Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE).
OBJECTIVE
To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome.


METHODS
Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation.


METHODS
Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand.


METHODS
43,810 patients (21,688 in derivation set; 22,122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005.


METHODS
Death and myocardial infarction.


RESULTS
1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries).


CONCLUSIONS
This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.
Fox
Keith A A
KA
Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh EH16 4SB. k.a.a.fox@ed.ac.uk
Dabbous
Omar H
OH
Goldberg
Robert J
RJ
Pieper
Karen S
KS
Eagle
Kim A
KA
Van de Werf
Frans
F
Avezum
Alvaro
A
Goodman
Shaun G
SG
Flather
Marcus D
MD
Anderson
Frederick A
FA
Granger
Christopher B
CB
D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000401:mortality*; D011379:Prognosis; D012720:Severity of Illness Index; D013577:Syndrome; D014218:Triage / Q000379:methods