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Rao SV, O'Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, Baber U, Baker H, Cohen MG, Cruz-Ruiz M, Davis LL, de Lemos JA, DeWald TA, Elgendy IY, Feldman DN, Goyal A, Isiadinso I, Menon V, Morrow DA, Mukherjee D, Platz E, Promes SB, Sandner S, Sandoval Y, Schunder R, Shah B, Stopyra JP, Talbot AW, Taub PR, Williams MS. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2025; 151:e771-e862. [PMID: 40014670 DOI: 10.1161/cir.0000000000001309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2025]
Abstract
AIM The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease." METHODS A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | - Tanveer Rab
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | | | | | | | | | | | | | - Dmitriy N Feldman
- Society for Cardiovascular Angiography and Interventions representative
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Rao SV, O'Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, Baber U, Baker H, Cohen MG, Cruz-Ruiz M, Davis LL, de Lemos JA, DeWald TA, Elgendy IY, Feldman DN, Goyal A, Isiadinso I, Menon V, Morrow DA, Mukherjee D, Platz E, Promes SB, Sandner S, Sandoval Y, Schunder R, Shah B, Stopyra JP, Talbot AW, Taub PR, Williams MS. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2025:S0735-1097(24)10424-X. [PMID: 40013746 DOI: 10.1016/j.jacc.2024.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2025]
Abstract
AIM The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease." METHODS A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Bo X, Liu Y, Yang M, Lu Z, Zhao Y, Chen L. Development and Validation of a Nomogram of In-hospital Major Adverse Cardiovascular and Cerebrovascular Events in Patients With Acute Coronary Syndrome. Front Cardiovasc Med 2021; 8:699023. [PMID: 34434977 PMCID: PMC8380764 DOI: 10.3389/fcvm.2021.699023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/29/2021] [Indexed: 12/23/2022] Open
Abstract
Background and Objective: This study aims to develop and validate a nomogram for the occurrence of in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) in acute coronary syndrome (ACS) patients. Methods: A total of 1,360 ACS patients admitted between November 2014 and October 2019 from Zhongda Hospital and Yancheng Third People's Hospital were included. Patients admitted in Zhongda Hospital before 2018 were split into the training cohort (n = 793). Those admitted after 2018 in Zhongda Hospital and patients from Yancheng Third People's Hospital were split into the validation cohort (n = 567). Twenty eight clinical features routinely assessed including baseline characteristics, past medical history and auxiliary examinations were used to inform the models to predict in-hospital MACCE (all-cause mortality, reinfarction, stroke, and heart failure) in ACS patients. The best-performing model was tested in the validation cohort. The accuracy and clinical applicability were tested by the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analyses (DCA). Results: The in-hospital MACCE occurred in 93 (6.83%) patients. The final prediction model consists of four variables: age, Killip grading, fasting blood-glucose (FBG) and whether percutaneous coronary intervention (PCI) was performed at early stage. A nomogram was used to present the final result. Individualized nomogram exhibited comparable discrimination to the Global Registry of Acute Coronary Events (GRACE) score [AUC: 0.807 (95% CI 0.736-0.878) vs. 0.761 (95% CI 0.69-0.878)], P = 0.10) and a better discrimination than the Evaluation of the Methods and Management of Acute Coronary Events (EMMACE) score [AUC: 0.807 (95% CI 0.736-0.878) vs. 0.723(95% CI 0.648-0.798), P = 0.01] in predicting the risk of in-hospital MACCE in ACS patients. A good prediction performance was maintained in the validation cohort (AUC =0.813, 95% CI 0.738-0.889). The prediction model also exhibited decent calibration (P = 0.972) and clinical usefulness. Conclusion: The nomogram may be a simple and effective tool in predicting the occurrence of in-hospital MACCE in ACS patients. Further longitudinal studies are warranted to validate its value in guiding clinical decision-making and optimizing the treatment of high-risk patients.
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Affiliation(s)
- Xiangwei Bo
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Liu
- School of Medicine, Southeast University, Nanjing, China
| | - Mingming Yang
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhengri Lu
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yuanyuan Zhao
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lijuan Chen
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Department of Cardiology, Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, Nanjing, China
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Mitarai T, Tanabe Y, Akashi YJ, Maeda A, Ako J, Ikari Y, Ebina T, Namiki A, Fukui K, Michishita I, Kimura K, Suzuki H. A novel risk stratification system "Angiographic GRACE Score" for predicting in-hospital mortality of patients with acute myocardial infarction: Data from the K-ACTIVE Registry. J Cardiol 2020; 77:179-185. [PMID: 32921529 DOI: 10.1016/j.jjcc.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/18/2020] [Accepted: 08/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Global Registry of Acute Coronary Events (GRACE) score is the most accurate risk assessment system for acute myocardial infarction (AMI), which was proposed in Western countries. However, it is unclear whether GRACE score is applicable to the present Japanese patients with a high prevalence of emergent percutaneous coronary intervention (PCI) and vasospasm. This study aimed to clarify the usefulness of GRACE risk score for risk stratification of Japanese AMI patients treated with early PCI and to evaluate a novel risk stratification system, "angiographic GRACE score," which is the GRACE risk score adjusted by the information of the culprit coronary artery and its flow at pre- and post-PCI, to improve its predicting availability. METHODS The subjects were 1817 AMI patients who underwent PCI within 24 h of onset between October 2015 and August 2017 and were registered in Kanagawa Acute Cardiovascular (K-ACTIVE) Registry via survey form. The association between the clinical parameters and in-hospital mortality was investigated. RESULTS A total of 79 (4.3%) in-hospital deaths were identified. The C-statistics for the in-hospital mortality of the GRACE score was 0.86, which was higher than that of the other conventional risk factors, including age (0.65), systolic blood pressure (0.70), heart rate (0.62), Killip classification (0.77), and serum levels of creatinine (0.68) and peak creatine kinase (0.74). The angiographic GRACE score improved the C-statistics from 0.86 of the original GRACE score to 0.89 (p < 0.05). In the setting of the cut-off value at 200, in-hospital mortality in the patients with the angiographic GRACE score <200 was 0.6%, which was relatively lower than those with ≥200, 9.4%. CONCLUSIONS The GRACE score is a useful predictor of in-hospital mortality among Japanese AMI patients in the PCI era. Moreover, the angiographic GRACE score could improve the predicting availability.
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Affiliation(s)
- Takanobu Mitarai
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yasuhiro Tanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Atsuo Maeda
- Department of Emergency and Disaster Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Junya Ako
- Division of Cardiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yuji Ikari
- Division of Cardiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Toshiaki Ebina
- Department of Laboratory Medicine and Clinical Investigation, Yokohama City University Medical Center, Kanagawa, Japan
| | - Atsuo Namiki
- Division of Cardiology, Kanto Rosai Hospital, Kanagawa, Japan
| | - Kazuki Fukui
- Division of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Kanagawa, Japan
| | - Ichiro Michishita
- Division of Cardiology, Yokohama Sakae Kyosai Hospital, Kanagawa, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Kanagawa, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital, Kanagawa, Japan
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Utility of the QT interval in predicting outcomes in patients presenting to the emergency department with chest pain. Coron Artery Dis 2015; 26:422-4. [PMID: 25851456 DOI: 10.1097/mca.0000000000000249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether prolongation of the heart rate-corrected QT interval (QTc) is an independent risk factor for predicting future acute coronary syndrome (ACS) occurrence or mortality in patients with at least one cardiac risk factor presenting with chest pain to the emergency department (ED). METHODS This is a single-center, retrospective study of patients presenting with chest pain to the ED of Einstein Medical Center, Philadelphia, between 2011 and 2012. Proportional hazards models were used to calculate hazard ratios (HRs) for occurrence of ACS or death within 1 year. Kaplan-Meier curves were used to determine the time to event for QTc low (< 460 ms) versus QTc high (≥ 460 ms) groups. RESULTS A total of 595 patients met the inclusion criteria. Older age, hypertension, diabetes mellitus, and hyperlipidemia were more common in the QTc high group. Patients in the QTc high group were more likely to experience subsequent ACS or death (HR 8.12, 95% confidence interval 4.00-16.72), even after adjusting for traditional cardiac risk factors (HR 7.68, 95% confidence interval 3.57-16.61). CONCLUSION QTc prolongation at ED presentation with chest pain and at least one cardiac risk factor predicts subsequent ACS and death.
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Mahmoud KD, Holmes DR. Role and timing of coronary intervention in non-ST-elevation myocardial infarction. Interv Cardiol 2014. [DOI: 10.2217/ica.14.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Ketchum ES, Dickstein K, Kjekshus J, Pitt B, Wong MF, Linker DT, Levy WC. The Seattle Post Myocardial Infarction Model (SPIM): prediction of mortality after acute myocardial infarction with left ventricular dysfunction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 3:46-55. [PMID: 24562803 DOI: 10.1177/2048872613502283] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS Ischemic heart disease is a leading worldwide cause of death. The Seattle Post Myocardial Infarction Model (SPIM) was developed to predict survival 6 months to 2 years after an acute myocardial infarction with evidence of left ventricular dysfunction. METHODS AND RESULTS A total of 6632 subjects from the EPHESUS trial were used to derive the predictive model, while 5477 subjects from the OPTIMAAL trial were used to validate the model. Cox proportional hazards modeling was used to develop a multivariate risk score predictive of all-cause mortality. The SPIM risk score integrated lab and vital parameters, Killip class, reperfusion or revascularization, the number of cardiac evidence-based medicines (aspirin, statin, β blocker, ACEI/ARB, aldosterone blocker), and the number of cardiac risk factors. The model was predictive of all-cause mortality after myocardial infarction, with an AUC of 0.75 at 6 months and 0.75 at 2 years in the derivation cohort and 0.77 and 0.78 for the same time points in the validation cohort. Model predicted versus Kaplan-Meier observed survival was excellent in the derivation cohort. It remained so in the validation cohort--84.9% versus 85.0% at 2 years. The 10% of subjects with the highest predicted risk had approximately 25 times higher mortality at 2 years than the 10% of subjects with the lowest predicted risk. CONCLUSION The SPIM score was a powerful predictor of outcomes after myocardial infarction with left ventricular dysfunction. Its highly accurate predictions should improve patient and physician understanding of survival and may prove a useful tool in post-infarct risk stratification.
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Treatment of NSTEMI (Non-ST Elevation Myocardial Infarction). CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-012-0006-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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D'Ascenzo F, Biondi-Zoccai G, Moretti C, Bollati M, Omedè P, Sciuto F, Presutti DG, Modena MG, Gasparini M, Reed MJ, Sheiban I, Gaita F. TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: a meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients. Contemp Clin Trials 2012; 33:507-514. [PMID: 22265976 DOI: 10.1016/j.cct.2012.01.001] [Citation(s) in RCA: 173] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 12/20/2011] [Accepted: 01/03/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute coronary syndromes (ACS) represent a difficult challenge for physicians. Risk scores have become the cornerstone in clinical and interventional decision making. METHODS AND RESULTS PubMed was systematically searched for ACS risk score studies. They were divided into ACS studies (evaluating Unstable Angina; UA, Non ST Segment Elevation Myocardial Infarction; NSTEMI, and ST Segment Elevation Myocardial Infarction; STEMI), UA/NSTEMI studies or STEMI studies. The c-statistics of validation studies were pooled when appropriate with random-effect methods. 7 derivation studies with 25,525 ACS patients and 15 validation studies including 257,654 people were formally appraised. Pooled analysis of GRACE scores, both at short (0.82; 0.80-0.89 I.C 95%) and long term follow up (0.84; 0.82-0.87; I.C 95%) showed the best performance, with similar results to Simple Risk Index (SRI) derivation cohorts at short term. For NSTEMI/UA, 18 derivation studies with 56,560 patients and 18 validation cohorts with 56,673 patients were included. Pooled analysis of validations studies showed c-statistics of 0.54 (95% CI = 0.52-0.57) and 0.67 (95% CI = 0.62-0.71) for short and long term TIMI validation studies, and 0.83 (95% CI = 0.79-9.87) and 0.80 (95% CI = 0.74-0.89) for short and long term GRACE studies. For STEMI, 15 studies with 134,557 patients with derivation scores, and 17 validation studies with 187,619 patients showed a pooled c-statistic of 0.77 (95% CI = 0.71-0.83) and 0.77 (95% CI = 0.72-0.85) for TIMI at short and long term, and a pooled c-statistic of 0.82 (95% CI = 0.81-0.83) and 0.81 (95% CI = 0.80-0.82) for GRACE at short and long terms respectively. CONCLUSIONS TIMI and GRACE are the risk scores that up until now have been most extensively investigated, with GRACE performing better. There are other potentially useful ACS risk scores available however these have not undergone rigorous validation. This study suggests that these other scores may be potentially useful and should be further researched.
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Aragam KG, Tamhane UU, Kline-Rogers E, Li J, Fox KAA, Goodman SG, Eagle KA, Gurm HS. Does simplicity compromise accuracy in ACS risk prediction? A retrospective analysis of the TIMI and GRACE risk scores. PLoS One 2009; 4:e7947. [PMID: 19956773 PMCID: PMC2776353 DOI: 10.1371/journal.pone.0007947] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 10/27/2009] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The Thrombolysis in Myocardial Infarction (TIMI) risk scores for Unstable Angina/Non-ST-elevation myocardial infarction (UA/NSTEMI) and ST-elevation myocardial infarction (STEMI) and the Global Registry of Acute Coronary Events (GRACE) risk scores for in-hospital and 6-month mortality are established tools for assessing risk in Acute Coronary Syndrome (ACS) patients. The objective of our study was to compare the discriminative abilities of the TIMI and GRACE risk scores in a broad-spectrum, unselected ACS population and to assess the relative contributions of model simplicity and model composition to any observed differences between the two scoring systems. METHODOLOGY/PRINCIPAL FINDINGS ACS patients admitted to the University of Michigan between 1999 and 2005 were divided into UA/NSTEMI (n = 2753) and STEMI (n = 698) subpopulations. The predictive abilities of the TIMI and GRACE scores for in-hospital and 6-month mortality were assessed by calibration and discrimination. There were 137 in-hospital deaths (4%), and among the survivors, 234 (7.4%) died by 6 months post-discharge. In the UA/NSTEMI population, the GRACE risk scores demonstrated better discrimination than the TIMI UA/NSTEMI score for in-hospital (C = 0.85, 95% CI: 0.81-0.89, versus 0.54, 95% CI: 0.48-0.60; p<0.01) and 6-month (C = 0.79, 95% CI: 0.76-0.83, versus 0.56, 95% CI: 0.52-0.60; p<0.01) mortality. Among STEMI patients, the GRACE and TIMI STEMI scores demonstrated comparably excellent discrimination for in-hospital (C = 0.84, 95% CI: 0.78-0.90 versus 0.83, 95% CI: 0.78-0.89; p = 0.83) and 6-month (C = 0.72, 95% CI: 0.63-0.81, versus 0.71, 95% CI: 0.64-0.79; p = 0.79) mortality. An analysis of refitted multivariate models demonstrated a marked improvement in the discriminative power of the TIMI UA/NSTEMI model with the incorporation of heart failure and hemodynamic variables. Study limitations included unaccounted for confounders inherent to observational, single institution studies with moderate sample sizes. CONCLUSIONS/SIGNIFICANCE The GRACE scores provided superior discrimination as compared with the TIMI UA/NSTEMI score in predicting in-hospital and 6-month mortality in UA/NSTEMI patients, although the GRACE and TIMI STEMI scores performed equally well in STEMI patients. The observed discriminative deficit of the TIMI UA/NSTEMI score likely results from the omission of key risk factors rather than from the relative simplicity of the scoring system.
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Affiliation(s)
- Krishna G. Aragam
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Umesh U. Tamhane
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jin Li
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Keith A. A. Fox
- Cardiovascular Research, Division of Medical and Radiological Sciences, The University of Edinburgh, Edinburgh, Scotland
| | - Shaun G. Goodman
- Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kim A. Eagle
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Hitinder S. Gurm
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
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Abstract
This article reviews the current risk assessment models available for patients presenting with myocardial infarction (MI). These practical tools enhance the health care provider's ability to rapidly and accurately assess patient risk from the event or revascularization therapy, and are of paramount importance in managing patients presenting with MI. This article highlights the models used for ST-elevation MI (STEMI) and non-ST elevation MI (NSTEMI) and provides an additional description of models used to assess risks after primary angioplasty (ie, angioplasty performed for STEMI).
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Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, 200 1st Street South West, Rochester, MN 55905, USA.
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Yan AT, Jong P, Yan RT, Tan M, Fitchett D, Chow CM, Roe MT, Pieper KS, Langer A, Goodman SG. Clinical trial--derived risk model may not generalize to real-world patients with acute coronary syndrome. Am Heart J 2004; 148:1020-7. [PMID: 15632888 DOI: 10.1016/j.ahj.2004.02.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Accurate risk stratification can guide clinical decision-making in the management of acute coronary syndromes (ACS). However, the applicability of risk models to the general ACS population remains unclear. The purpose of this study was to validate and compare a modified international clinical trial and a registry-based risk model in a contemporary, less selected ACS population. METHODS In the prospective, observational Canadian ACS Registry, 4627 patients with ACS were enrolled from 51 centers. Baseline patient data were recorded on standardized case report forms. We evaluated risk models derived from the Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) and the Global Registry of Acute Cardiac Events (GRACE) predicting in-hospital death among patients with non-ST-elevation ACS. Model discrimination was measured by the c-statistic, and calibration was assessed graphically and by the Hosmer-Lemeshow goodness-of-fit test. RESULTS In-hospital mortality rates were 2.4% overall and 1.5% among the patients with non-ST-elevation ACS (n = 2925; 63.2%) in our validation cohort. Both the in-hospital PURSUIT and GRACE risk models showed similar and good prognostic discrimination (c-statistics = 0.84 and 0.83, respectively; P = .69 for difference). The GRACE model also demonstrated good calibration (Hosmer-Lemeshow P = .40). In contrast, calibration in the PURSUIT model was poor (Hosmer-Lemeshow P < .001), with consistent overestimation of risks. CONCLUSIONS Both the PURSUIT and GRACE models demonstrated good discrimination for in-hospital mortality rates in the Canadian ACS Registry. However, the GRACE risk model, derived from a less selected population, provided superior calibration in risk assessment across the spectrum of ACS. Our findings underscore the potential importance of risk model validation in the general ACS population rather than a clinical trial population to establish its generalizability before integration into clinical practice.
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Affiliation(s)
- Andrew T Yan
- Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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