title: TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: a meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients.
abstract: BACKGROUND
  Acute coronary syndromes (ACS) represent a difficult challenge for physicians. Risk scores have become the cornerstone in clinical and interventional decision making.
  
  
  RESULTS
  PubMed was systematically searched for ACS risk score studies. They were divided into ACS studies (evaluating Unstable Angina; UA, Non ST Segment Elevation Myocardial Infarction; NSTEMI, and ST Segment Elevation Myocardial Infarction; STEMI), UA/NSTEMI studies or STEMI studies. The c-statistics of validation studies were pooled when appropriate with random-effect methods. 7 derivation studies with 25,525 ACS patients and 15 validation studies including 257,654 people were formally appraised. Pooled analysis of GRACE scores, both at short (0.82; 0.80-0.89 I.C 95%) and long term follow up (0.84; 0.82-0.87; I.C 95%) showed the best performance, with similar results to Simple Risk Index (SRI) derivation cohorts at short term. For NSTEMI/UA, 18 derivation studies with 56,560 patients and 18 validation cohorts with 56,673 patients were included. Pooled analysis of validations studies showed c-statistics of 0.54 (95% CI = 0.52-0.57) and 0.67 (95% CI = 0.62-0.71) for short and long term TIMI validation studies, and 0.83 (95% CI = 0.79-9.87) and 0.80 (95% CI = 0.74-0.89) for short and long term GRACE studies. For STEMI, 15 studies with 134,557 patients with derivation scores, and 17 validation studies with 187,619 patients showed a pooled c-statistic of 0.77 (95% CI = 0.71-0.83) and 0.77 (95% CI = 0.72-0.85) for TIMI at short and long term, and a pooled c-statistic of 0.82 (95% CI = 0.81-0.83) and 0.81 (95% CI = 0.80-0.82) for GRACE at short and long terms respectively.
  
  
  CONCLUSIONS
  TIMI and GRACE are the risk scores that up until now have been most extensively investigated, with GRACE performing better. There are other potentially useful ACS risk scores available however these have not undergone rigorous validation. This study suggests that these other scores may be potentially useful and should be further researched.
authors.affiliation: Division of Cardiology, University of Turin, Turin, Italy. fabrizio.dascenzo@gmail.com
authors.forename: Fabrizio
authors.initials: F
authors.lastname: D'Ascenzo
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Biondi-Zoccai
authors.forename: Claudio
authors.initials: C
authors.lastname: Moretti
authors.forename: Mario
authors.initials: M
authors.lastname: Bollati
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Omedè
authors.forename: Filippo
authors.initials: F
authors.lastname: Sciuto
authors.forename: Davide G
authors.initials: DG
authors.lastname: Presutti
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Modena
authors.forename: Mauro
authors.initials: M
authors.lastname: Gasparini
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Reed
authors.forename: Imad
authors.initials: I
authors.lastname: Sheiban
authors.forename: Fiorenzo
authors.initials: F
authors.lastname: Gaita
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000473:pathology / Q000628:therapy*; D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D019540:Area Under Curve; D016001:Confidence Intervals; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D018570:Risk Assessment / Q000379:methods*