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.; Dabbous, O.; Goldberg, Robert J.; Pieper, Karen S.; Eagle, Kim A.; Werf, Frans Van de; Avezum, Álvaro; Goodman, Shaun G.; Flather, Marcus; Anderson, Frederick A.; Granger, Christopher B.

doi:10.1136/bmj.38985.646481.55

Cited by 1,347 publications

(1,078 citation statements)

References 29 publications

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“…In fact, a recent report from the GRACE (Global Registry of Acute Coronary Events) demonstrated that ≈5% of patients with ACS admission had died during the indexed hospitalization, and an additional 10% of patients experienced subsequent events, including death and MI within 6 months after discharge 19. In accordance with this previous report, the overall ACS admission was associated with an increased risk of long‐term mortality in our study.…”

Section: Discussionsupporting

confidence: 91%

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

Inohara

Kohsaka

Matsubara

et al. 2017

JAHA

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BackgroundWhereas composite end points are often used in clinical trials of percutaneous coronary interventions (PCI), the impact of individual components on subsequent survival is incompletely defined. We evaluated the association of subsequent acute coronary syndromes (ACS) and unplanned coronary revascularization post‐PCI with long‐term survival.Methods and ResultsFrom 2009 to 2011, the KiCS‐PCI (Keio interhospital Cardiovascular Studies) consecutively enrolled patients undergoing PCI in 14 Japanese teaching hospitals. We identified patients who experienced ACS or unplanned coronary revascularization following their index PCI and compared subsequent survival during the 2‐year follow‐up period using propensity‐matched cohorts of patients who did and did not experience these events. Cox proportional hazard models were used to assess 2‐year all‐cause mortality. Because unstable angina is less severe than acute myocardial infarction, we also generated a separate propensity‐matched cohort for UA post‐PCI. Among 3348 PCI patients (mean age, 67.5±10.7 years; 79.7% male), 214 (6.4%) experienced a subsequent ACS (168 events [78.5%] were unstable angina), and 198 (5.9%) underwent unplanned revascularization. In the propensity‐matched cohorts, patients with a subsequent ACS admission had an increased risk of mortality as compared with those without (hazard ratio, 4.73; 95% confidence interval=1.35–16.6; P=0.015), whereas those with an unplanned revascularization did not have significantly higher risk (hazard ratio, 2.97; 95% confidence interval=0.57–14.3; P=0.19). Among unstable angina events, no association with mortality was observed (hazard ratio, 1.39; 95% confidence interval=0.48–4.00; P=0.54).ConclusionsIn the KiCS‐PCI registry, the incidence of a subsequent ACS was associated with higher mortality, but this association was less apparent after unplanned coronary revascularization or unstable angina. The prognostic implications of different outcomes in a composite end point should be considered when interpreting the results of clinical trials in PCI.

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Section: Discussionsupporting

confidence: 91%

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

Inohara

Kohsaka

Matsubara

et al. 2017

JAHA

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“…Finally, we evaluated whether FI is a predictor of 6‐month all‐cause and cardiac‐specific mortality. Multivariable logistic regression models were used to estimate the marginal effect of FI separately by MI type (NSTEMI and STEMI) after adjusting for sex and GRACE (Global Registry of Acute Coronary Events) risk score 13, 14. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported per 0.1 FI.…”

Section: Methodsmentioning

confidence: 99%

Frailty and Outcomes After Myocardial Infarction: Insights From the CONCORDANCE Registry

Patel

Goodman

Yan

et al. 2018

JAHA

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BackgroundLittle is known about the prognostic implications of frailty, a state of susceptibility to stressors and poor recovery to homeostasis in older people, after myocardial infarction (MI).Methods and ResultsWe studied 3944 MI patients aged ≥65 years treated at 41 Australian hospitals from 2009 to 2016 in the CONCORDANCE (Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events) registry. Frailty index (FI) was determined using the health deficit accumulation method. All‐cause and cardiac‐specific mortality at 6 months were compared between frail (FI >0.25) and nonfrail (FI ≤0.25) patients. Among 1275 patients with ST‐segment–elevation MI (STEMI), 192 (15%) were frail, and among 2669 non‐STEMI (NSTEMI) patients, 902 (34%) were frail. Compared with nonfrail counterparts, frail STEMI patients received 30% less reperfusion therapy and 22% less revascularization during index hospitalization; frail NSTEMI patients received 30% less diagnostic angiography and 39% less revascularization. Unadjusted 6‐month all‐cause mortality (STEMI: 13% versus 3%; NSTEMI: 13% versus 4%) and cardiac‐specific mortality (STEMI: 6% versus 1.4%, NSTEMI: 3.2% versus 1.2%) were higher among frail patients. After adjustment for known prognosticators, FI was significantly associated with higher 6‐month all‐cause (STEMI: odds ratio: 1.74 per 0.1 FI [95% confidence interval, 1.37–2.22], P<0.001; NSTEMI: odds ratio: 1.62 per 0.1 FI [95% confidence interval, 1.40–1.87], P<0.001) but not cardiac‐specific mortality (STEMI: P=0.99; NSTEMI: P=0.93).ConclusionsFrail patients receive lower rates of invasive cardiac care during MI hospitalization. Increased frailty was independently associated with increased postdischarge all‐cause mortality but not cardiac‐specific mortality. These findings inform identification of frailty during MI hospitalization as a potential opportunity to address competing risks for mortality in this high‐risk population.

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“…We excluded patients with: ST‐segment elevation of ≥1 mm in 2 contiguous leads on the presenting ECG; any significant rise in cardiac troponin (>9th percentile); pretest probability <15%; Global Registry of Acute Coronary Events (GRACE) score >1408 known CAD or awaiting revascularization; history and clinical examination suggesting non‐cardiac chest pain; abnormal resting echocardiography and/or chest X‐ray; hemoglobin <13 g/dL; or thyroid disorder. No sex‐based or race/ethnicity‐based differences were addressed.…”

Section: Methodsmentioning

confidence: 99%

Specific Pharmacological Profile of A _2A Adenosine Receptor Predicts Reduced Fractional Flow Reserve in Patients With Suspected Coronary Artery Disease

Paganelli

Resseguier

Marlinge

et al. 2018

JAHA

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BackgroundThe rapid and reliable exclusion of myocardial revascularization is a major unmet clinical need in patients with suspected coronary artery disease (CAD) and non‐contributive electrocardiography and troponin. Non‐invasive tests have high rates of false positives and negatives, and there is no biomarker to assess myocardial ischemia. The presence of spare adenosine A2A receptors (A2 AR)—characterized by a high dissociation constant/half maximal effective concentration (KD/EC 50) ratio—expressed on peripheral blood mononuclear cells (PBMC) has been associated with ischemia during exercise stress testing in patients with CAD. In this work, we investigated the diagnostic accuracy of spare A2 AR versus fractional flow reserve (FFR) in patients with suspected CAD.Methods and ResultsSixty patients with suspected CAD, but non‐contributive electrocardiography and troponin, were consecutively enrolled in this prospective study. The binding (KD), functional response (cyclic adenosine monophosphate [cAMP] production; EC 50) on PBMC A2 AR were compared with FFR results. Patients were divided into 3 groups: 17 (group 1) with normal coronary angiography (n=13) or stenosis <20% (n=4); 21 with CAD and non‐significant FFR (group 2); and 22 with CAD and significant FFR (group 3). Median KD/EC 50 was 6‐fold higher in group 3 (4.20; interquartile range: 2.81–5.00) than group 2 (0.66; interquartile range: 0.47–1.25) and 7‐fold higher than group 1 (0.60; interquartile range: 0.30–0.66).ConclusionsIn patients with suspected CAD and non‐contributive electrocardiography and troponin, the absence of spare A2 AR on PBMC may help to rule out myocardial ischemia.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03218007.

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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.

Cited by 1,347 publications

References 29 publications

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

Frailty and Outcomes After Myocardial Infarction: Insights From the CONCORDANCE Registry

Specific Pharmacological Profile of A _2A Adenosine Receptor Predicts Reduced Fractional Flow Reserve in Patients With Suspected Coronary Artery Disease

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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.

Cited by 1,347 publications

References 29 publications

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

Prognostic Impact of Subsequent Acute Coronary Syndrome and Unplanned Revascularization on Long‐Term Mortality After an Index Percutaneous Coronary Intervention: A Report From a Japanese Multicenter Registry

Frailty and Outcomes After Myocardial Infarction: Insights From the CONCORDANCE Registry

Specific Pharmacological Profile of A 2A Adenosine Receptor Predicts Reduced Fractional Flow Reserve in Patients With Suspected Coronary Artery Disease

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Specific Pharmacological Profile of A _2A Adenosine Receptor Predicts Reduced Fractional Flow Reserve in Patients With Suspected Coronary Artery Disease