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Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better
Andrew T Yan1, Raymond T Yan, Mary Tan
1Canadian Heart Research Centre, Toronto, Ontario, Canada.
Insights
The Global Registry of Acute Cardiac Events (GRACE) risk score and Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy risk score (PURSUIT RS) better predict mortality in non-ST-elevation acute coronary syndromes (ACS) than the Thrombolysis in Myocardial Infarction risk score (TIMI RS). These scores improve patient risk stratification beyond physician assessment.
Area of Science:
- Cardiology
- Clinical Risk Stratification
- Acute Coronary Syndromes
Background:
- Non-ST-elevation acute coronary syndromes (ACS) represent a spectrum of myocardial infarction.
- Accurate risk stratification is crucial for guiding treatment decisions and improving patient outcomes in ACS.
- Existing risk scores, including TIMI RS, PURSUIT RS, and GRACE RS, aim to predict mortality but require comparative validation.
Purpose of the Study:
- To compare the discriminatory performance of TIMI RS, PURSUIT RS, and GRACE RS for in-hospital and 1-year mortality in patients with non-ST-elevation ACS.
- To assess the incremental prognostic utility of these risk scores beyond physician-based risk assessment.
Main Methods:
- Prospective, multicentre enrollment of 1,728 patients with non-ST-elevation ACS in the Canadian ACS II Registry.
- Calculation and comparison of TIMI RS, PURSUIT RS, and GRACE RS using the c-statistic (area under the receiver-operating characteristic curve).
- Statistical comparison of risk score performance using DeLong's method and multivariable analysis.
Main Results:
- All three risk scores demonstrated good discrimination for in-hospital and 1-year mortality.
- PURSUIT RS and GRACE RS showed significantly better discrimination than TIMI RS for both in-hospital and 1-year mortality.
- Risk score stratification into low, intermediate, and high-risk groups provided independent prognostic information beyond physician assessment for 1-year outcomes.
Conclusions:
- PURSUIT RS and GRACE RS offer superior discrimination for mortality prediction in non-ST-elevation ACS compared to TIMI RS.
- These validated risk scores provide significant prognostic value beyond clinical judgment, aiding in refined risk stratification.
- Implementation of these scores can potentially enhance patient care in routine clinical practice for ACS management.
Aims:
Our objectives were (i) to compare the discriminatory performance of the Thrombolysis in Myocardial Infarction risk score (TIMI RS), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy risk score (PURSUIT RS), and Global Registry of Acute Cardiac Events risk score (GRACE RS) for in-hospital and 1 year mortality across the broad spectrum of non-ST-elevation acute coronary syndromes (ACS) and (ii) to determine their incremental prognostic utility beyond overall risk assessment by physicians.
Methods And Results:
We calculated the TIMI RS, PURSUIT RS, and GRACE RS for 1,728 patients with non-ST-elevation ACS in the prospective, multicentre, Canadian ACS II Registry. Discriminatory performance was measured by the c-statistic (area under receiver-operating characteristic curve) and compared by the method described by DeLong. TIMI RS, PURSUIT RS, and GRACE RS all demonstrated good discrimination for in-hospital death (c-statistics = 0.68, 0.80, 0.81, respectively, all P < 0.001) and 1 year mortality (c-statistics = 0.69, 0.77, 0.79, respectively, all P < 0.0001). However, PURSUIT RS and GRACE RS performed significantly better than the TIMI RS in predicting in-hospital (P = 0.036 and 0.02, respectively) and 1 year (P = 0.006 and 0.001, respectively) outcomes. In multivariable analysis adjusting for the use of in-hospital revascularization, stratification by tertiles of risk scores (into low, intermediate, and high-risk groups) furnished independent and greater prognostic information compared with risk assessment by treating physicians for 1 year outcome.
Conclusion:
Compared with TIMI RS, both PURSUIT RS and GRACE RS allow better discrimination for in-hospital and 1 year mortality in patients presenting with a wide range of ACS. All three risk scores confer additional important prognostic value beyond global risk assessment by physicians. These validated risk scores may refine risk stratification, thereby improving patient care in routine clinical practice.
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