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Published on: August 9, 2024
Impact of Coronary Artery Disease Extent on GRACE Risk Score Prognostic Performance After ST-Segment-Elevation
Kayode O Kuku1, Chris Lenselink1, Constantijn S Venema1
1Department of Cardiology University of Groningen, University Medical Center Groningen Groningen the Netherlands.
Insights
The GRACE score effectively predicts risk in ST-segment-elevation myocardial infarction (STEMI) with single-vessel disease but is less reliable for multivessel disease. This highlights the score's variable utility based on coronary anatomy after STEMI.
Area of Science:
- Cardiology
- Clinical Risk Stratification
- Acute Coronary Syndromes
Background:
- The GRACE score is validated for non-ST-segment-elevation myocardial infarction but less established for ST-segment-elevation myocardial infarction (STEMI).
- Prognostic performance of the GRACE score in STEMI, considering coronary disease extent, requires further evaluation.
Purpose of the Study:
- To assess the prognostic performance of the GRACE score in a STEMI cohort.
- To evaluate the GRACE score's utility relative to coronary disease burden in STEMI patients.
Main Methods:
- A cohort of 1099 STEMI patients from the CardioLines Coronary Biobank (2015-2021) with evaluable GRACE scores and follow-up data was analyzed.
- Patients were stratified by the number of coronary vessels with significant stenosis.
- Primary endpoint: 1-year all-cause death. Secondary endpoint: 1-year composite of death, recurrent ACS, stroke, or revascularization.
Main Results:
- GRACE scores positively correlated with the number of diseased vessels (P<0.001).
- Each 10-point GRACE score increase correlated with higher 1-year risks: 31% for all-cause death and 14% for the composite endpoint.
- Discrimination for all-cause death was excellent early in single-vessel disease (AUC 0.874 at 30 days) but poor in 3-vessel disease (AUC 0.52-0.57).
- Discrimination was significantly better in single-vessel versus multivessel disease early on, with differences diminishing by 1 year.
Conclusions:
- The GRACE score effectively stratifies risk in STEMI patients with single-vessel disease.
- The GRACE score demonstrates poor prognostic performance in STEMI patients with multivessel disease.
- Prognostic utility of the GRACE score varies with coronary anatomic burden post-STEMI, necessitating caution in its application across different STEMI subgroups.
Background:
The GRACE (Global Registry of Acute Coronary Events) score is well validated for risk stratification in non-ST-segment-elevation myocardial infarction, but less well established in ST-segment-elevation myocardial infarction (STEMI), particularly relative to coronary disease burden. We therefore assessed its prognostic performance in a STEMI cohort, accounting for baseline coronary disease extent.
Methods:
We studied 1099 patients with STEMI from the CardioLines Coronary Biobank (2015-2021) with evaluable GRACE score and follow-up data. Patients were stratified by the number of coronary vessels with significant stenosis. The primary end point was all-cause death at 1 year; the secondary end point was a combined end point, including all-cause death, recurrent acute coronary syndrome, stroke, and revascularization at 1 year.
Results:
Mean GRACE scores increased with the number of diseased vessels (P<0.001). In multivariable models, each 10-point increase in GRACE score was associated with a 31% higher risk of all-cause death and a 14% higher risk of the combined end point at 1 year. In single-vessel disease, discrimination for all-cause death was excellent early (30-day area under the curve, 0.874 [95% CI, 0.755-0.991]) and moderate at 1 year (area under the curve, 0.77 [95% CI, 0.613-0.927]), but consistently poor in 3-vessel disease (area under the curve, 0.52-0.57). Discrimination was significantly higher in single- versus multivessel disease at earlier time points, with differences attenuated by 1 year. Stratified regression analyses confirmed stronger associations in single-vessel versus multivessel disease.
Conclusions:
In this contemporary STEMI cohort, the GRACE score effectively stratifies event risk in single-vessel but performs poorly in multivessel disease. These findings suggest variable prognostic utility of the GRACE score across anatomic disease burden post-STEMI and caution when applying it across STEMI subgroups.
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