International guidelines increasingly recommend routine use of objective risk scores, like the Global Registry of Acute Coronary Events (GRACE) score, as part of optimal care for patients with acute coronary syndromes (ACS). However, while findings from a study assessing the value of the GRACE risk score suggest a small reduction in the overall composite of death, myocardial infarction (MI) and worsening heart failure, researchers saw no improvement in hospital adherence to guideline-recommended treatment in high-risk ACS patients.

The study, presented by David B. Brieger, MBBS, PhD, FACC, Aug. 31 at ESC Congress 2019, randomized 1,403 high-risk ACS patients to standard care (687) or objective risk assessment (716) using the GRACE risk score. The average age of both groups was 70 years. The mean performance score was 2.35 in the control/standard care group, compared with 2.42 in the active/objective risk group.

Overall findings showed "routine implementation of the GRACE risk score coupled with decision support recommendations did not increase use of guideline recommended treatment," according to Brieger, et al. "This was largely explained by better than expected performance in control hospitals and a failure of the intervention to impact on medication prescription or rehabilitation referral," they said.

In terms of the secondary endpoint – a reduction in death, recurrent MI or worsening heart failure among high-risk ACS patients at 12 months – the composite of clinical events was higher in the control group (6.8) compared with the active group (6.4). However, broken down by event, cardiac death was significantly higher in the control group (2.0) vs. the active group (0.4), but the incidence of MI was roughly the same across both groups (3.2 vs. 3.3) and worsening heart failure was higher in the active group (3.4) vs. the control group (3.0).

Based on the findings, Brieger and colleagues recommend that future studies and ongoing international efforts to show the value of objective risk stratification and decision support ensure adequate representation of sites with known gaps in evidence-based care.

Keywords: ESC 19, ESC Congress, Acute Coronary Syndrome, Risk Assessment, Angiography, Percutaneous Coronary Intervention

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