A risk score to predict in-hospital mortality in patients with acute coronary syndrome at early medical contact: results from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) Project

Abstract

Background: A number of models have been built to evaluate risk in patients with acute coronary syndrome (ACS). However, accurate prediction of mortality at early medical contact is difficult. This study sought to develop and validate a risk score to predict in-hospital mortality among patients with ACS using variables available at early medical contact.

Methods: A total of 62,546 unselected ACS patients from 150 tertiary hospitals who were admitted between 2014 and 2017 and enrolled in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project, were randomly assigned (at a ratio of 7:3) to a training dataset (n=43,774) and a validation dataset (n=18,772). Based on the identified predictors which were available prior to any blood test, a new point-based risk score for in-hospital death, CCC-ACS score, was derived and validated. The CCC-ACS score was then compared with Global Registry of Acute Coronary Events (GRACE) risk score.

Results: The in-hospital mortality rate was 1.9% in both the training and validation datasets. The CCC-ACS score, a new point-based risk score, was developed to predict in-hospital mortality using 7 variables that were available before any blood test including age, systolic blood pressure, cardiac arrest, insulin-treated diabetes mellitus, history of heart failure, severe clinical conditions (acute heart failure or cardiogenic shock), and electrocardiographic ST-segment deviation. This new risk score had an area under the curve (AUC) of 0.84 (P=0.10 for Hosmer-Lemeshow goodness-of-fit test) in the training dataset and 0.85 (P=0.13 for Hosmer-Lemeshow goodness-of-fit test) in the validation dataset. The CCC-ACS score was comparable to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of in-hospital death in the validation dataset.

Conclusions: The newly developed CCC-ACS score, which utilizes factors that are acquirable at early medical contact, may be able to stratify the risk of in-hospital death in patients with ACS.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616.

Keywords: Acute coronary syndrome (ACS); early medical contact; in-hospital death; risk score.

Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-21-31). Dr. DQY and Dr. PR report grants from Guangzhou Science and Technology Innovation Commission, during the conduct of the study; Dr. GL and Dr. JQY reports grants from Sailing Foundation, during the conduct of the study. The other authors have no conflicts of interest to declare.

2021 Annals of Translational Medicine. All rights reserved.

Figures

Figure 1

Study flow chart. The enrolled study population was divided into a training dataset and a validation dataset. ACS, acute coronary syndrome. STEMI, ST-segment elevation myocardial infarction. NSTE-ACS, non–ST-segment elevation acute coronary syndromes.

Figure 2

Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome risk score (CCC-ACS score). SBP, systolic blood pressure. AHF, acute heart failure. CS, cardiogenic shock.

Figure 3

Calibration of Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome risk score (CCC-ACS score). (A) Calibration of CCC-ACS score in the training dataset. (B) Calibration of CCC-ACS score in the validation dataset. The diagonal line indicates perfect calibration.

Figure 4

Observed incidence of in-hospital death. Observed incidence of in-hospital death according to categories of the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome risk score (CCC-ACS score) in the training and validation datasets. low risk (score ≤12), moderate risk (score: 13–20), and high risk (score ≥21).