GRACE score for risk stratification and completeness of revascularization in older patients with myocardial
Luigi Spadafora1,2, Marco Bernardi1,2, Giuseppe Biondi-Zoccai1,3
1Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome.
Insights
The GRACE score predicts adverse outcomes in older patients with myocardial infarction (MI). Complete revascularization benefits patients across all GRACE scores, indicating it should not be withheld based on score alone.
Area of Science:
- Cardiology
- Geriatric Medicine
- Clinical Trials
Background:
- The GRACE score predicts mortality in myocardial infarction (MI) patients.
- Its role and interaction with revascularization in older MI patients are unclear.
Purpose of the Study:
- Assess GRACE score's predictive value for adverse events in older MI patients from the FIRE trial.
- Determine if complete revascularization benefits are consistent across GRACE score spectrums.
Main Methods:
- Subanalysis of 1445 patients (≥75 years) with MI and multivessel coronary artery disease from the FIRE trial.
- Patients stratified by GRACE score tertiles; primary endpoint: 1-year all-cause mortality.
- Secondary endpoints: 1-year cardiovascular death and composite of cardiovascular death or MI.
Main Results:
- Higher GRACE score tertiles correlated with significantly increased 1-year all-cause mortality, cardiovascular death, and composite endpoints.
- The GRACE score independently predicted adverse outcomes (HRs >1, P <0.001 for all).
- No significant interaction found between revascularization strategy and GRACE score tertiles for any outcome (P >0.05).
Conclusions:
- The GRACE score accurately predicts adverse outcomes in elderly MI patients.
- Physiology-guided complete revascularization offers benefits across the GRACE score spectrum in this population.
- GRACE score alone should not be a barrier to complete revascularization in older MI patients.
Background:
The GRACE score is a well established tool for predicting mortality outcomes in patients with myocardial infarction (MI). However, its prognostic role and interaction with revascularization strategies in older patients with MI remain unclear. This study aimed to assess whether the GRACE score was predictive of adverse events in the FIRE trial cohort and whether the benefits of complete revascularization were consistent across the spectrum of the GRACE score.
Methods:
The FIRE trial randomized 1445 patients aged 75 years or older with MI and multivessel coronary artery disease to receive either culprit-only or complete revascularization. In this subanalysis, patients were stratified according to GRACE score tertiles: the first tertile (GRACE 92.6-128.0), the second tertile (GRACE 128.1-146.5), and the third tertile (GRACE 146.6-236.0). The primary endpoint was all-cause mortality at 1 year. Other key endpoints included cardiovascular death and a composite of cardiovascular death or MI at 1 year.
Results:
According to GRACE score tertiles, 487 patients were in the first tertile (33.7%), 477 in the second tertile (33.0%), and 481 in the third tertile (33.3%). Patients in the third tertile were more compromised in terms of cardiovascular risk factors and comorbidities. At 1 year, all-cause mortality was significantly higher in the third tertile (P < 0.0001), as well as cardiovascular death (P < 0.0001) and the composite of cardiovascular death or MI (P < 0.0001). However, the effect of physiology-guided revascularization did not differ across GRACE score tertiles (P for interaction > 0.05 for all the outcomes of interest). Survival analysis confirmed that the GRACE score was significantly associated with increased all-cause mortality [hazard ratio 1.027, 95% confidence interval (95% CI) 1.021-1.033, P < 0.001], cardiovascular death (hazard ratio 1.031, 95% CI 1.023-1.039, P < 0.001), and the composite of cardiovascular death or MI (hazard ratio 1.020, 95% CI 1.013-1.026, P < 0.001). Again, no interaction was found between revascularization strategy and GRACE score (all P for interaction > 0.05). The best discriminative value of the GRACE score for all-cause mortality at 1 year was 137.
Conclusion:
The GRACE score was confirmed to be predictive of adverse outcomes even in older MI patients. Physiology-guided complete revascularization was associated with benefit across the GRACE spectrum, suggesting that the GRACE score alone should not preclude this strategy in older patients with MI.
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