Dataset Information

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).

ABSTRACT:

Objective

To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome.

Design

Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation.

Setting

Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand.

Population

43,810 patients (21,688 in derivation set; 22,122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005.

Main outcome measures

Death and myocardial infarction.

Results

1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries).

Conclusions

This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.

SUBMITTER: Fox KA

PROVIDER: S-EPMC1661748 | biostudies-literature | 2006 Nov

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).

Fox Keith A A KA Dabbous Omar H OH Goldberg Robert J RJ Pieper Karen S KS Eagle Kim A KA Van de Werf Frans F Avezum Alvaro A Goodman Shaun G SG Flather Marcus D MD Anderson Frederick A FA Granger Christopher B CB

BMJ (Clinical research ed.) 20061010 7578

<h4>Objective</h4>To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome.<h4>Design</h4>Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation.<h4>Setting</h4>Ninety four hospitals in 14 countries in Europe, North and South America, Au ...[more]

PMID: 17032691

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Project description:BackgroundPercutaneous coronary intervention with placement of a drug-eluting stent in a diabetic patient with ST-elevation myocardial infarction is a relatively common procedure, and always requires subsequent treatment with dual antiplatelet therapy. It is sometimes necessary to add oral anticoagulation therapy because of individual clinical circumstances, which further increases the risk of bleeding.Case presentationA 66-year-old hypertensive diabetic man with a history of gastrointestinal bleeding was admitted with an ST-elevation inferior myocardial infarction that had been evolving over 72 h. Electrocardiography showed ST segment elevation in the inferior leads and Q waves in the inferior and anterior leads. He reported a similar episode of chest pain 1 month previously, for which he had not sought medical treatment. Coronary angiography showed chronic occlusion of the mid-left anterior descending coronary artery, and acute occlusion of the mid-right coronary artery. He was treated by percutaneous coronary intervention, with placement of a drug-eluting stent in the right coronary artery. Soon after admission, transthoracic echocardiography showed abnormal left ventricular contractility and a large left intraventricular thrombus. Three weeks after admission, the patient was discharged on dual antiplatelet therapy (clopidogrel and aspirin) and oral anticoagulation therapy (acenocoumarol). Four months after discharge, transthoracic echocardiography showed absence of left ventricular thrombus and resolution of the abnormal contractility in the area supplied by the revascularized right coronary artery. Given the high risk of bleeding, oral anticoagulation therapy was stopped. Six months later, transthoracic echocardiography showed recurrent left ventricular apical thrombus, and an underlying hypercoagulable state was ruled out. Oral anticoagulation therapy was restarted on an indefinite basis, and dual antiplatelet therapy was continued.ConclusionsThe present case illustrates the need for repeat transthoracic echocardiography following the withdrawal of oral anticoagulation therapy in patients with ST-elevation myocardial infarction, both to monitor thrombus status and to assess left ventricular segmental contraction. In patients who require anticoagulation, avoidance of a drug-eluting stent is strongly preferred and second-generation stents are recommended. The alternative regimen of oral anticoagulation and clopidogrel may be considered in this scenario. In patients with recurrent intraventricular thrombus an underlying hypercoagulable state should be ruled out.

Project description:BACKGROUND:Risk prediction after myocardial infarction is often complex in older patients. The Global Registry of Acute Coronary Events (GRACE) model includes clinical parameters and age, but not frailty. We hypothesised that frailty would enhance the prognostic properties of GRACE. METHODS:We performed a prospective observational cohort study in two independent cardiology units: the Royal Infirmary of Edinburgh, UK (primary cohort) and the South Yorkshire Cardiothoracic Centre, Sheffield, UK (external validation). The study sample included 198 patients ?65?years old hospitalised with type 1 myocardial infarction (primary cohort) and 96 patients ?65?years old undergoing cardiac catheterisation for myocardial infarction (external validation). Frailty was assessed using the Clinical Frailty Scale (CFS). The GRACE 2.0 estimated risk of 12-month mortality, Charlson comorbidity index and Karnofsky disability scale were also determined for each patient. RESULTS:Forty (20%) patients were frail (CFS ?5). These individuals had greater comorbidity, functional impairment and a higher risk of death at 12?months (49% vs. 9% in non-frail patients, p?<?0.001). The hazard of 12-month all-cause mortality nearly doubled per point increase in CFS after adjustment for age, sex and comorbidity (Hazard Ratio [HR] 1.90, 95% CI 1.47-2.44, p?<?0.001). The CFS had good discrimination for mortality by Receiver Operating Characteristic (ROC) curve analysis (Area Under the Curve [AUC] 0.81, 95% CI 0.72-0.89) and enhanced the GRACE estimate (AUC 0.86 vs. 0.80 without CFS, p?=?0.04). At existing GRACE thresholds, the CFS resulted in a Net Reclassification Improvement (NRI) of 0.44 (95% CI 0.28-0.60, p?<?0.001), largely through reductions in risk estimates amongst non-frail patients. Similar findings were observed in the external validation cohort (NRI 0.46, 95% CI 0.23-0.69, p?<?0.001). CONCLUSIONS:The GRACE score overestimated mortality risk after myocardial infarction in these cohorts of older patients. The CFS is a simple guided frailty tool that may enhance prediction in this setting. These findings merit evaluation in larger cohorts of unselected patients. TRIAL REGISTRATION:Clinicaltrials.gov; NCT02302014 (November 26th 2014, retrospectively registered).

Dataset Information

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).

Objective

Design

Setting

Population

Main outcome measures

Results

Conclusions

Publications

Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).

Similar Datasets

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