Walking Beyond the GRACE (Global Registry of Acute Coronary Events) Model in the Death Risk Stratification During Hospitalization in Patients With Acute Coronary Syndrome: What Do the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and GWTG [Get With the Guidelines] Database), NCDR (National Cardiovascular Data Registry), and EuroHeart Risk Scores Provide?

Study Questions:

What is the in-hospital prognostic value of the original and updated GRACE (Global Registry of Acute Coronary Events) risk score and the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and the GWTG [Get With the Guidelines] Database) risk score in acute coronary syndromes (ACS)?


The authors assessed the prognostic value of various risk scores in 4,497 consecutive patients admitted to a single center in Spain with an ACS from 2004 to 2010. Of the total, 32.1% had ST-segment elevation myocardial infarction (STEMI), 19.2% had unstable angina, and the remainder had NSTEMI. Discrimination (C-statistic) and calibration (Hosmer-Lemeshow [HL]) indexes were used to assess performance of each risk score.


There were 265 in-hospital deaths (5.9%). Original and updated GRACE risk score and the AR-G risk score all demonstrated good discrimination for in-hospital death (C-statistics: 0.91, 0.90, and 0.90, respectively) with optimal calibration (HL p = 0.42, 0.50, and 0.47, respectively) in all spectra of ACS. In patients undergoing percutaneous coronary intervention, GRACE risk score demonstrated superior discrimination (C-statistic = 0.91) compared with EuroHeart score (C-statistic = 0.80) or the National Cardiovascular Data Registry risk score (C-statistic = 0.84).


The GRACE risk score has excellent discrimination in this group of patients with ACS.


Current American College of Cardiology/American Heart Association and European Society of Cardiology guidelines recommend that either the GRACE or TIMI (Thrombolysis in Myocardial Infarction) score be used for risk stratification of patients with ACS. The GRACE score has consistently demonstrated excellent discrimination for predicting death in patients with ACS, and has been previously demonstrated to be superior to the more commonly used TIMI score (see Aragam KG, et al., PLoS One, 2009). This study corroborates prior work and confirms that the GRACE score continues to be excellent at predicting patients at risk of in-hospital death.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS

Keywords: Prognosis, Registries, Myocardial Infarction, Acute Coronary Syndrome, Calibration, Spain, Percutaneous Coronary Intervention

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