Background The Zwolle score is recommended to identify ST-segment elevation myocardial infarction (STEMI) patients with low-risk eligible for early discharge. Our aim was to ascertain if creatinine variation (Δ-sCr) would improve Zwolle score in the decision-making of early discharge after primary percutaneous coronary intervention (PCI). Methods and results A total of 3296 patients with STEMI that underwent primary PCI were gathered from the Portuguese Registry on Acute Coronary Syndromes. A Modified-Zwolle score, including Δ-sCr, was created and compared with the original Zwolle score. Δ-sCr was also compared between low (Zwolle score ≤3) and non-low-risk patients (Zwolle score >3). The primary endpoint is 30-day mortality and the secondary endpoints are in-hospital mortality and complications. Thirty-day mortality was 1.5% in low-risk patients (35 patients) and 9.2% in non-low-risk patients (92 patients). The Modified-Zwolle score had a better performance than the original Zwolle score in all endpoints: 30-day mortality (area under curve 0.853 versus 0.810, P < 0.001), in-hospital mortality (0.889 versus 0.845, P < 0.001) and complications (0.728 versus 0.719, P = 0.037). Reclassification of patients lead to a net reclassification improvement of 6.8%. Additionally, both original Zwolle score low-risk patients and non-low-risk patients who had a Δ-sCr ≥0.3 mg/dl had higher 30-day mortality (low-risk: 1% versus 6.6%, P < 0.001; non-low-risk 4.4% versus 20.7%, P < 0.001), in-hospital mortality and complications. Conclusion Δ-sCr enhanced the performance of Zwolle score and was associated with higher 30-day mortality, in-hospital mortality and complications in low and non-low-risk patients. This data may assist the selection of low-risk patients who will safely benefit from early discharge after STEMI.

Introduction The Zwolle score (ZS) is recommended to identify low-risk patients eligible for early discharge after acute ST-segment elevation myocardial infarction (STEMI), but as only one-third of STEMIs have a low ZS, the discharge is often postponed. Creatinine variation (Δ-Cr) also provide prognostic information after STEMI. Purpose The authors intend to study the “modified Zwolle Score” (MZS) model, which encompasses Δ-Cr as a variable that may enhance the discriminative power of the standard ZS. The outcome is 30-day mortality, time range that starts right after the ACS. Methods This is a retrospective study with data from a national multicentre registry. We have included 3.296 patients with STEMI. Zwolle score was calculated for each patient. It is defined as shown in figure 1. Δ-Cr was defined as maximum serum creatinine minus admission serum creatinine. A Δ-Cr≥0.3 was assigned 2 points in the Modified Zwolle Score, after interpretation of odds ratio via multivariate analysis. For prediction quality assessment, we have performed ROC curve analysis with both scoring systems versus 30-day mortality. Regarding survival analysis, we have performed Kaplan-Meier curves with Log-rank analysis. We have also registered complications during hospital stay. Results The sample mean age is 63±14, and it is composed by 76.8% of males. The majority of patients presented Killip Class I (87.3%). The STEMI was anterior in 49.7% of patients and inferior in 49.8% of patients. The mean admission time was 5 days. Intrahospital mortality was 3% and 30-day mortality was 4%. The mean ZS was 3.1±2.8 points, the mean MZS was 3±2.1 points and the mean Δ-Cr was 0.2±0.6mg/dL. The ROC curve analysis between ZS and early mortality revealed a c-statistic of 0.810 (CI 0.796–0.823), whereas the ROC curve between MZS and early mortality revealed a c-statistic of 0.853 (95% CI: 0.841–0.865). The ROC curves comparison showed superiority of the MZS c-statistic, with a difference between AUC of 0.043 (p&lt;0.001, 95% CI: 0.024–0.063). Regarding low-risk patients, 30-day mortality was 3.3% using ZS (0–2 points) and 2.4% using modified ZS (0–2 points). Fifty patients (1.5%) died between 3rd and 10th day after ACS: original ZS low-risk criteria registered 0.09% and modified ZS low-risk criteria 0.06% fatalities. Kappa coefficient for intergroup concordance was good (0.73). Conclusion We conclude that by adding Δ-Cr to the standard ZS, a renal function parameter that was lacking in the ZS, its predicting capacity regarding early mortality in patients admitted with STEMI was increased. Comparing both scores, low-risk patients defined by MZS registered less complications, 3–10 day mortality and 30-day mortality than low-risk patients defined by the original ZS. This fact may lead to better distinction of patients who will benefit from early discharge. Zwolle Score, ROC curves and survival Funding Acknowledgement Type of funding source: None

Individuals affected by Prader-Willi syndrome (PWS) may show increased risk for coronary artery disease (CAD), which probably relates, at least, with high burden of cardiovascular risk factors.A 27-year-old man with PWS, obesity, hypertension, diabetes mellitus and dyslipidaemia attended the emergency department with complaints of flu-like condition and chest pain. The ECG revealed a mild ST-segment elevation in inferior leads, followed by positive myocardial necrosis biomarkers. Attending to the high cardiovascular risk profile, ST-segment elevation in inferior territory and wall motion abnormalities, a coronary angiogram was performed. The latter showed a three-vessel CAD, 60% stenosis in midanterior descending artery, total occlusion (100%) of the obtuse marginal artery and 99% stenosis with high thrombi burden in the proximal right coronary artery.The present case report emphasises the plausibility of premature CAD in patients with PWS, a possible underdiagnosed feature of this condition.

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