title: Walking beyond the GRACE (Global Registry of Acute Coronary Events) model in the death risk stratification during hospitalization in patients with acute coronary syndrome: what do the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and GWTG [Get With the Guidelines] Database), NCDR (National Cardiovascular Data Registry), and EuroHeart Risk Scores Provide?
abstract: OBJECTIVE
  This study sought to compare the in-hospital prognostic values of the original and updated GRACE (Global Registry of Acute Coronary Events) risk score (RS) and the AR-G (ACTION [Acute Coronary Treatment and Intervention Outcomes Network] Registry and the GWTG [Get With the Guidelines] Database) RS in acute coronary syndromes (ACS). To evaluate the utility of recalculating risk after percutaneous coronary intervention (PCI) with newer RS models (NCDR [National Cardiovascular Data Registry] and EHS [EuroHeart Score] RS).
  
  
  BACKGROUND
  Defined in 2003, GRACE is among the most popular systems of risk stratification in ACS. An updated version of GRACE has since appeared and new RS have been developed, aiming to improve risk prediction.
  
  
  METHODS
  From 2004 to 2010, 4,497 consecutive patients admitted to a single center in Spain with an ACS were included (32.1% ST-segment elevation myocardial infarction, 19.2% unstable angina). Discrimination (C-statistic) and calibration (Hosmer-Lemeshow [HL]) indexes were used to assess performance of each RS. A comparative analysis of RS designed to predict post-PCI mortality NCDR and EHS RS versus the GRACE and AR-G RS was performed in a subgroup of 1,113 consecutive patients included in the study.
  
  
  RESULTS
  There were 265 in-hospital deaths (5.9%). Original and updated GRACE RS and the AR-G RS all demonstrated good discrimination for in-hospital death (C-statistics: 0.91, 0.90 and 0.90, respectively) with optimal calibration (HL p: 0.42, 0.50, and 0.47, respectively) in all spectra of ACS, according to different managements (PCI vs. conservative) and without significant differences between the 3 different RS. In patients undergoing PCI, EHS and NCDR RS (C-statistic = 0.80 and 0.84, respectively) were not superior to GRACE RS (C-statistic = 0.91), albeit in the subgroup of patients undergoing PCI who were categorized as high risk using the GRACE RS, both EHS and NCDR have contributed to decrease the false positive rate generated by using the GRACE RS.
  
  
  CONCLUSIONS
  Despite having been developed over 8 years ago, the GRACE RS still maintains its excellent performance for predicting in-hospital risk of death among ACS patients.
authors.affiliation: Department of Cardiology, University Clinical Hospital of Santiago de Compostela, A Coruña, Spain.
authors.forename: Sergio
authors.initials: S
authors.lastname: Raposeiras-Roubín
authors.forename: Emad
authors.initials: E
authors.lastname: Abu-Assi
authors.forename: Pilar
authors.initials: P
authors.lastname: Cabanas-Grandío
authors.forename: Rosa María
authors.initials: RM
authors.lastname: Agra-Bermejo
authors.forename: Santiago
authors.initials: S
authors.lastname: Gestal-Romarí
authors.forename: Eva
authors.initials: E
authors.lastname: Pereira-López
authors.forename: Rubén
authors.initials: R
authors.lastname: Fandiño-Vaquero
authors.forename: Belén
authors.initials: B
authors.lastname: Álvarez-Álvarez
authors.forename: Cristina
authors.initials: C
authors.lastname: Cambeiro
authors.forename: Marta
authors.initials: M
authors.lastname: Rodríguez-Cordero
authors.forename: Pamela
authors.initials: P
authors.lastname: Lear
authors.forename: Amparo
authors.initials: A
authors.lastname: Martínez-Monzonís
authors.forename: Carlos
authors.initials: C
authors.lastname: Peña-Gil
authors.forename: José María
authors.initials: JM
authors.lastname: García-Acuña
authors.forename: José Ramón
authors.initials: JR
authors.lastname: González-Juanatey
mesh_terms: D054058:Acute Coronary Syndrome / Q000401:mortality*; D000368:Aged; D016208:Databases, Factual; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*