title: Improving long-term risk prediction in patients with acute chest pain: the Global Registry of Acute Coronary Events (GRACE) risk score is enhanced by selected nonnecrosis biomarkers.
abstract: BACKGROUND
  The Global Registry of Acute Coronary Events (GRACE) risk score is widely recommended for risk assessment in patients with acute coronary syndrome. However, there is limited knowledge regarding the utility of this score for long-term risk prediction in unselected patients with acute chest pain and whether it might be improved by the integration of nonnecrosis biomarkers.
  
  
  METHODS
  We calculated the GRACE risk score in 453 chest pain patients and assessed its value for risk assessment together with the additive prognostic information obtained from N-terminal pro-B-type natriuretic peptide, C-reactive protein, growth differentiation factor-15 (GDF-15), and cystatin C.
  
  
  RESULTS
  After a median follow-up of 5.8 years, 92 patients (20.7%) had died. The GRACE risk score was significantly higher in patients who died (median 146 vs 93, P < .001) and provided a c-statistic regarding mortality of 0.78. A significant increase of the c-statistic was achieved only after addition of GDF-15 (c-statistic 0.81, P = .003) and, to a minor extent, after addition of cystatin C (c-statistic 0.81, P = .035). Assessment of the integrated discriminative improvement yielded similar results. N-terminal pro-B-type natriuretic peptide had only limited incremental prognostic value, and C-reactive protein was not predictive for outcome.
  
  
  CONCLUSIONS
  The GRACE risk score allows for the prediction of mortality in chest pain patients even after almost 6 years of follow-up. However, its predictive value could be further enhanced by the addition of selected nonnecrosis biomarkers, in particular GDF-15 or cystatin C.
authors.affiliation: Department of Medical Sciences, Cardiology, Uppsala University Hospital and Uppsala Clinical Research Center, Uppsala, Sweden. kai.eggers@ucr.uu.se
authors.forename: Kai M
authors.initials: KM
authors.lastname: Eggers
authors.forename: Tibor
authors.initials: T
authors.lastname: Kempf
authors.forename: Per
authors.initials: P
authors.lastname: Venge
authors.forename: Lars
authors.initials: L
authors.lastname: Wallentin
authors.forename: Kai C
authors.initials: KC
authors.lastname: Wollert
authors.forename: Bertil
authors.initials: B
authors.lastname: Lindahl
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000150:complications* / Q000453:epidemiology; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism*; D002637:Chest Pain / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology; D003325:Coronary Care Units; D018450:Disease Progression; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D055436:Growth Differentiation Factor 15 / Q000097:blood; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D009336:Necrosis / Q000097:blood; D010446:Peptide Fragments / Q000097:blood*; D015995:Prevalence; D011379:Prognosis; D011498:Protein Precursors; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D055333:Salivary Cystatins / Q000097:blood; D012720:Severity of Illness Index; D013548:Sweden / Q000453:epidemiology; D013997:Time Factors; D019210:Troponin I / Q000097:blood*
chemical_list: D015415:Biomarkers; D055436:Growth Differentiation Factor 15; D010446:Peptide Fragments; D011498:Protein Precursors; D055333:Salivary Cystatins; D019210:Troponin I; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain; D002097:C-Reactive Protein