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Performance of the GRACE 2.0 Score for Type 1 and 2 MI
Quick Takes
- The GRACE 2.0 score provides good discrimination for all-cause death in patients with type 1 MI, but provided only moderate discrimination in patients with type 2 MI.
- The inclusion of absolute troponin concentration, comorbidities, or additional covariates, such as hemoglobin levels, could improve model performance in type 2 MI, but requires validation.
- For now, clinicians should continue using the GRACE 2.0 score to guide prognosis and management in patients with type 2 MI.
Study Questions:
What is the performance of the GRACE (Global Registry of Acute Coronary Events) 2.0 score for the prediction of all-cause death in patients with type 1 and type 2 myocardial infarction (MI)?
Methods:
The investigators calculated the GRACE 2.0 score in two cohorts of consecutive patients with suspected acute coronary syndrome from 10 hospitals in Scotland (n = 48,282) and a tertiary care hospital in Sweden (n = 22,589), to estimate death at 1 year. GRACE score performance was assessed by evaluating previously defined categories of mortality risk (<3% low, ≥3 and ≤8% intermediate, and >8% high risk) using the Kaplan–Meier method. Discrimination was evaluated by the area under the receiver operating curve (AUC), and compared for those with an adjudicated diagnosis of type 1 and type 2 MI using DeLong’s test.
Results:
Type 1 MI was diagnosed in 4,981 (10%) and 1,080 (5%) patients in Scotland and Sweden, respectively. At 1 year, 720 (15%) and 112 (10%) patients died with an AUC for the GRACE 2.0 score of 0.83 (95% confidence interval [CI], 0.82–0.85) and 0.85 (95% CI, 0.81–0.89). Type 2 MI occurred in 1,121 (2%) and 247 (1%) patients in Scotland and Sweden, respectively, with 258 (23%) and 57 (23%) deaths at 1 year. The AUC was 0.73 (95% CI, 0.70–0.77) and 0.73 (95% CI, 0.66–0.81) in type 2 MI, which was lower than for type 1 MI in both cohorts (p < 0.001 and p = 0.008, respectively).
Conclusions:
The authors concluded that the GRACE 2.0 score provided good discrimination for all-cause death at 1 year in patients with type 1 MI, and moderate discrimination for those with type 2 MI.
Perspective:
This cohort study reports that the GRACE 2.0 score provides good discrimination for all-cause death in patients with type 1 MI, but provided moderate discrimination in the prediction of all-cause death in patients with type 2 MI. As the GRACE 2.0 score performed better in patients with type 1 MI, there may be opportunities to develop a modified model for risk prediction in patients with type 2 MI. Whether the inclusion of absolute troponin concentration, comorbidities, or additional covariates, such as hemoglobin levels, could improve model performance in type 2 MI requires additional study. For now, and until newer models are developed and validated, clinicians should continue using the GRACE 2.0 score to guide prognosis and subsequent management in patients with type 2 MI.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Prevention
Keywords: Acute Coronary Syndrome, Comorbidity, Hemoglobins, Myocardial Infarction, Prognosis, Risk, Secondary Prevention, Tertiary Care Centers, Troponin
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