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Acute coronary syndromes
Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the Global Registry of Acute Coronary Events
  1. D Brieger1,
  2. K A A Fox2,
  3. G FitzGerald3,
  4. K A Eagle4,
  5. A Budaj5,
  6. Á Avezum6,
  7. C B Granger7,
  8. B Costa1,
  9. F A Anderson Jr3,
  10. Ph G Steg8
  1. 1
    Coronary Care Unit, Concord Hospital, Concord, Australia
  2. 2
    Cardiovascular Research, Division of Medical & Radiological Sciences, The University of Edinburgh, Edinburgh, UK
  3. 3
    Center for Outcomes Research, University of Massachusetts Medical School, Worcester, USA
  4. 4
    University of Michigan Health System, Ann Arbor, Michigan, USA
  5. 5
    Postgraduate Medical School, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
  6. 6
    Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
  7. 7
    Duke University Medical Center, Durham, North Carolina, USA
  8. 8
    Département de Cardiologie, INSERM U-698, Université Paris 7, AP-HP, Paris, France
  1. Dr D Brieger, Concord Repatriation General Hospital, Coronary Care Unit, Level 3, Multi Building, Hospital Road, Concord, NSW Australia 2139; davidb{at}


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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  • Funding: GRACE is funded by an unrestricted educational grant from sanofi-aventis (Paris, France) to the Center for Outcomes Research, University of Massachusetts Medical School (Worcester, Massachusetts). Sanofi-aventis had no involvement in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

  • Competing interests: DB: National Heart Foundation of Australia, sanofi-aventis, Eli Lilly, Astra Zeneca, Schering Plough. KAAF: British Heart foundation, Medical Research Council, The Wellcome Trust, sanofi-aventis, GlaxoSmithKline, Bristol-Myers Squibb. GF: none. K A Eagle: Biosite, Bristol-Myers Squibb, Cardiac Sciences, Blue Cross Blue Shield of Michigan, Hewlett Foundation, Mardigian Fund, Pfizer, sanofi-aventis, Varbedian Fund, NIH NHLBI, Robert Wood Johnson Foundation. AB: sanofi-aventis, GlaxoSmithKline, Astra Zeneca, Boehringer Ingelheim. ÁA: sanofi-aventis, Population Health Research Institute, Boehringer-Ingelheim. CBG: Alexion, Astra Zeneca, Boehringer Ingelheim, Bristol Myers Squibb, decode Genetics, Genentech, GlaxoSmithKline, Novartis, Proctor and Gamble, Sanofi-aventis, The Medicines Company, INO Therapeutics, Medicure, Proctor and Gamble. FAA: sanofi-aventis. PhGS: Astra Zeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Merck, GlaxoSmithKline, sanofi-aventis, Pfizer, Servier, Takeda, Novartis, Nycomed, Sankyo, ZLB-Behring.