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Predicting freedom from clinical events in non–ST-elevation acute coronary syndromes. The Global Registry of Acute Coronary Events
  1. David Brieger (davidb{at}
  1. Concord Hospital, Australia
    1. Keith A A Fox ({at}
    1. University of Edinburgh, United Kingdom
      1. Gordon FitzGerald (gordon.fitzgerald{at}
      1. UMASS Medical School, United States
        1. Kim A Eagle (keagle{at}
        1. University of Michigan Cardiovascular Center, United States
          1. Andrzej Budaj (abudaj{at}
          1. Grochowski Hospital, Poland
            1. Alvaro Avezum (avezum{at}
            1. Dante Pazzanese Institute of Cardiology, Brazil
              1. Christopher B Granger (christopher.granger{at}
              1. Duke University Medical Center, United States
                1. Bernadette Costa (bernadette.costa{at}
                1. Concord Hospital, Australia
                  1. Frederick A Anderson (fred.anderson{at}
                  1. UMASS Medical School, United States
                    1. Philippe Gabriel Steg (gabriel.steg{at}
                    1. INSERM U-698, Université Paris 7, AP-HP, France


                      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 rate (<0.5%) and an uncomplicated clinical course (>93% event-free in hospital). The model also predicted freedom from post-discharge 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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