Predictive power of the grace score in population with diabetes.

INTRODUCTION: Current clinical practice guidelines recommend risk stratification in patients with acute coronary syndrome (ACS) upon admission to hospital. Diabetes mellitus (DM) is widely recognized as an independent predictor of mortality in these patients, although it is not included in the GRACE risk score. OBJECTIVES: The objective of this study is to validate the GRACE risk score in a contemporary population and particularly in the subgroup of patients with diabetes, and to test the effects of including the DM variable in the model. MATERIAL AND METHODS: Retrospective cohort study in patients included in the ARIAM-SEMICYUC registry, with a diagnosis of ACS and with available in-hospital mortality data. We tested the predictive power of the GRACE score, calculating the area under the ROC curve. We assessed the calibration of the score and the predictive ability based on type of ACS and the presence of DM. Finally, we evaluated the effect of including the DM variable in the model by calculating the net reclassification improvement. RESULTS: The GRACE score shows good predictive power for hospital mortality in the study population, with a moderate degree of calibration and no significant differences based on ACS type or the presence of DM. Including DM as a variable did not add any predictive value to the GRACE model. CONCLUSIONS: The GRACE score has an appropriate predictive power, with good calibration and clinical applicability in the subgroup of diabetic patients.

GRACE Score Validation in Predicting Hospital Mortality: Analysis of the Role of Sex.

Background: The GRACE (Global Registry of Acute Coronary Events) risk score is recommended for risk stratification in acute coronary syndrome (ACS). It does not include sex, a variable strongly associated with ACS prognosis. The aim of this study was to examine if sex adds prognostic information to the GRACE score in a contemporary population. Materials and Methods: Analysis of discrimination and calibration of GRACE score in the validation population, derived from the ARIAM-SEMICYUC registry (2012-2015). Outcome was hospital mortality. The uniformity of fit of the score was tested in predefined subpopulations: with and without ST-segment elevation myocardial infarction (STEMI and NSTEMI). Results: A total of 9781 patients were included: 4598 with NSTEMI (28% women) and 5183 with STEMI (23% women). Discriminative capacity of the GRACE score was significantly lower in women with STEMI compared to men (area under the receiver operating characteristic curve [AUC] 0.82, 95% CI 0.78-0.86 vs. AUC 0.90, 95% CI 0.88-0.92, p = 0.0006). In multivariate analysis, female sex predicted hospital mortality independently of GRACE in STEMI (p = 0.019) but not in NSTEMI (p = 0.356) (interaction p = 0.0308). However, neither the AUC nor the net reclassification index (NRI) improved by including female sex in the STEMI subpopulation (NRI 0.0011, 95% CI -0.023 to 0.025; p = 0.928). Conclusions: Although female sex was an independent predictor of hospital mortality in the STEMI subpopulation, it does not substantially improve the discriminative ability of GRACE score.

Accessibility to Reperfusion Therapy Among Women with Acute Myocardial Infarction: Impact on Hospital Mortality.

BACKGROUND: The available evidence about the effect of gender and/or sex on mortality differences is contradictory. Our aim is to assess the impact of gender on the access to reperfusion therapy in patients with acute coronary syndrome with ST-segment elevation (STEMI), and secondly, to analyze the effect of delay on the differences with regard to hospital mortality. METHODS: A retrospective cohort study was conducted among consecutive patients with STEMI included in the ARIAM-SEMICYUC registry (2010-2013). RESULTS: A total of 4816 patients were included (22.09% women). Women were older, presented with longer patient delay (90 vs. 75 minutes, p=0.0066), higher risk profile (GRACE>140: 75.1% vs. 56.05%, p<0.0001), and received less reperfusion therapy (68.8% vs. 74.7%, p<0.0001) with longer total reperfusion time (307 vs. 240 minutes, p<0.0001). Women received less thrombolysis (24.53% vs. 29.98%, p<0.0001) and longer door-to-needle time (85 vs. 70 minutes, p 0.0023). We found no differences regarding primary percutaneous coronary intervention or door-to-balloon time. Women also had higher hospital mortality (crude odds ratio 2.54, 95% confidence interval 1.99-3.26, p<0.0001), which persisted after controlling the effect of patient delay, age, risk (GRACE), and reperfusion (adjusted odds ratio 1.43, 95% confidence interval 1.0-2.06, p=0.0492). Using TIMI or Killip risk scores as risk estimates yielded nonsignificant results. CONCLUSIONS: Compared with men, women with STEMI have worse access to reperfusion and higher hospital mortality. The impact of the differences in accessibility on mortality gap remains uncertain.

Uso de estrategia invasiva precoz en pacientes diabéticos con síndrome coronario agudo sin elevación del ST / Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndromes

Fundamento y objetivos: La estrategia invasiva reduce la mortalidad de los pacientes con síndrome coronario agudo sin elevación del ST (SCASEST) de alto riesgo, entre los que se incluyen los pacientes diabéticos. Sin embargo, diversas publicaciones han puesto de manifiesto una infrautilización de esta estrategia invasiva en estos pacientes. El objetivo de este estudio es conocer las características de los pacientes diabéticos que se tratan de forma conservadora, e identificar determinantes del uso de una u otra estrategia. Paciente y métodos: Estudio de cohortes retrospectivo, realizado en diabéticos con SCASEST incluidos en los cortes anuales de 2010 y 2011 en el registro ARIAM-SEMICYUC. Se realizó un análisis bruto y ajustado mediante regresión logística no condicional. Resultados: Se han analizado 531 pacientes diabéticos, de los cuales 264 (49,7%) recibieron estrategia invasiva. Los pacientes diabéticos que se tratan de forma conservadora son un subgrupo caracterizado por su mayor edad y comorbilidad cardiovascular, mayor riesgo hemorrágico y ausencia de electrocardiograma (ECG) de alto riesgo. Se identifican como variables predictoras independientes asociadas al tratamiento conservador, el ECG de bajo riesgo, el Killip al ingreso superior a 1, alto riesgo hemorrágico y el tratamiento previo con clopidogrel. Conclusiones: El temor a las complicaciones hemorrágicas o la presencia de lesiones coronarias avanzadas podrían ser la causa de la infrautilización de la estrategia invasiva en los pacientes diabéticos con SCASEST (AU)

Background and objectives In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy. Patients and Methods Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n = 531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression. Results We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class > 1, high risk of bleeding and pretreatment with clopidogrel. Conclusions The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS (AU)

[Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndromes]. / Uso de estrategia invasiva precoz en pacientes diabéticos con síndrome coronario agudo sin elevación del ST.

BACKGROUND AND OBJECTIVES: In the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS), several studies have shown a reduction in mortality with the use of an invasive strategy in high-risk patients, including diabetic patients. Paradoxically, other studies have shown an under-utilization of this invasive strategy in these patients. The aim of this study is to determine the characteristics of patients managed conservatively and identify determinants of the use of invasive or conservative strategy. PATIENTS AND METHODS: Retrospective cohort study conducted in diabetic patients with NSTE-ACS included in the ARIAM-SEMICYUC registry (n=531) in 2010 and 2011. We performed crude and adjusted unconditional logistic regression. RESULTS: We analyzed 531 diabetic patients, 264 (49.7%) of which received invasive strategy. Patients managed conservatively were a subgroup characterized by older age and cardiovascular comorbidity, increased risk of bleeding and the absence of high-risk electrocardiogram (ECG). In diabetic patients with NSTE-ACS, independent predictors associated with conservative strategy were low-risk ECG, initial Killip class>1, high risk of bleeding and pretreatment with clopidogrel. CONCLUSIONS: The fear of bleeding complications or advanced coronary lesions could be the cause of the underutilization of an invasive strategy in diabetic patients with NSTE-ACS.

Prinzmetal's angina in a patient with angiosarcoma of the right cardiac chambers.

Variant (Prinzmetal's) angina pectoris is a clinical syndrome characterized by the presence of angina at rest, coinciding with a transient ST-segment elevation. This syndrome is often caused by vasospasm, either on a normal coronary artery or at the site of a coronary atherosclerotic stenosis. We describe a classic case of variant angina associated with an angiosarcoma of the right heart chambers.