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.

Conflict of interest statement

Competing interests: KAAF has received grant funding from the British Heart Foundation and his department is supported by the British Heart Foundation, Medical Research Council, Wellcome Trust, Sanofi-Aventis, Bristol-Myers Squibb, and MSD. KAE has received grants from Biosite, Bristol-Myers Squibb, Cardiac Sciences, Blue Cross Blue Shield of Michigan, Hewlett Foundation, Mardigian Fund, Sanofi-Aventis, Varbedian Fund, National Heart, Lung and Blood NIH, and Pfizer. FVdeW has received research grants from Boehringer Ingelheim, Sanofi-Aventis, Proctor and Gamble, Servier, Novartis, MSD, and Schering Plough. ÁA has received funding from Sanofi-Aventis, Population Health Research Institute, and Boehringer Ingelheim. SGG has received funding from AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, Hoffmann-LaRoche Pharmaceuticals, Merck, Novartis, Pfizer, Sanofi-Synthelabo, Schering Corp, and Millennium Pharmaceuticals. MDF, FAA, CBG, and BK have all received funding from Sanofi-Aventis.

Figures

Fig 1 GRACE study profile (derivation set of patients)

Fig 2 Overall risk of death in hospital, from hospital admission to six months after discharge (patients separated into unstable angina, non-ST segment elevation myocardial infarction, and ST segment elevation myocardial infarction), and from hospital discharge to six months

Fig 3 GRACE risk calculator for death or myocardial infarction from admission to hospital to six months after discharge with the simplified model (www.outcomes.org/grace)