The GRACE score's performance in predicting in-hospital and 1-year outcome in the era of high-sensitivity cardiac troponin assays and B-type natriuretic peptide

Abstract

Objective: To compare the accuracy of the GRACE score, a strong prognosticator in acute coronary syndrome (ACS) that is calculated using conventional cardiac troponin (cTn) assays, with that calculated with high-sensitivity cTn (hs-cTn) and with the combination of the GRACE score with hs-cTn or B-type natriuretic peptide (BNP). Design: Prospective international cohort. Settings: University Hospital. Patients: Patients enrolled in the Predictors of Acute Coronary Syndromes Evaluation prospective study with proven ACS. Main outcome measured: The capacity to predict in-hospital mortality, 1-year mortality and combined death/acute myocardial infarction (AMI) at 1 year. Results: 370 patients were enrolled (173 with unstable angina and 197 with AMI). In-hospital mortality was 4.1%; 1-year mortality was 12.5%. The GRACE score was significantly higher in patients who died than in those discharged alive (200 (174-222) vs 125 (98-155); p<0.001), and in those who died than in those who survived for 1 year (151 (133-169) vs 104 (85-125); p<0.001). The area under the curve of the GRACE score was 0.87 regarding in-hospital mortality and 0.88 for 1-year mortality; if calculated with hs-cTn, it was 0.87 and 0.88, respectively (p=NS for all comparisons). The addition of hs-cTn to the GRACE score resulted in no increased value, whereas the addition of BNP tended to improve 1-year mortality prediction (p=0.058). Conclusion: The GRACE score is accurate for determining both in-hospital and long-term mortality in patients with ACS in the era of hs-cTn. The addition of hs-cTn or BNP to the GRACE score does not significantly improve risk prediction.