Modification of GRACE Risk Score for Risk Prediction in ACS
- There is an additive value of incorporating continuous hs-cTnT at presentation compared with the original or calibrated GRACE risk scores.
- These data suggest that integration of continuous rather than dichotomous hs-cTnT in a modified GRACE risk score improves 30-day, in-hospital, and, to a lesser extent, long-term risk stratification of patients with ACS.
- The clinical utility of the modified score should ideally be validated in prospective studies.
What is the incremental predictive value of a modified GRACE score incorporating high-sensitivity cardiac troponin T (hs-cTnT) at presentation?
The investigators conducted a retrospectively designed longitudinal cohort study and examined three independent cohorts of 9,803 patients with acute coronary syndrome (ACS) enrolled from September 2009 to December 2017; two ACS derivation cohorts (Heidelberg ACS cohort and Newcastle STEMI cohort) and an ACS validation cohort (SPUM-ACS study). The Heidelberg ACS cohort included 2,535 and the SPUM-ACS study 4,288 consecutive patients presenting with a working diagnosis of ACS. The Newcastle STEMI cohort included 2,980 consecutive patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention. Data were analyzed from March to June 2023. In-hospital, 30-day, and 1-year mortality risk estimates were derived from an updated risk score that incorporates continuous hs-cTnT at presentation (modified GRACE). The main outcome was the predictive value of continuous hs-cTnT and modified GRACE risk score compared with the original GRACE risk score. Study endpoints were all-cause mortality during hospitalization and at 30 days and 1 year after the index event.
Of 9,450 included patients, 7,313 (77.4%) were male, and the mean (SD) age at presentation was 64.2 (12.6) years. Using continuous rather than binary hs-cTnT conferred improved discrimination and reclassification compared with the original GRACE score (in-hospital mortality: area under the receiver operating characteristic curve [AUC], 0.835 vs. 0.741; continuous net reclassification improvement [NRI], 0.208; 30-day mortality: AUC, 0.828 vs. 0.740; NRI, 0.312; 1-year mortality: AUC, 0.785 vs. 0.778; NRI, 0.078) in the derivation cohort. These findings were confirmed in the validation cohort. In the pooled population of 9,450 patients, the modified GRACE risk score showed superior performance compared with the original GRACE risk score in terms of reclassification and discrimination for in-hospital mortality endpoint (AUC, 0.878 vs. 0.780; NRI, 0.097), 30-day mortality endpoint (AUC, 0.858 vs. 0.771; NRI, 0.08), and 1-year mortality endpoint (AUC, 0.813 vs. 0.797; NRI, 0.056).
The authors report that using continuous rather than binary hs-cTnT at presentation, a proxy of the extent of myocardial injury, in the GRACE risk score improved the mortality risk prediction in patients with ACS.
This study reports an additive value of incorporating continuous hs-cTnT at presentation, compared with the original or calibrated GRACE risk scores. Overall, these data suggest that integration of continuous rather than dichotomous hs-cTnT in a modified GRACE risk score improves 30-day, in-hospital, and, to a lesser extent, long-term risk stratification of patients with ACS. The clinical utility of the modified score should ideally be validated in prospective studies. If validated, the modified GRACE score may facilitate clinical decision-making regarding optimal antithrombotic treatment duration and intensity and timing and need for revascularization.
Keywords: Acute Coronary Syndrome, Percutaneous Coronary Intervention, Risk Assessment, Troponin T
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