title: Improved risk stratification of patients with acute coronary syndromes using a combination of hsTnT, NT-proBNP and hsCRP with the GRACE score.
abstract: BACKGROUND
  Clinical scores and biomarkers improve risk stratification of patients with acute coronary syndromes. However, little is known about their value in patients referred for coronary angiography.
  
  
  METHODS
  Consecutive patients admitted at four Swiss university hospitals with a diagnosis of acute coronary syndrome were enrolled into the SPUM-ACS Biomarker Cohort between 2009 and 2012. Patients were followed at 30 days and 1 year with assessment of adjudicated events including all-cause mortality and the composite of all-cause mortality or non-fatal recurrent myocardial infarction.
  
  
  RESULTS
  Events and biomarkers were analysed in 1892 patients (52.4% with ST-segment elevation myocardial infarction, 43.3% with non-ST-segment elevation myocardial infarction and 4.3% with unstable angina). Death at 30 days occurred in 35 patients (1.9%) and at 1 year in 80 patients (4.3%). The choice of troponin assay (conventional versus high sensitivity) to calculate the Global Registry of Acute Coronary Events (GRACE) score did not affect risk prediction. The prognostic accuracy of the GRACE score was improved when combined with three individual biomarkers including high sensitivity troponin T (hsTnT), N-terminal-pro B-type natriuretic peptide (NT-proBNP) and high sensitivity C-reactive protein (hsCRP) to yield a 9% increment (C-statistic 0.73->0.82) for the discrimination of short-term risk for all-cause mortality. In contrast, the novel biomarkers placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and the ratio sFlt-1/PlGF did not improve risk stratification.
  
  
  CONCLUSIONS
  In patients with acute coronary syndrome referred for coronary angiography, combinations of biomarkers including hsTnT, NT-proBNP and hsCRP with the GRACE score enhanced risk discrimination.
  
  
  BACKGROUND
  NCT01000701.
authors.affiliation: 1 Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland.
authors.forename: Roland
authors.initials: R
authors.lastname: Klingenberg
authors.affiliation: 2 Institute of Social and Preventive Medicine, (ISPM) University of Bern, Switzerland.|3 Department of Clinical Research, Clinical Trials Unit, ISPM, University of Bern, Switzerland.
authors.forename: Soheila
authors.initials: S
authors.lastname: Aghlmandi
authors.affiliation: 4 Department of Cardiology, Cardiovascular Center, University Hospital Bern, Switzerland.
authors.forename: Lorenz
authors.initials: L
authors.lastname: Räber
authors.affiliation: 5 Department of Cardiology, Cardiovascular Center, University Hospital Geneva, Switzerland.
authors.forename: Baris
authors.initials: B
authors.lastname: Gencer
authors.affiliation: 6 Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland.
authors.forename: David
authors.initials: D
authors.lastname: Nanchen
authors.affiliation: 2 Institute of Social and Preventive Medicine, (ISPM) University of Bern, Switzerland.|3 Department of Clinical Research, Clinical Trials Unit, ISPM, University of Bern, Switzerland.
authors.forename: Dik
authors.initials: D
authors.lastname: Heg
authors.affiliation: 7 Department of General Internal Medicine, University Hospital Geneva, Switzerland.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Carballo
authors.affiliation: 8 Department of General Internal Medicine, University Hospital Bern, Switzerland.|9 Institute of Primary Health Care (BIHAM), University of Bern, Switzerland.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Rodondi
authors.affiliation: 5 Department of Cardiology, Cardiovascular Center, University Hospital Geneva, Switzerland.
authors.forename: François
authors.initials: F
authors.lastname: Mach
authors.affiliation: 3 Department of Clinical Research, Clinical Trials Unit, ISPM, University of Bern, Switzerland.
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.affiliation: 10 Applied Health Research Centre (AHRC), Department of Medicine, University of Toronto, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Jüni
authors.affiliation: 11 Institute of Clinical Chemistry, University Hospital Zurich, Switzerland.
authors.forename: Arnold
authors.initials: A
authors.lastname: von Eckardstein
authors.affiliation: 1 Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland.
authors.forename: Christian M
authors.initials: CM
authors.lastname: Matter
authors.affiliation: 1 Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland.
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Lüscher
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood* / Q000175:diagnosis / Q000401:mortality; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism*; D002423:Cause of Death / Q000639:trends; D017023:Coronary Angiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D010446:Peptide Fragments / Q000097:blood*; D011379:Prognosis; D011446:Prospective Studies; D011498:Protein Precursors; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013557:Switzerland / Q000453:epidemiology; D020107:Troponin T / Q000097:blood*
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D011498:Protein Precursors; D020107:Troponin T; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain; D002097:C-Reactive Protein
keywords: Acute coronary syndromes; biomarkers; risk stratification