Predictors of one-year mortality at hospital discharge after acute coronary syndromes: A new risk score from the EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients) study

Stuart Pocock, Héctor Bueno, Muriel Licour, Jesús Medina, Lin Zhang, Lieven Annemans, Nicholas Danchin, Yong Huo, Frans Van de Werf, Stuart Pocock, Héctor Bueno, Muriel Licour, Jesús Medina, Lin Zhang, Lieven Annemans, Nicholas Danchin, Yong Huo, Frans Van de Werf

Abstract

Aims: A reliable prediction tool is needed to identify acute coronary syndrome (ACS) patients with high mortality risk after their initial hospitalization.

Methods: EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients: NCT01171404) is a prospective cohort study of 10,568 consecutive hospital survivors after an ACS event (4943 ST-segment elevation myocardial infarction (STEMI) and 5625 non-ST-elevation ACS (NSTE-ACS)). Of these cases, 65.1% underwent percutaneous coronary intervention (PCI) and 2.5% coronary artery bypass graft (CABG). Post-discharge mortality was recorded for up to two years. From over 50 potential predictor variables a new risk score for one-year mortality was developed using forward stepwise Cox regression, and examined for goodness-of-fit, discriminatory power, and external validation.

Results: A total of 407 patients (3.9%) died within one year of discharge. We identified 12 highly significant independent predictors of mortality (in order of predictive strength): age, lower ejection fraction, poorer EQ-5D quality of life, elevated serum creatinine, in-hospital cardiac complications, chronic obstructive pulmonary disease, elevated blood glucose, male gender, no PCI/CABG after NSTE-ACS, low hemoglobin, peripheral artery disease, on diuretics at discharge. When combined into a new risk score excellent discrimination was achieved (c-statistic=0.81) and this was also validated on a large similar cohort (9907 patients) in Asia (c=0.78). For both STEMI and NSTE-ACS there was a steep gradient in one-year mortality ranging from 0.5% in the lowest quintile to 18.2% in the highest decile. NSTE-ACS contributes over twice as many high-risk patients as STEMI.

Conclusions: Post-discharge mortality for ACS patients remains of concern. Our new user-friendly risk score available on www.acsrisk.org can readily identify who is at high risk.

Keywords: Acute coronary syndrome; hospital discharge; mortality; prognostic model; risk score.

Conflict of interest statement

Conflict of interest: S Pocock has received research funding from AstraZeneca; H Bueno has received advisory/consulting fees from AstraZeneca, Bayer, BMS, Daichii-Sankyo, Eli-Lilly, Novartis, Pfizer, Sanofi, and Roche, and grants from AstraZeneca; M Licour, J Medina, and L Zhang are employees of AstraZeneca; L Annemans has received consulting and lecture fees from AstraZeneca; N Danchin has received consulting or speaking fees from AstraZeneca, BMS, Boehringer-Ingelheim, GSK, MSD-Schering Plough, Novartis, Pierre Fabre, Pfizer, Roche, Sanofi-Aventis, Servier, Takeda, and The Medicines Company; Y Huo has nothing to disclose; F Van de Werf has received consulting fees and research grants from Boehringer Ingelheim and Merck, and consulting fees from Roche, Sanofi-Aventis, AstraZeneca, and The Medicines Company.

© The European Society of Cardiology 2014.

Figures

Figure 1.
Figure 1.
Mortality hazard ratios for each variable in the predictive model. CABG: coronary artery bypass graft; CI: confidence interval; COPD: chronic obstructive pulmonary disease; NSTE-ACS: non-ST-elevation acute coronary syndrome; PCI: percutaneous coronary intervention; STEMI: ST segment elevation myocardial infarction.
Figure 2.
Figure 2.
Risk score distribution (and predicted mortality risk).
Figure 3.
Figure 3.
Cumulative mortality in six risk groups. Risk groups 1–4 correspond to quintiles 1–4, with the fifth quintile subdivided into two deciles (risk groups 5 and 6).
Figure 4.
Figure 4.
Assessment of risk discrimination and model goodness-of-fit in six groups from low to very high risk (a) In original EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients) study and (b) In EPICOR Asia (validation cohort). For both plots, risk groups 1–4 correspond to quintiles 1–4, with the fifth quintile subdivided into two deciles (risk groups 5 and 6).

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