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Validity of GRACE Risk Score as a Prognostic Marker of In-hospital Mortality after Acute Coronary Syndrome
Samar Firdous1, Muhammad Amir Mehmood2, Uzma Malik1
1Department of Medicine, King Edward Medical University (KEMU), Lahore.
Insights
The GRACE risk score (GRS) effectively predicts in-hospital death for Acute Coronary Syndrome (ACS) patients. While valid for risk stratification, the GRS may slightly overestimate mortality risk in some cases.
Area of Science:
- Cardiology
- Clinical Risk Prediction
- Acute Coronary Syndromes
Background:
- Acute Coronary Syndrome (ACS) poses a significant risk of in-hospital mortality.
- Accurate risk stratification is crucial for managing ACS patients effectively.
- The GRACE risk score (GRS) is a widely used tool for assessing ACS patient risk.
Purpose of the Study:
- To validate the GRACE risk score (GRS) for predicting immediate in-hospital death in Acute Coronary Syndrome (ACS) patients.
- To analyze the proportion of cardiac deaths across different risk categories (high, intermediate, low) defined by the GRS.
Main Methods:
- A cross-sectional study was conducted in the Coronary Care Unit of Mayo Hospital, Lahore.
- 165 ACS patients were assessed using the online GRACE risk score calculator.
- Statistical analysis included ROC curve analysis for discrimination and Hosmer-Lemeshow test for calibration.
Main Results:
- The study included 165 ACS patients with an overall in-hospital mortality rate of 12.2%.
- The GRACE risk score demonstrated excellent discrimination (Area under ROC curve = 0.913, p<0.0001).
- The Hosmer-Lemeshow test indicated good calibration (p=0.236), with a significant correlation between GRS category and predicted death (Kendall's tau-b = 0.384, p<0.001).
Conclusions:
- The GRACE risk score is a valid and excellent tool for stratifying ACS patients into distinct risk categories.
- The predicted risk of death varied among patients, particularly those with higher GRACE scores.
- While effective, the GRACE score may have a tendency to overestimate the probability of death in some ACS cases, suggesting potential need for refinement.
Objective:
To determine validity of GRACE risk score as a determinant of immediate death during hospitalization for Acute Coronary Syndrome (ACS) and analyze the percentage of cardiac deaths among high, intermediate and low risk groups.
Study Design:
Cross-sectional study.
Place And Duration Of Study:
Coronary Care Unit of Mayo Hospital, Lahore, from April to July 2015.
Methodology:
Patients with acute chest pain were selected according to inclusion and exclusion criteria. Online GRACE risk score calculator was used to determine the predicted risk of death following ACS according to the score. Data was analyzed on SPSS 20. Quantitative data was in the form of median (IQR). Discrimination of GRS was evaluated by using c-statistics, area under the ROC curve. Calibration of GRS was tested by Hosmer-Lameshow test. The correlation between GRACE risk score category and predicted risk of death was determined using Kendall's tau-b bivariate correlation test. Shapiro-Wilk test was applied to check normality of data. The various parameters of GRACE score were studied in patients using Mann-Whitney U-test. The statistically significant p-value was <0.05.
Results:
There were 165 cases in the study. Overall median GRS was 139 (54). In-hospital deaths were 12.2%. Discrimination of GRS evaluated by area under the ROC curve was 0.913 (95% CI 0.843-0.982; p<0.0001). Application of Hosmer-Lameshow test revealed a p-value of 0.236. Kendall's tau-b bivariate correlation coefficient was 0.384 (p<0.001).
Conclusion:
GRS is an excellent tool to stratify patients of ACS into different risk categories according to various parameters noted at the time of presentation. The risk of predicted death according to the score was variable among different cases, especially those with higher scores. Even though GRS is an effective and valid tool, but it has some tendency of overestimating probability of death following ACS and may require a fine tuning in some cases.
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