Valor prognóstico do Escore de Risco GRACE versus Escore de Risco TIMI em síndromes coronarianas agudas / Prognostic Value of GRACE Scores versus TIMI Score in acute coronary syndromes

FUNDAMENTO: Embora o Escore de Risco TIMI seja o mais utilizado em síndromes coronarianas agudas sem supradesnível do segmento ST (SCA), o Escore GRACE tem potencial superioridade prognóstica, pois foi criado a partir de um registro observacional, parte das variáveis são tratadas de forma semiquantitativa e a função renal é computada em seu cálculo. OBJETIVO: Testar a hipótese de que o Escore de Risco GRACE tem superior valor prognóstico hospitalar, comparado ao Escore TIMI em pacientes admitidos com SCA. MÉTODOS: Foram incluídos indivíduos com angina instável ou infarto do miocárdio sem supradesnível do segmento ST, consecutivamente internados em unidade coronariana entre agosto de 2007 e janeiro de 2009. RESULTADOS: Foram estudados 154 pacientes, idade 71 ± 13 anos, 56 por cento do gênero feminino, mediana do GRACE de 117 e mediana do TIMI de 3. Durante o período de internamento, a incidência de eventos foi 8,4 por cento (12 óbitos e 1 infarto não fatal). O teste de Hosmer-Lemeshow aplicado ao Escore GRACE apresentou χ2 de 5,3 (P = 0,72), enquanto Escore TIMI apresentou χ2 de 1,85 (P = 0,60). Desta forma, ambos os escores apresentaram boa calibração. Quanto à análise de discriminação, o Escore GRACE apresentou estatística-C de 0,91 (95 por cento IC = 0,86 - 0,97), significativamente superior à estatística-C de 0,69 do Escore TIMI (95 por cento IC = 0,55 - 0,84) - P = 0,02 para diferença entre os escores. CONCLUSÃO: Em relação à predição de eventos hospitalares em pacientes com SCA, o Escore GRACE tem superior capacidade prognóstica quando comparado ao Escore TIMI.

BACKGROUND: Although the TIMI score is the one most frequently used in acute coronary syndromes (ACS) without ST-segment elevation, the GRACE score has potential prognostic superiority, as it was created based on an observational registry, part of the variables is treated in a semi-quantitative form and renal function is taken into account in its calculation. OBJECTIVE: To test the hypothesis that the GRACE risk score has superior in-hospital prognostic value, when compared to the TIMI score in patients admitted with ACS. METHODS: Individuals with unstable angina or myocardial infarction without ST-segment elevation, consecutively admitted at the Coronary Unit between August 2007 and January 2009, were included in the study. RESULTS: A total of 154 patients aged 71 ± 13 years, of which 56 percent were females, with a GRACE median of 117 and a TIMI median of 3 were studied. During the hospitalization period, the incidence of events was 8.4 percent (12 deaths and 1 non-fatal infarction). The Hosmer-Lemeshow test applied to the GRACE score presented an χ2 of 5.3 (P = 0.72), whereas the TIMI score presented an χ2 of 1.85 (P = 0.60). Therefore, both scores presented good calibration. As for the analysis of discrimination, the GRACE score presented a C-statistics of 0.91 (95 percentCI= 0.86 - 0.97), significantly superior to the C-statistics of 0.69 of the TIMI score (95 percentCI = 0.55 - 0.84) - P = 0.02 for the difference between the scores. CONCLUSION: Regarding the prediction of hospital events in patients with ACS, the GRACE score has superior prognostic capacity when compared to the TIMI score.

Prognostic value of cytokines and chemokines in addition to the GRACE Score in non-ST-elevation acute coronary syndromes.

BACKGROUND: Increased cytokine and chemokine levels are associated with cardiovascular events in patients with non-ST-elevation acute coronary syndromes (ACS), but the incremental prognostic value of these inflammatory markers is not known. We determined if cytokine and chemokine assessment adds prognostic information to the GRACE Score in patients with ACS. METHODS: Five cytokines (interleukin (IL)-1beta, IL-6, IL-10, IL-12p70, and tumor necrosis factor (TNF)-alpha soluble receptor I), five chemokines (IL-8, CCL5, CXCL9, CCL2, and CXCL10) and C-reactive protein (CRP) were measured at admission of 87 patients admitted with ACS. RESULTS: During hospitalization, the incidence of cardiovascular events was 13% (7 deaths, 1 nonfatal acute myocardial infarction, and 3 refractory unstable angina). Individuals who developed events had significantly greater levels of CRP, IL-1beta, IL-12, TNF-alpha, IL-8, CXCL9 and CCL2, compared with those free of events. Thus, these markers were used to build an Inflammatory Score, by the input of one point for each of these variables above the 75th percentile. After adjustment for the GRACE Score, the Inflammatory Score independently predicted events (OR=1.80; 95% CI=1.12-1.88). Incorporation of the Inflammatory Score into the GRACE Score promoted a C-statistics improvement from 0.77 (95% CI=0.58-0.96) to 0.85 (95% CI=0.71-1.0). Net reclassification improvement obtained with GRACE-Inflammatory Score was 13% (P=0.007), indicating a significant reclassification. When only CRP was incorporated into GRACE, the increase on C-statistics was not relevant (from 0.77 to 0.80). CONCLUSION: Cytokines and chemokines measured at admission add prognostic information to the GRACE Score in patients admitted with ACS.