Time course of events in acute coronary syndromes: implications for clinical practice from the GRACE registry
Keith A A Fox1, Frederick A Anderson, Shaun G Goodman
1Cardiovascular Research, Division of Medical and Radiological Sciences, University of Edinburgh, Edinburgh, Scotland, UK. k.a.a.fox@ed.ac.uk
Insights
The timing of adverse events after acute coronary syndromes varies by ST-segment category and GRACE risk score. Risk stratification should incorporate multiple factors beyond ST shift for better patient outcomes.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- The temporal pattern of events post-acute coronary syndromes (ACS) can impact therapeutic timing.
- Investigating the influence of initial risk status and ST-segment presentation is crucial.
Purpose of the Study:
- To analyze the impact of ST-segment category and GRACE risk score on the timing of adverse events within six months of ACS.
- To inform risk stratification strategies for ACS patients.
Main Methods:
- A cohort of 46,829 patients from the Global Registry of Acute Coronary Events (GRACE) was analyzed.
- Patients were categorized by ST-segment elevation, depression, or neither.
- Outcomes (death, reinfarction, stroke, major bleeding) were tracked within 0-4, 5-15, and 16-180 day periods.
Main Results:
- ST-segment elevation initially showed higher mortality risk (0-4 days), but this reversed after 15 days.
- Patients with ST deviation had higher overall mortality than those without.
- Higher GRACE risk scores correlated with significantly greater mortality risk across all ST categories.
Conclusions:
- ST-segment category and GRACE risk score influence the timing of post-ACS events.
- Effective risk stratification requires integrating multiple risk factors, not solely relying on ST-segment changes.
Background:
The time course of events after acute coronary syndromes might influence the timing and duration of therapeutic interventions. We investigated the impact of risk status and ST-segment category at presentation.
Methods:
The timing of death, reinfarction, stroke and major bleeding within 6 months of acute coronary syndromes was determined in 46,829 patients enrolled in the Global Registry of Acute Coronary Events (GRACE). Acute coronary syndromes were classified by elevation (n = 17,668), depression (n = 8,542), or neither (n = 20,619) in the ST segment. GRACE risk scores and hazard ratios (HR) were determined for three time periods: 0-4, 5-15 and 16-180 days.
Results:
ST-segment elevation was associated with a higher early risk of death than was ST-segment depression (0-4 days, HR 1.89, 95% CI 1.60-2.24 versus 5-15 days, HR 1.26, 95% CI 1.05-1.50), but after 15 days the risk was reversed (16-180 days, HR 0.85, 95% CI 0.75-0.97). Throughout the study, patients with ST-segment deviation had a higher mortality risk than those without. Within each ST category, the highest GRACE risk scores were associated with a 10-40-fold greater risk of death than the lowest scores (all categories P <0.0001). Most deaths occurred after day 4 (57%, 74%, and 78% for ST-segment elevation, depression and neither, respectively).
Conclusion:
The timing of events after acute coronary syndromes was affected by ST category and influenced by GRACE risk score within each electrocardiographic category of acute coronary syndromes. Risk stratification should, therefore, include multiple risk factors rather than ST shift alone.
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