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Acute coronary syndromes
A comparison between B-type natriuretic peptide, Global Registry of Acute Coronary Events (GRACE) score and their combination in ACS risk stratification
  1. D S C Ang,
  2. L Wei,
  3. M P C Kao,
  4. C C Lang,
  5. A D Struthers
  1. Division of Medicine and Therapeutics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
  1. Correspondence to Dr Donald S C Ang, Division of Medicine and Therapeutics, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK; donaldscang{at}


Background: In acute coronary syndrome (ACS), both the Global Registry of Acute Coronary Events (GRACE) score and B-type natriuretic peptide (BNP) predict cardiovascular events. However, it is unknown how BNP compares with GRACE and how their combination performs in ACS.

Methods: The authors recruited 449 consecutive ACS patients and measured admission GRACE score and bedside BNP levels. The main outcome measure was all-cause mortality, readmission with ACS or congestive heart failure (defined as a cardiovascular event) at 10 months from presentation.

Results: Of the 449 patients, 120 patients presented with ST-elevation myocardial infarction (MI) (27%). There were 90 cardiovascular events at 10 months. Both higher GRACE terciles and higher BNP terciles predicted cardiovascular events. There was a significant but only partial correlation between the GRACE score and log BNP (R = 0.552, p<0.001). On multivariate analyses, after adjusting for the GRACE score itself, increasing BNP terciles independently predicted cardiovascular events (second BNP tercile adjusted RR 2.28 (95% CI 1.15 to 4.51) and third BNP tercile adjusted RR 4.91 (95% CI 2.62 to 9.22)). Patients with high GRACE score-high BNP were more likely to experience cardiovascular events at 10 months (RR 6.00 (95% CI 2.40 to 14.83)) compared to those with high GRACE score-low BNP (RR 2.40 (95% CI 0.76 to 7.56)).

Conclusion: In ACS, most but not all of our analyses suggest that BNP can predict cardiovascular events over and above the GRACE score. The combined use of both the GRACE score and BNP can identify a subset of ACS patients at particularly high risk. This implies that both the GRACE score and BNP reflect somewhat different risk attributes when predicting adverse prognosis in ACS and their synergistic use can enhance risk stratification in ACS to a small but potentially useful extent.

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  • Funding British Heart Foundation.

  • Competing interests ADS is a consultant to a company with a BNP assay.

  • Provenance and peer review Not commissioned; externally peer reviewed.