduce subsequent cardiac events but the balance between risk and benefit is critical.

  • Identifying high-risk patients for more intensive long-term treatment after ACS presents a challenge.
  • An updated version of the GRACE risk score is easier to use (works on a range of electronic devices including smart phones) and has the potential for practical applications to identify higher-risk patents for more intensive management.
  • Also, when added to age, gender, and HF on initial admission, the GRACE score improves prediction of heart failure readmission among people admitted to hospital with an ACS.
  • More robust, user-friendly, "less clunky" risk-scoring tools are required to define higher-risk patients over the longer term. The GRACE risk score has been validated and is used widely in Europe to guide early management of ACS. However, it has not been clear whether the GRACE score accurately predicts longer-term outcomes.

    To address this, an updated and easy-to-use electronic version of the GRACE score was created: call it GRACE 2.0. It was developed from data on 32,037 patients who experienced 3,655 deaths or MIs. The original model included eight factors: age, heart rate, systolic blood pressure, Killip class, creatinine, ST-deviation, biomarkers of necrosis, and cardiac arrest. A simplified version of the GRACE score used substitutions for creatinine (history of renal dysfunction) and Killip class (diuretic usage). It conveyed more than 90% of the predictive accuracy of the complete multivariable model. So, how does it do long term?

    Investigators recently presented the first analysis of longer-term outcomes based on the predictive accuracy of GRACE 2.0 up to 1 year and up to 3 years after ACS. The longer-term calculations of GRACE 2.0 were validated externally against the FAST-MI registry—a nationwide French registry that included 3,059 patients with ST-elevation or non-ST-elevation MI in 223 centers. All variables to calculate the new GRACE score were available in 97% of patients.

    Simpler Risk Assessment

    Simpler, of course, means little unless it is also accurate. The authors found high levels of predictive accuracy in the overall population, including in-hospital and post-discharge events, and also in hospital survivors based on C statistics (the probability that predicting an outcome is better than chance). Models are typically considered reasonable when the C statistic is higher than 0.7 and strong when C exceeds 0.8. In evaluating GRACE 2.0, the C statistics for death and death/MI at 1 year (0.81 and 0.73) and 3 years (0.80 and 0.74) were similar to those seen with the original algorithm for 6-month death and death/MI (0.82 and 0.70).

    According to Prof. Keith A.A. Fox, MBChB, professor of cardiology at the University of Edinburgh, "GRACE 2.0 is really a smart, updated version of the original risk score. In each of our guidelines—the American College of Cardiology guidelines, our European guidelines—we recommend that clinicians should use a risk score, particularly for the intermediate-risk ACS patient or the non ST-elevation MI patient because many of these are higher risk than the clinician imagines. The trouble is the old risk scores were a bit cumbersome."

    It makes it easier, he said, for clinicians to use it in daily practice or it can be used in undifferentiated patients with symptoms suggestive of ACS. "The first responder, whether that's a doctor or a paramedic, can do the evaluation and they can do it within seconds. And this will help to guide the distribution and management of the patient."

    Keywords: Survivors, Registries, Probability, Risk Assessment, Patient Discharge, ACC Publications, CardioSource WorldNews

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