TY - JOUR
T1 - External validation of the GRACE risk score and the risk-treatment paradox in patients with acute coronary syndrome
AU - van der Sangen, Niels M. R.
AU - Azzahhafi, Jaouad
AU - Chan Pin Yin, Dean R. P. P.
AU - Peper, Joyce
AU - Rayhi, Senna
AU - Walhout, Ronald J.
AU - Tjon Joe Gin, Melvyn
AU - Nicastia, Deborah M.
AU - Langerveld, Jorina
AU - Vlachojannis, Georgios J.
AU - van Bommel, Rutger J.
AU - Appelman, Yolande
AU - Henriques, José P. S.
AU - ten Berg, Jurriën M.
AU - Kikkert, Wouter J.
N1 - Funding Information: Dr Wouter J Kikkert has received a research grant from AstraZeneca. Dr Georgios J Vlachojannis has research grants from MicroPort and Ferrer and personal fees from Terumo and AstraZeneca. Dr Yolande Appelman has received a research grant from the Dutch Heart Foundation. Professor Dr José PS Henriques has received research grants from Abbott Vascular, AstraZeneca, B. Braun, Getinge, Ferrer, Infraredx and ZonMw. Professor Dr Jurriën M ten Berg has received research grants from AstraZeneca and ZonMw and personal fees from AstraZeneca, Accu-Metrics, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, Ferrer, Idorsia, Pfizer and The Medicines Company. All other authors have no relationships with industry to disclose. Funding Information: The FORCE-ACS registry is supported by grants from ZonMw, the St. Antonius Research Fund and AstraZeneca. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the manuscript and its final contents. Publisher Copyright: © Author(s) (or their employer(s)) 2022.
PY - 2022/3/1
Y1 - 2022/3/1
N2 - Objectives To validate the Global Registry of Acute Coronary Events (GRACE) risk score and examine the extent and impact of the risk-treatment paradox in contemporary patients with acute coronary syndrome (ACS). Methods Data from 5015 patients with ACS enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used for model validation. The performance of the GRACE risk score for predicting in-hospital and 1-year mortality was evaluated based on indices of model discrimination and calibration. Differences in the delivery of guideline-recommended care among patients who survived hospitalisation (n=4911) per GRACE risk stratum were assessed and the association with postdischarge mortality was examined. Results Discriminative power of the GRACE risk score was good for predicting in-hospital (c-statistic: 0.86; 95% CI: 0.83 to 0.90) and 1-year mortality (c-statistic: 0.82; 95% CI: 0.79 to 0.84). However, the GRACE risk score overestimated the absolute in-hospital and 1-year mortality risk (Hosmer-Lemeshow goodness-of-fit test p<0.01). Intermediate-risk and high-risk patients were 12% and 29% less likely to receive optimal guideline-recommended care compared with low-risk patients, respectively. Optimal guideline-recommended care was associated with lower mortality in intermediate- and high-risk patients. Conclusions The GRACE risk score identified patients at higher risk for in-hospital and 1-year mortality, but overestimated absolute risk levels in contemporary patients. Optimal guideline-recommended care was associated with lower mortality in intermediate-risk and high-risk patients, but was less likely to be delivered with increasing mortality risk.
AB - Objectives To validate the Global Registry of Acute Coronary Events (GRACE) risk score and examine the extent and impact of the risk-treatment paradox in contemporary patients with acute coronary syndrome (ACS). Methods Data from 5015 patients with ACS enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used for model validation. The performance of the GRACE risk score for predicting in-hospital and 1-year mortality was evaluated based on indices of model discrimination and calibration. Differences in the delivery of guideline-recommended care among patients who survived hospitalisation (n=4911) per GRACE risk stratum were assessed and the association with postdischarge mortality was examined. Results Discriminative power of the GRACE risk score was good for predicting in-hospital (c-statistic: 0.86; 95% CI: 0.83 to 0.90) and 1-year mortality (c-statistic: 0.82; 95% CI: 0.79 to 0.84). However, the GRACE risk score overestimated the absolute in-hospital and 1-year mortality risk (Hosmer-Lemeshow goodness-of-fit test p<0.01). Intermediate-risk and high-risk patients were 12% and 29% less likely to receive optimal guideline-recommended care compared with low-risk patients, respectively. Optimal guideline-recommended care was associated with lower mortality in intermediate- and high-risk patients. Conclusions The GRACE risk score identified patients at higher risk for in-hospital and 1-year mortality, but overestimated absolute risk levels in contemporary patients. Optimal guideline-recommended care was associated with lower mortality in intermediate-risk and high-risk patients, but was less likely to be delivered with increasing mortality risk.
KW - Acute coronary syndrome
KW - Clinical
KW - Myocardial infarction
KW - Pharmacology
UR - http://www.scopus.com/inward/record.url?scp=85134678712&partnerID=8YFLogxK
U2 - https://doi.org/10.1136/openhrt-2022-001984
DO - https://doi.org/10.1136/openhrt-2022-001984
M3 - Article
C2 - 35354660
SN - 2398-595X
VL - 9
JO - Open Heart
JF - Open Heart
IS - 1
M1 - e001984
ER -