ORIGINAL ARTICLES

Acute coronary syndromes

Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the Global Registry of Acute Coronary Events

D Brieger¹, K A A Fox², G FitzGerald³, K A Eagle⁴, A Budaj⁵, Á Avezum⁶, C B Granger⁷, B Costa¹, F A Anderson Jr³, Ph G Steg⁸, for the GRACE Investigators

¹ Coronary Care Unit, Concord Hospital, Concord, Australia
² Cardiovascular Research, Division of Medical & Radiological Sciences, The University of Edinburgh, Edinburgh, UK
³ Center for Outcomes Research, University of Massachusetts Medical School, Worcester, USA
⁴ University of Michigan Health System, Ann Arbor, Michigan, USA
⁵ Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
⁶ Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
⁷ Duke University Medical Center, Durham, North Carolina, USA
⁸ Département de Cardiologie, INSERM U-698, Université Paris 7, AP-HP, Paris, France

Dr D Brieger, Concord Repatriation General Hospital, Coronary Care Unit, Level 3, Multi Building, Hospital Road, Concord, NSW Australia 2139; davidb{at}email.cs.nsw.gov.au

Objective: To identify patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) with a low likelihood of any adverse in-hospital event.

Design, setting and patients: Data were analysed from 24 097 patients with NSTEMI or unstable angina included in the Global Registry of Acute Coronary Events (January 2001 to September 2007).

Main outcome measures: In-hospital events were myocardial infarction, arrhythmia, congestive heart failure or shock, major bleeding, stroke or death. Two-thirds of the patients were randomly chosen for model development and the remainder for model validation. Multiple logistic regression identified predictors of freedom from an in-hospital event, and a Freedom-from-Event score was developed.

Results: Of the 16 127 patients in the model development group, 19.1% experienced an in-hospital adverse event. Fifteen factors independently predicted freedom from an adverse event: younger age; lower Killip class; unstable angina presentation; no hypotension; no ST deviation; no cardiac arrest at presentation; normal creatinine; decreased pulse rate; no hospital transfer; no history of diabetes, heart failure, peripheral arterial disease, or atrial fibrillation; prehospital use of statins, and no chronic warfarin. In the validation group, 18.6% experienced an adverse event. The model discriminated well between patients experiencing an in-hospital event and those who did not in both derivation and validation groups (c-statistic = 0.77 in both). Patients in the three lowest risk deciles had a very low in-hospital mortality (<0.5%) and an uncomplicated clinical course (>93% event-free in hospital). The model also predicted freedom from postdischarge events (death, myocardial infarction, stroke; c-statistic = 0.77).

Conclusions: The GRACE Freedom-from-Event score can predict the in-hospital course of NSTE-ACS, and identifies up to 30% of the admitted population at low risk of death or any adverse in-hospital event.

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This article has been cited by other articles:

• Lim, R, Starmer, G (2009). ACS scores: risky business?. Heart 95: 1707-1707 [Full Text]  
• Brieger, D, Fitzgerald, G, Steg, G, Fox, K (2009). The authors' reply:. Heart 95: 1707-1707 [Full Text]  

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