Adjustment of the GRACE score by HemoglobinA1c enables a more accurate prediction of long-term major adverse cardiac events in acute coronary syndrome without diabetes undergoing percutaneous coronary intervention.

BACKGROUND: The Global Registry of Acute Coronary Events (GRACE) risk score is widely recommended for risk assessment in patients with acute coronary syndrome (ACS). Chronic hyperglycemia [hemoglobinA1c (HbA1c)] can independently predict major adverse cardiac events (MACEs) in patients with ACS. We investigated whether the prediction of MACEs with the GRACE score could be improved with the addition of HbA1c content in ACS patients without diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI). METHODS: We enrolled 549 ACS patients without DM who underwent PCI. The GRACE score and HbA1c content were determined on admission. Correlation was analyzed by Spearman's rank correlation. Cumulative MACE curve was calculated using the Kaplan-Meier method. Multivariate Cox regression was used to identify predictors of MACEs. Additionally, the predictive value of HbA1c content alone and combined with GRACE score was estimated by the area under the receiver-operating characteristic curve (AUC), continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS: During a median of 42.3 months (interquartile range 39.3-44.2 months), 16 (2.9%) were lost to follow-up, and patients experienced 69 (12.9%) MACEs: 51 (9.6%) all-cause deaths and 18 (3.4%) nonfatal myocardial infarction cases. The GRACE score was positively associated with HbA1c content. Multivariate Cox analysis showed that both GRACE score and HbA1c content were independent predictors of MACEs (hazard ratio 1.030; 95% CI 1.020-1.040; p < 0.001; 3.530; 95% CI 1.927-6.466; p < 0.001, respectively). Furthermore, Kaplan-Meier analysis demonstrated increased risk of MACEs with increasing HbA1c content (log-rank 33.906, p < 0.001). Adjustment of the GRACE risk estimate by HbA1c improved the predictive value of the GRACE score [increase in AUC from 0.75 for the GRACE score to 0.80 for the GRACE score plus HbA1c, p = 0.012; IDI = 0.055, p < 0.001; NRI (>0) = 0.70, p < 0.001]. CONCLUSIONS: HbA1c content is positively associated with GRACE risk score and their combination further improved the risk stratification for ACS patients without DM undergoing PCI.

Combination of mean platelet volume and the GRACE risk score better predicts future cardiovascular events in patients with acute coronary syndrome.

Both the Global Registry of Acute Coronary Events (GRACE) risk score and mean platelet volume (MPV) can independently predict adverse cardiovascular disease (CVD) events in patients with acute coronary syndrome (ACS). This study was aimed at investigating whether MPV was related to the GRACE risk score and whether the combination of them could have a better performance in predicting CVD in Patients with ACS. Totally 297 ACS patients were included. MPV was measured on admission. The GRACE risk score was calculated and its predictive value alone and together with MPV was assessed, respectively. During a median period of 52 months (range, 6 to 65), 11 of the 297 subjects (3.7%) were lost to follow-up, and 132 (46.2%) had adverse CVD including 32 deaths. Both MPV and the GRACE score were higher in patients with CVD events than those without events, and the GRACE score increased with the increase of MPV. Multivariate Cox analysis demonstrated that both MPV and the GRACE score were significant and independent predictors for CVD events (HR: 1.13; 95% CI: 1.10 to 1.15; p = 0.006; HR: 1.30; 95% CI: 1.24 to 1.37; p < 0.001; respectively). The area under the ROC curve was 0.70 (95% CI: 0.64 to 0.76, p < 0.001) when the GRACE score was calculated alone, whereas it increased to 0.85 (95% CI: 0.81 to 0.90, p < 0.001) with the addition of MPV, indicating that the combination of MPV with the scoring system improved the predictive value. This study demonstrates for the first time that MPV is positively associated with the GRACE risk score and it may complement the scoring system in predicting CVD events in patients with ACS.

Biomarkers enhance the long-term predictive ability of the KAMIR risk score in Chinese patients with ST-elevation myocardial infarction.

BACKGROUND: The Global Registry of Acute Coronary Events (GRACE) score is recommended by current ST-elevation myocardial infarction (STEMI) guidelines. But it has inherent defects. The present study aimed to investigate the more compatible risk stratification for Chinese patients with STEMI and to determine whether the addition of biomarkers to the Korea Acute Myocardial Infarction Registry (KAMIR) score could enhance its predictive value for long-term outcomes. METHODS: A total of 1093 consecutive STEMI patients were included and followed up 48.2 months. Homocysteine, hypersensitive C-reactive protein (hs-CRP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were detected. The KAMIR score and the GRACE score were calculated. The performance between the KAMIR and the GRACE was compared. The predictive power of the KAMIR alone and combined with biomarkers were assessed by the receiver-operating characteristic (ROC) curve. RESULTS: The KAMIR demonstrated a better risk stratification and predictive ability than the GRACE (death: AUC = 0.802 vs. 0.721, P < 0.001; major adverse cardiovascular events (MACE): AUC = 0.683 vs. 0.656, P < 0.001). It showed that the biomarkers could independently predict death [homocysteine: HR = 1.019 (1.015-1.024), P < 0.001; hs-CRP: HR = 1.052 (1.000-1.104), P = 0.018; NT-pro BNP: HR = 1.142 (1.004-1.280), P = 0.021] and MACE [homocysteine: HR = 1.019 (1.015-1.024), P < 0.001; hs-CRP: HR = 1.012 (1.003-1.021), P = 0.020; NT-pro BNP: HR = 1.136 (1.104-1.168), P = 0.006]. When they were used in combination with the KAMIR, the area under the ROC curve (AUC) significantly increased for death [homocysteine: AUC = 0.802 vs. 0.890, Z = 5.982, P < 0.001; hs-CRP: AUC = 0.802 vs. 0.873, Z = 3.721, P < 0.001; NT-pro BNP: AUC = 0.802 vs. 0.871, Z = 2.187, P = 0.047; homocysteine, hs-CRP and NT-pro BNP: AUC = 0.802 vs. 0.940, Z = 6.177, P < 0.001] and MACE [homocysteine: AUC = 0.683 vs. 0.771, Z = 6.818, P < 0.001; hs-CRP: AUC = 0.683 vs. 0.712, Z = 2.022, P = 0.031; NT-pro BNP: AUC = 0.683 vs. 0.720, Z = 2.974, P = 0.003; homocysteine, hs-CRP and NT-pro BNP: AUC = 0.683 vs. 0.789, Z = 6.900, P < 0.001]. CONCLUSION: The KAMIR is better than the GRACE in risk stratification and prognosis prediction in Chinese STEMI patients. A combination of above-mentioned biomarkers can develop a more predominant prediction for long-term outcomes.