Curriculum in Cardiology
Risk scores in acute coronary syndrome and percutaneous coronary intervention: A review

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Patients with acute coronary syndrome (ACS) need to be risk stratified to deliver the most appropriate therapy. The GRACE and TIMI risk scores have penetrated contemporary guidelines with the former most commonly used in clinical practice. However, ACS prediction models need to be re-evaluated in contemporary practice with evolving diagnostic and treatment options. Moreover, the increased availability of percutaneous coronary intervention (PCI) as a treatment option for ACS combined with an expanding case mix and emphasis on quality control have triggered the creation of PCI specific prognostic models. These allow clinicians and patients to have an understanding of expected outcomes following PCI by predicting outcomes in-hospital to 5 years following intervention. The aim of this review is to evaluate the most recognized and studied ACS/PCI risk models, focusing on their strengths and limitations, and to assess the need for more robust tools to predict outcomes in a period of constantly advancing technologies and changing patient demographics.

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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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