Curriculum in CardiologyRisk scores in acute coronary syndrome and percutaneous coronary intervention: A review
Section snippets
Methods and search strategy
The literature review was conducted on PubMed and Medline using the following search terms: ‘risk score’, ‘acute coronary syndrome’, ‘percutaneous coronary intervention’, ‘mortality’, ‘myocardial infarction’, ‘major adverse cardiac events’. References for included studies were also searched and evaluated. For each risk score, the strengths and limitations of the original derivation study were assessed and evidence of external validation sought. The research was supported by the National
Risk scores in ACS
The GRACE and TIMI scores are the most popular and validated ACS prediction models. Their performances in other populations as well as against lesser known ACS risk scores are assessed. The characteristics of the derivation studies, with details of C-statistics in test and internal validation cohorts, are presented in Table I.
Novel biomarkers in ACS risk scores
In addition to clinical variables, novel biomarkers have been included to determine if they would augment the prognostic value of current ACS risk models. The most clinically relevant are the high-sensitivity troponin (hs-cTn) assays which are rapidly superseding conventional troponin assays for detecting ACS. Meune et al showed that calculating the GRACE score using hs-cTn instead of conventional troponin and the combination of the GRACE score with hs-cTn did not alter the accuracy of the
PCI risk scores
PCI risk models are not yet established in practice guidelines but have evolved rapidly with advancing technology, changing patient demographics and need for quality control. The models are presented as those predicting short term outcomes, in-patient mortality and major adverse cardiac events (MACE) and those predicting longer term outcomes (up to 5 years). Further details of derivation studies along with C-statistics in test and validation cohorts are included in Table II.
Michigan PCI risk score
The Michigan Risk Score31 was one of the earliest PCI prediction tools and included the following variables: acute MI (1 point), cardiogenic shock (2.5 points), creatinine level >1.5 mg/dL (1.5 point), history of cardiac arrest (1.5 points), number of diseased vessels (0.5 point), age ≥70 years (1.0 point), ejection fraction <50% (0.5 point), thrombus (0.5 point), peripheral vascular disease (PVD) (0.5 point) and female sex (0.5 point). Evaluation of the model in an independent cohort of 5216
PAMI risk score
The PAMI Risk Score was derived from amalgamated data from various PAMI trials to determine 6-month mortality following primary PCI (C statistics 0.78).44 The risk score comprised age >75 years (7 points), age 65–75 (3 points), Killip class >1 (2 points), HR >100 (2 points), diabetes mellitus (2 points), anterior myocardial infarction or left bundle branch block (2 points). Patients with cardiogenic shock, stroke over the last month, end stage renal failure, life expectancy <1 year from a
SYNTAX and Clinical SYNTAX scores
The SYNTAX score is a purely anatomical model designed for deciding on the optimal mode of revascularization in complex coronary artery disease (3-vessel disease and left main stem disease).50 It was validated in the SYNTAX trial51 which was composed mainly of stable angina patients. When applied to the ACUITY subgroup of 2627 NSTEMI patients treated with urgent PCI, the SYNTAX score was an independent predictor of 1-year mortality, cardiac death, AMI and target vessel revascularization on
Discussion
The GRACE and TIMI risk scores are recommended by contemporary guidelines with the former considered the most robust in evaluating risk of adverse outcomes in patients with ACS at initial presentation. Routine use of risk scores could improve decision making, especially with some data suggesting a “treatment-risk” paradox in current clinical practice.56 However, there are limited studies on how risk scores could actually inform best therapy. A randomized controlled trial investigating early
Conclusion
Risk scores in acute coronary syndrome have penetrated contemporary guidelines with the GRACE and TIMI models established in clinical practice. However, with evolving novel biomarkers and treatment options, these tools need to be re-evaluated. While being more suited for quality assurance purposes, risk prediction models following PCI can increase understanding of expected outcomes at the individual level. Current PCI risk models have demonstrated good discriminatory performance in predicting
Disclosures
None of the authors have any conflict of interest to disclose.
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2023, Cardiovascular Revascularization MedicineCitation Excerpt :These clinical risk factors may help to further refine criteria for safe, early discharge after STEMI. This analysis underscores the importance of optimal secondary prevention and follow up of patients with adverse prognostic features even in an apparent low to intermediate risk STEMI cohort [20,21]. Primary PCI has improved outcomes for STEMI patients through reduction in both morbidity and mortality.
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2022, AtherosclerosisCitation Excerpt :Myocardial revascularization procedures are the most performed procedures in cardiovascular medicine and optimal revascularization strategy is chosen with regards to the clinical risk-benefit ratio. Numerous clinical risk scores have been developed using traditional statistical analysis to estimate adverse events risk [18]. While some scores (e.g., ACEF score) were developed to evaluate risk in general and can be applied in a wide area of clinical scenarios, other models were developed to assess risk comparatively after PCI versus CABG (SYNTAX score II 2020) or after an ACS (GRACE or TIMI score) [1–3].
In-hospital adverse events in low-risk patients with acute myocardial infarction – Potential implications for earlier discharge
2022, Journal of CardiologyCitation Excerpt :Low, intermediate, and high risks were determined by the scores of 0-2, 3-5, and ≥6 (Online Table S1) [9]. The primary outcome of the present study was a composite of in-hospital major adverse events consisting of all-cause death, sustained ventricular arrhythmia (ventricular fibrillation and tachycardia), recurrent MI, heart failure requiring intravenous treatment (diuretic, vasodilator, and catecholamine), stroke, and major bleeding events (Bleeding Academic Research Consortium type 3 or 5), adjudicated with the consensus documents [18–20]. The timing (days after admission) of the first major adverse events during the hospitalization was evaluated across the low-, intermediate-, and high-risk groups.