title: Improving risk stratification in non-ST-segment elevation myocardial infarction with combined assessment of GRACE and CRUSADE risk scores.
abstract: BACKGROUND
  Risk assessment is fundamental in the management of acute coronary syndromes (ACS), enabling estimation of prognosis.
  
  
  OBJECTIVE
  To evaluate whether the combined use of GRACE and CRUSADE risk stratification schemes in patients with myocardial infarction outperforms each of the scores individually in terms of mortality and haemorrhagic risk prediction.
  
  
  METHODS
  Observational retrospective single-centre cohort study including 566 consecutive patients admitted for non-ST-segment elevation myocardial infarction. The CRUSADE model increased GRACE discriminatory performance in predicting all-cause mortality, ascertained by Cox regression, demonstrating CRUSADE independent and additive predictive value, which was sustained throughout follow-up. The cohort was divided into four different subgroups: G1 (GRACE<141; CRUSADE<41); G2 (GRACE<141; CRUSADE≥41); G3 (GRACE≥141; CRUSADE<41); G4 (GRACE≥141; CRUSADE≥41).
  
  
  RESULTS
  Outcomes and variables estimating clinical severity, such as admission Killip-Kimbal class and left ventricular systolic dysfunction, deteriorated progressively throughout the subgroups (G1 to G4). Survival analysis differentiated three risk strata (G1, lowest risk; G2 and G3, intermediate risk; G4, highest risk). The GRACE+CRUSADE model revealed higher prognostic performance (area under the curve [AUC] 0.76) than GRACE alone (AUC 0.70) for mortality prediction, further confirmed by the integrated discrimination improvement index. Moreover, GRACE+CRUSADE combined risk assessment seemed to be valuable in delineating bleeding risk in this setting, identifying G4 as a very high-risk subgroup (hazard ratio 3.5; P<0.001).
  
  
  CONCLUSIONS
  Combined risk stratification with GRACE and CRUSADE scores can improve the individual discriminatory power of GRACE and CRUSADE models in the prediction of all-cause mortality and bleeding. This combined assessment is a practical approach that is potentially advantageous in treatment decision-making.
authors.affiliation: Coimbra's Hospital and University Centre, Coimbra, Portugal. Electronic address: luisvpaiva@gmail.com.
authors.forename: Luis
authors.initials: L
authors.lastname: Paiva
authors.affiliation: Coimbra's Hospital and University Centre, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
authors.forename: Rui
authors.initials: R
authors.lastname: Providência
authors.affiliation: Papworth Hospital, Cambridge, England, UK.
authors.forename: Sérgio N
authors.initials: SN
authors.lastname: Barra
authors.affiliation: Coimbra's Hospital and University Centre, Coimbra, Portugal.
authors.forename: Paulo
authors.initials: P
authors.lastname: Dinis
authors.affiliation: Coimbra's Hospital and University Centre, Coimbra, Portugal.
authors.forename: Ana C
authors.initials: AC
authors.lastname: Faustino
authors.affiliation: Coimbra's Hospital and University Centre, Coimbra, Portugal.
authors.forename: Marco
authors.initials: M
authors.lastname: Costa
authors.affiliation: Coimbra's Hospital and University Centre, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
authors.forename: Lino
authors.initials: L
authors.lastname: Gonçalves
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D005260:Female; D006470:Hemorrhage / Q000209:etiology; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D011174:Portugal; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D018487:Ventricular Dysfunction, Left / Q000209:etiology / Q000503:physiopathology; D016277:Ventricular Function, Left
keywords: CRUSADE; GRACE; Myocardial infarction; Risk; Risque; Syndrome coronaire aigu