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Published on: October 23, 2020
Improving risk stratification in non-ST-segment elevation myocardial infarction with combined assessment of GRACE and
Luis Paiva1, Rui Providência2, Sérgio N Barra3
1Coimbra's Hospital and University Centre, Coimbra, Portugal.
Insights
Combining GRACE and CRUSADE risk scores improves prediction of mortality and bleeding in myocardial infarction patients. This dual approach offers better prognostic insight than individual scores alone.
Area of Science:
- Cardiology
- Clinical Risk Assessment
Background:
- Risk assessment is crucial for managing acute coronary syndromes (ACS).
- Prognostic estimation is key in ACS patient management.
Purpose of the Study:
- To assess if combined GRACE and CRUSADE risk scores outperform individual scores for myocardial infarction (MI).
- To evaluate prediction accuracy for mortality and bleeding risk in MI patients.
Main Methods:
- Retrospective observational study of 566 non-ST-segment elevation MI patients.
- Utilized Cox regression and subgroup analysis (G1-G4) for mortality and bleeding risk.
- Assessed GRACE and CRUSADE models individually and in combination.
Main Results:
- Combined GRACE+CRUSADE model showed superior mortality prediction (AUC 0.76) vs. GRACE alone (AUC 0.70).
- Clinical severity and outcomes worsened progressively across risk subgroups (G1-G4).
- Identified a very high-risk subgroup (G4) for bleeding events (HR 3.5).
Conclusions:
- Combined GRACE and CRUSADE risk stratification enhances prediction of mortality and bleeding in MI.
- This practical approach aids in clinical decision-making for ACS management.
Background:
Risk assessment is fundamental in the management of acute coronary syndromes (ACS), enabling estimation of prognosis.
Aims:
To evaluate whether the combined use of GRACE and CRUSADE risk stratification schemes in patients with myocardial infarction outperforms each of the scores individually in terms of mortality and haemorrhagic risk prediction.
Methods:
Observational retrospective single-centre cohort study including 566 consecutive patients admitted for non-ST-segment elevation myocardial infarction. The CRUSADE model increased GRACE discriminatory performance in predicting all-cause mortality, ascertained by Cox regression, demonstrating CRUSADE independent and additive predictive value, which was sustained throughout follow-up. The cohort was divided into four different subgroups: G1 (GRACE<141; CRUSADE<41); G2 (GRACE<141; CRUSADE≥41); G3 (GRACE≥141; CRUSADE<41); G4 (GRACE≥141; CRUSADE≥41).
Results:
Outcomes and variables estimating clinical severity, such as admission Killip-Kimbal class and left ventricular systolic dysfunction, deteriorated progressively throughout the subgroups (G1 to G4). Survival analysis differentiated three risk strata (G1, lowest risk; G2 and G3, intermediate risk; G4, highest risk). The GRACE+CRUSADE model revealed higher prognostic performance (area under the curve [AUC] 0.76) than GRACE alone (AUC 0.70) for mortality prediction, further confirmed by the integrated discrimination improvement index. Moreover, GRACE+CRUSADE combined risk assessment seemed to be valuable in delineating bleeding risk in this setting, identifying G4 as a very high-risk subgroup (hazard ratio 3.5; P<0.001).
Conclusions:
Combined risk stratification with GRACE and CRUSADE scores can improve the individual discriminatory power of GRACE and CRUSADE models in the prediction of all-cause mortality and bleeding. This combined assessment is a practical approach that is potentially advantageous in treatment decision-making.
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