2.1 Risk Score for UA NSTEMI - dr. Rukma Sp.JP.pdf

8/18/2019 2.1 Risk Score for UA NSTEMI - dr. Rukma Sp.JP.pdf

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RISK SCORES FOR PROGNOSIS OF UNSTABLE ANGINA/NSTEMI

RUKMA JUSLIM

Introduction

Cardiovascular diseases are currently the leading cause of death inindustrialized countries and are expected to become so in emerging countriesby 2020. The clinical presentations of CAD include silent ischaemia, stableangina pectoris, unstable angina, myocardial infarction (MI), heart failure andsudden death. Murray CJ, Lopez AD .

Registry data consistenly show that NSTE-ACS is more frequent than STE-ACS.The annual incidence is ~3 per 1000 inhabitans, but varies between countries.Hospital mortality is higher in patients with STEMI than among those withNSTE-ACS (7% vs 3-5%, respectively), but at 6 months the mortality rates arevery similarin both conditions (12% & 13%, respectively). Yeh RW,Sidney S. Et al.

It is well established that ACS in their different clinical presentations

share a widely common pathophysiological substrate. Pathological, imaging,and biological observations have demonstrated that atherosclerotic plaquerupture or erosion, with differing degrees of superimposed thrombosis anddistal embolization resulting in myocardial underperfusion, form the basicpathophysiological mechanism in most conditions of ACS .Bassand JP et al .

The Guidelines aim to present management recommendations based onall of the relevant evidence on a particular subject in order to help physicians

to select the best possible management srategy forthe individual patient. Thestrength of evidence for or againts particular procedures or treatments isweighted, according to predefined scales for grading recommendations andlevels of evidence. ESC Guidelines on the diagnosis & treatment OF NSTEMI.

Definition & Classification

Unstable angina is defined as angina pectoris (or equivalent type ofischemic discomfort) with at least one of three features: occuring at rest and

usually lasting > 20 minutes (if not interrupted by nitoglyserin administration);


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being severe and described as frank pain and new onset; occuring with acressendo pattern. Braunwald EA, et al

UA/NSTEMI comprises such a heterogeneous group of patients,

classification schemes based on clinical features are usefull.

Table 1.

Class Definition † or MI(1yr)%

I New onset of severe angina/ accelerated ;no rest pain

7,3

II Angina at rest within past month but within

preceding 48 hr(angina at rest, subacute)

10,3

III Angina at rest within 48 hr (angina at rest,subacute)

10,8

ClinicalCircumstanceA (secondary angina) Develops in the presence of extracardiac

condition that intensifies myoc.ischemia14,1

B (primary angina) Develops in the absence of extracardiac 8,5C (Post InfarctionAngina)

UA patients:1).Tx. chronic stable angina(-)2).during Tx. 3).Despite max.antiisch. Tx.

18,5

Braunwald Clinical Classification of UA/NSTEMI

Five pathophysiological processes may contribute to development ofUA/NSTEMI. Plaque ruptureor erosionwith superimposed nonocclusivethrombus; dynamic obstruction (i.e. coronary spasm); progessive mechanicalobstruction; Inflamation; secondary unstable angina related increasedmyocardial oxygen demand or decreased supply (i.e. anemia)

Diagnosis and risk assessment The Task Force for Diagnosis & Treatment NSTE-ACS of the ESC 2007

Diagnostic tools include : physical examination, electrocardiogram,biochemical markers, echocardiography, imaging of the coronary anatomy.Clinical history, ECG findings and biomarkers are essential for diagnosticandprognostic purposes.

The resting 12-lead ECG is the first line diagnostic tool in the assessment

of patients with suspected NSTEMI. It should be obtained within 10 minutesafter first medical contact.The characteristic ECG abnormalities of NSTEMI are


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ST segment depression or transient elevation and/or T wave changes. A normalECG does not exclude the possibilty of NSTEMI.

Biomarkers reflect different pathophysiological aspects of NSTEMI.Trop

T or I are peferred biomarkers to predict short-term (30 days) outcome withrespect to MI and death. The prognostic value of troponin measurements hasalso been confirmed for the long term (1year & beyond). Any troponinelevation is associated with an adverse prognosis.The diagnosis Of NSTEMIshould never be made only on the basis of cardiac biomarkers whose elevationshould be interpreted in the context of other clinical findings.

Risk Stratification

Several risk stratification scores have been developed and validated inlarge patient populations. The GRACE risk score is based on a large unselectedpopulationof an international registry with a full spectrum of ACS patients. Therisk factors were derived with independent predictive power for in-hospitaldeaths and post discharge deathsat 6 months. GRACE risk score makes itpossible to assess risk of in-hospital and 6-month death.

Table 2. Mortality in hospital and 6 months in low, Intermediate and high riskcategories in registry populations according to the Grace Risk Score.

Risk category (tertiles) Grace Risk Score In-hospital deaths(%)Low ≤ 108 < 1

Intermediate 109 – 140 1-3High >140 > 3

Risk category (tertiles) Grace Risk Score Post-discharge to 6months deaths (%)

Low ≤ 88 < 3Intermediate 89-118 3-8High >118 > 8

http:/www.outcomes-umassmed.org/grace/

Risk Scores

The risk of death and cardiovascular events after ACS varies widely.Accurate identification of patients with the highest clinical risk will make itpossible to help those who may benefit from closer follow-up and more


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aggressive treatment and, in general, improve the prognosis of ACS.Consequently, risk stratification is a key component of ACS management.

Various scores based on multivariate statistical models have been developed

to predict ACS risk, and several risk models are available for ST-segmentelevation ACS (STEACS): Thrombolysis In Myocardial Infarction (TIMI), theControlled Abciximab and Device Investigation to Lower Late AngioplastyComplications (CADILLAC), and the Primary Angioplasty in MyocardialInfarction (PAMI). In non-STEACS, the risk model most widely used is theGlobal Registry for Acute Coronary Events (GRACE). However, there is a paucityof data on the comparative prognostic value of these risk models in STEACS. Elizabet Méndez-Eirín

Several risk stratification scores have been developed and validated inlarge patient populations. In clinical practise, two risk scores that arecommonly used are:

TIMI Risk Score- it is less accuratein predicting but is simple andwidely accepted. Antman EM et al

GRACE risk scores.

Both risk scores confer additional important prognostic value beyond global

risk assessment by physicians. These validated risk scores may refine riskstratification, thereby improving patient care in routineclinical practise.

TIMI Risk Score Antman EM, Cohen M et al

The TIMI risk score is determined by the sum of presence of sevenvariables at admission.

One point is given for each the following variables :

1. Age 65 years or older

2. At least 3 risk factors for Coronar Artery Disease ( family history ofpremature CAD, hypertension, elevated cholestrols, active smoker,diabetes melitus )

3. Known CAD ( coronary stenosis of ≥ 50% )

4. Use of Aspirin in prior 7 days


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5. ST-segment deviation ( ≥ 0,5 mm ) on Electrocardiography

6. At least two anginal episodes in prior 24 hours

7. Elevated serum cardiac biomarkers

Total score = 7 points; Low risk : ≤ 2 point; Moderate risk : 3-4 points; ≥ 5points.

TIMI Risk Score All-cause Mortality, New or RecurrentMI, or severe Recurrent Ischemiarequiring Urgent Revascularizationthrough 14 days afterrandomization(%)

0-1 4,72 8,33 13,24 19,95 26,2

6-7 40,9Sabatine MS, Morrow DA, et al

GRACE Risk Score Emad Abu-Assi , et al

Heart Rate (beats One of the major achievements of the main GRACEProgramme was development of a clinical risk prediction tool for estimating thecumulative risk of death and death or myocardial infarction to aid triage andmanagement of patients with ACS. Known as the GRACE Risk Score, thismodel was originally developed to estimate the risk of in-hospital mortality for

patients presenting to hospital with a suspected ACS. The model was furtherdeveloped to include prediction of mortality 6 months post discharge. Followingrecognition that there was a requirement for a comprehensive risk model to

predict not only death, but death or myocardial infarction for up to a period of 6months after hospital discharge, the GRACE Risk Score was again furtherdeveloped. 8 clinical variables were involved in calculating the risk for death,and death or myocardial infarction from admission to hospital to 6 months afterdischarge. It is this version which has been most widely applied in clinicalsettings for estimation of risk for patients with ACS.

8 Clinical Variables

1. Age (years)2. Heart rate (per minute)


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3. Systolic blood pressure (mmHg)4. Creatinine (mg/dL or μmol/L) 5. Congestive Heart Failure (Killip)6. Cardiac arrest at admission

7. ST-segment deviation8. Elevated cardiac enzymes/biomarkers.

Emad Abu-Assi a, José M. García-Acuña a, Carlos Peña-Gil a, José R. González-Juanatey a

Non STE-ACS: 6 Month Post-discharge Mortality


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REFERENCES

1. Murray CJ, Lopez AD. Alternative projections of mortality and disability

by cause 1990-2020: Global Burden of Disease Study. Lancet 1997;349:1498-1504.

2. Bassand JP, Hamm CW, et al. Guidelines for the diagnosis and treatmentof non-ST-segment elevation acute coronary syndromes. Eur Heart J2007;28:1598-1660.

3. Yeh RW,Sidney S,Chandra M, et al. Population trends in the Incidenceand outcomes of acute myocardial infarction. N Eng J Med 2010;362:2155-65.

4. Braunwald E, Antman EM, Beasley JW, et al: ACC/AHA Guideline updatefor the management of patients with unstable angina and NSTEMI2002.Circulation 106:1893-900.2002.

5. The Task Force for Diagnosis & Treatment NSTE-Acute CoronarySyndrome of the European Society of Cardiology, 2007

6. Antman EM , Cohen M, Bernink PJ et al. The TIMI risk score for unstableangina/NSTEMI: a method for prognostification and therapeutic decisionmaking.JAMA 2000;284:835-42.

7. Sabatine MS, Morrow DA, Giugliano RP et al. Implications of upstreamGPIIb/IIa inhibition and coronary artery stenting in the invasive management ofunstable angina/NSTEMI.A Comparison of the Thrombolysis in MyocardialInfarction (TIMI) IIIB trial and the treat angina with Aggrastat and determinecost of therapy with invasive or conservative strategy(TACTICS)-TIMI 18trial.Circulation 2004;109:874-880.

Risk Category(tertiles)

GRACERisk Score

Probability of DeathPost-discharge to

6 Months (%)

Low 1-88 8


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8. Ardissino D, Boersma E, Budaj A, Fernández-Avilés F, Fox KA, Hasdai D, etal. Guía de Práctica Clínica para el diagnóstico y tratamiento del síndromecoronario agudo sin elevación del segmento ST. Rev Esp Cardiol.2007;60:1070.e1-e80.9. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr,et al. ACC/AHA 2007 guidelines for the management of patients with unstableangina/non-ST-Elevation myocardial infarction. Am Coll Cardiol. 2007;50:e1-e157.

10. Emad Abu-Assi a, José M. García-Acuña a, Carlos Peña-Gil a, José R.González-Juanatey .Validation of the GRACE Risk Score for Predicting Death

Within 6 Months of Follow-Up in a Contemporary Cohort of Patients WithAcute Coronary Syndrome. Vol 63. Num 06. June 2010.

11. Elizabet Méndez-Eirín, Xacobe Flores-Ríos et al. Comparison of thePrognostic Predictive Value of the TIMI, PAMI, CADILLAC, and GRACERisk Scores in STEACS Undergoing Primary or Rescue PCI. Rev Esp Cardiol.2012;65:227-33. - Vol. 65 Num.03 DOI: 10.1016/j.rec.2011.10.021

GRACE Variable Definitions – Version of March 2006

Page1GRACE STANDARD DIAGNOSISSTEMINew or presumed new ST-elevation >1 mm seen in any location on theindexECG or on any subsequent ECG, together with one or more positiveenzymes, based on laboratory ranges in use at each hospital.Non-STEMINo new ST-elevation seen on the index or on any subsequent ECG, withone

http://revespcardiol.org/en/vol-63-num-06/sumario/13008469/http://revespcardiol.org/en/vol-63-num-06/sumario/13008469/http://www.outcomes-umassmed.org/grace/Files/Standard_Definitions.pdf#page=7http://www.outcomes-umassmed.org/grace/Files/Standard_Definitions.pdf#page=6http://www.outcomes-umassmed.org/grace/Files/Standard_Definitions.pdf#page=5http://www.outcomes-umassmed.org/grace/Files/Standard_Definitions.pdf#page=4http://www.outcomes-umassmed.org/grace/Files/Standard_Definitions.pdf#page=3http://www.outcomes-umassmed.org/grace/Files/Standard_Definitions.pdf#page=2http://www.outcomes-umassmed.org/grace/Files/Standard_Definitions.pdf#page=1http://revespcardiol.org/en/vol-63-num-06/sumario/13008469/


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or more positive cardiac enzymes, based on laboratory ranges in use ateachhospital.Unstable angina

Negative enzyme findings, CRF discharge diagnosis of ACS.Other cardiac/non-cardiacCases where these were the only discharge diagnoses.ENROLLMENT CRITERIAPatients must meet the following criteria:• Must have one of the Acute Coronary Syndromes as a presumptivediagnosis•

Must be≥ 18 years old.• Must be alive at the time of hospital presentation.• The qualifying acute coronary syndrome must not have been precipitatedor accompanied by a significant co-morbidity such as a motor vehicle

accident, trauma, severe gastrointestinal bleeding, operation orprocedure. Inpatients who develop ACS symptoms while hospitalized forany reason are not eligible for enrollment in GRACE.• Patients transferred into or out of a registry hospital can be enrolledregardless of the time spent at the transferring hospital.• For patients transferred out of a registry hospital, data collection for theInitial CRF will end with the transfer and indication of purpose of transfer.•

Patients may be re-enrolled in GRACE provided that≥ 6 months haspassed since their prior enrollment. When a patient is re-enrolled, a newpatient number must be assigned.• The criteria for ACS as defined below must be met, with one exception:• Patients hospitalized for < 1 day that die and do not meet the criteria maybe enrolled provided that the cause of death is confirmed to be due to

ACS.


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• Patients who meet eligibility criteria and who die shortly after admissione.g. in the emergency room should also be included.

Acute Coronary Syndromes

(Including Unstable or Intermediate Coronary Syndromes AND/OR AcuteMyocardial Infarction):GRACE Variable Definitions

– Version of March 2006Page2Eligible patients should have symptoms considered as consistent withacute cardiac ischemia within 24 hours of hospital presentation.They should also have at least one of the following:•

ECG Changes− Transient ST segment elevations of≥ 1 mm∗ − ST segment depressions of≥ 1mm− New T wave inversions of≥ 1mm∗ − Pseudo-normalization of previously inverted T waves∗ −

New Q-waves (1/3 the height of the R wave or≥ 0.04 seconds)∗ − New R wave > S wave in lead V1

(posterior MI)− New left bundle branch block∗ Changes should be seen in two or more contiguous leads.


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• Documentation of Coronary Artery Disease− History of MI, angina, CHF felt to be due to ischemia or resuscitated

sudden cardiac death− History of, or new positive stress test, with or without imaging− Prior, or new, cardiac catheterization documenting coronary arterydisease− Prior, or new, percutaneous coronary intervention or coronary arterybypass surgery•

Increase in Cardiac Enzymes− CK-MB > 2x upper limit of the hospital’s normal range or if no CK -MBavailable, then total CPK > 2x upper limit of the hospital’s normal range.− Positive troponin I− Positive troponin TNOTE: Patients with unstable or intermediate coronary syndromes whoare hospitalized for < 1 day cannot qualify for GRACE based onsymptoms and history alone (i.e., they must have one of the ECGchanges or new documentation of CAD as listed above).MEDICAL HISTORY - SELECTED DEFINITIONSSmokerHistory of cigarette smoking (pipe and cigar smoking is excluded).Smoker Codes• Former smoker – defined as previous smoker who reports having quit

smoking cigarettes >1 month prior to admission.• Current smoker – defined as person who reports active smoking ofcigarettes within one month prior to this admission.• Smoking status not recorded i.e. no information in case notes availableon the patient’s smoking status.DiabetesPrevious diagnosis of diabetes mellitus regardless of duration of disease orneed for anti-diabetic agents. Patient may have been treated with diet, oralhypoglycemic agents or insulin at any time prior to hospitalization. Record


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GRACE Variable Definitions – Version of March 2006Page3

the patient’scurrent treatment at presentationusing the following treatmenttypes:Diabetes Treatment Types• Diet controlled• Oral hypoglycemics•

Insulin-dependent• No treatment or diet regimen being used• Type not recordedRenalInsufficiency

Any documented history of renal compromise.MEDICATION CONTRAINDICATIONS

ASA• patients with true allergy to aspirin• patient with active bleeding on admission• patient admitted on warfarin (coumadin)• patient refuses aspirin•

taking other antiplatelet medication• taking nonsteroidal anti-inflammatory agents (NSAID)• other documented reasonBeta Blockers• allergy or intolerance to beta blockers• bradycardia (heart rate < 60 bpm) while not on a beta blocker•


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symptomatic heart failure• systolic blood pressure less than 100mmHg•

PR intervals greater than 0.24 seconds on electrocardiogram (ECG)• second or third degree heart block on ECG• asthma

ACE Inhibitors• allergy or intolerance to ACE Inhibitors• patients on an angiotensin receptor blocking agent (ARB)

• moderate or severe aortic stenosis• bilateral renal artery stenosis• history of angioedema, hives, or rash with ACEI use other reasons, such ashyperkalemia, symptomatic hypotension, severe renal dysfunction

ARB• allergy or intolerance to ARB• patients on ACE Inhibitors• bilateral renal artery stenosis• severe CHF• hepatic insufficiencyGRACE Variable Definitions

– Version of March 2006Page4Statins• acute liver disease• hypersensitivity to HMG-CoA reductase inhibitors• alcohol abuse•


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history of, or suspected rhabdomolysisLMWH• major bleeding disorders

• thrombocytopenia• active gastric or duodenal ulceration• recent ischemic CVA• any patient with increased risk of hemorrhage• uncontrolled severe hypertension

• hypersensitivity to LMWHUnfractionatedHeparin• major bleeding disorders• thrombocytopenia• peptic ulcer• recent cerebral hemorrhage• severe hypertension• severe liver disease• renal failure•

recent trauma (including surgery)• hypersensitivity to heparinIN-HOSPITAL EVENTSCHF/PulmonaryEdemaCHF=CongestiveHeart Failure.Criteria same as Killip Class II: Bibasilar rales in50% or lessof lung fields,or


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an S3 heart sound.Pulmonary Edema = Criteria same as Killip Class III: Bibasilar rales inmorethan 50%

of lung fields.CardiogenicShockCriteria same asKillip Class IV: Pulmonary edema and hypo perfusioncharacterized by systolic BP < 80mmHg.Cardiac

Arrest/VF (afterpresentation)

Ventricular Fibrillation, Rapid ventricular tachycardia with hemodynamicinstability, asystole, or EMD (Electrical-Mechanical Dissociation) requiringCPR.

AtrialFib/FlutterDocumented in physician’s note or by ECG documentation. Sustained VT(after presentation)SustainedVT (Ventricular Tachycardia): Documented in physician’s note orby ECG documentation and requiring intervention.Thrombocyto-peniaThrombocytopenia - any etiology.Defined as documented platelet levels < the lower limit of normal for thelocallaboratory.GRACE Variable Definitions

– Version of March 2006

Page5HITHIT = Heparin Induced Thrombocytopenia defined asThrombocytopenia occurring≥ to 4 days post initiation of heparin withplatelets < 100,000 or≥ 50% drop from baseline AND one of the (HIT)following:1. Associated with venous or arterial thrombotic event,


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OR2. Positive assay for heparin associated antibodies (C-serotonin, ELISA,platelet aggregation study, etc.)OR

3. If only clinical diagnosis of HIT, thrombocytopenia promptingdiscontinuation of heparin product.VenousThrombo-embolism

Any documented evidence of acute deep vein thrombosis (DVT) and/orpulmonary embolism (PE) during index hospitalization.

Acute RenalFailure

Acute renal failure with oliguria

andelevation of creatinine > 2.0 mg/dl or177 μmol/l.

AV Block(Mobitz II, 3rddegree)

Atrio-ventricular block: as shown on ECG:Mobitz II 2 degree (second degree), 3 degree (third degree) or complete

AVblock.MechanicalComplicationVentricular Septal DefectMitral RegurgitationFree Wall RuptureMI > 24 hoursafter hospitalpresentation/Re-infarction

MI is documented by positive markers with the time of the first positivemarkerdetermining the time of diagnosis.1. Patients with an admission diagnosis of unstable angina who develop anMI> 24 hours after presentation.Note: The biomarker (troponin, CPK or CKMB) confirming the MI should bedrawn beyond the first 24 hours of presentation to hospital.2. Patients who are diagnosed with an MI after CABG or a PCI (and > 24hours after presentation) as long as they qualified forGRACE


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prior to theCABG or PCI.Post CABG or PCI Myocardial Infarction Criteria•

Following PCI, CK-MB (or CPK) elevation must be > 3 X ULN• Following CABG, CK-MB (or CPK) must be > 5 X ULN3. Patients who are diagnosed as having had a recurrent MI confirmed byECG changes or elevation of cardiac markers.Criteria for patients with an initial diagnosis of MI as the qualifying eventwho subsequently reinfarct.GRACE Variable Definitions

– Version of March 2006Page

6In patients with acute MI as the qualifying event, marker criteria forrecurrentinfarction are:

A.re-elevationof the CK-MB to above the ULN and increased by at least50% over the previous value.B. If CK-MB is not available, thenre-elevationof total CPK must be either> 2 X ULN and increased by 25% over the previous value, or > 1.5 XULN and increased by at least 50% over the previous value.C. Following PCI, CK-MB (or CK) elevation must be > 3 X ULN andincreased by at least 50% over previous value.D. Following CABG, the criteria for recurrent infarction requirebothenzyme criteria in C. above and ECG changes consistent with MI.Stroke

Stroke-related neurological signs or symptoms, e.g., loss or slurring ofspeech, altered state of consciousness.Confirmed by either computed tomography or magnetic resonanceimaging.Stroke type:Embolic/IschemicEmbolic w/Hemorrhagic ConversionHemorrhagic/ Subdural HematomaOtherMajor Bleeding(except


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hemorrhagicstroke)Life-threatening bleeding requiring a transfusion of 2 or more units ofpacked

red cells or resulting in an absolute decrease in Hematocrit of≥ 10% orresulting in death. (Excludes bleeding post CABG surgery)OUTCOMES (6-MONTH FOLLOW-UP)DeathRecordNo, if the patient was alive at the time of the 6-month follow-up.Record

Yes,if the patient died during the 6 months following discharge fromthe hospital. IfYes, record the day, month, and year that the patient died. Ifyou are unable to determine the exact day of death, please report theapproximate day or even justthe month and year of death.Indicate the main cause of death as one of the following:CardiacTraumaSuicidePulmonary EmbolismOther Non-CardiacIf the patient died in the 6-month follow-up period, please endeavor tocomplete all information on unscheduled re-hospitalization, MI, stroke andprocedures.GRACE Variable Definitions

– Version of March 2006

Page7MIRecordYes,if a Myocardial Infarction was diagnosed (or if the patientreported that an MI was diagnosed) at any time during period postdischargeup to 6-month follow-up point.If a patient was re-admitted into thehospital with a clinical syndrome of suspected acute ischemia, with a


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positive rise in troponin, or CKMB, then record this event as aMyocardial Infarction even if the discharge diagnosis in the patient chartwas either unstable angina, or acute coronary syndrome.(This is based on the current ACC/ESC guidelines regarding the

definition of MI).If Myocardial Infarction was reported asYes,record date ofmyocardial infarction. If more than one myocardial infarction occurred,recordthe date of the first myocardial infarction. RecordNo,ifno

MyocardialInfarction was diagnosed.

GRACE Variable Definitions – Version of March 2006Page1GRACE STANDARD DIAGNOSISSTEMINew or presumed new ST-elevation >1 mm seen in any location on theindexECG or on any subsequent ECG, together with one or more positiveenzymes, based on laboratory ranges in use at each hospital.Non-STEMINo new ST-elevation seen on the index or on any subsequent ECG, withone

or more positive cardiac enzymes, based on laboratory ranges in use ateachhospital.Unstable anginaNegative enzyme findings, CRF discharge diagnosis of ACS.Other cardiac/non-cardiacCases where these were the only discharge diagnoses.ENROLLMENT CRITERIAPatients must meet the following criteria:• Must have one of the Acute Coronary Syndromes as a presumptive


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diagnosis• Must be≥

18 years old.• Must be alive at the time of hospital presentation.• The qualifying acute coronary syndrome must not have been precipitatedor accompanied by a significant co-morbidity such as a motor vehicleaccident, trauma, severe gastrointestinal bleeding, operation orprocedure. Inpatients who develop ACS symptoms while hospitalized forany reason are not eligible for enrollment in GRACE.• Patients transferred into or out of a registry hospital can be enrolledregardless of the time spent at the transferring hospital.• For patients transferred out of a registry hospital, data collection for theInitial CRF will end with the transfer and indication of purpose of transfer.• Patients may be re-enrolled in GRACE provided that≥

6 months haspassed since their prior enrollment. When a patient is re-enrolled, a newpatient number must be assigned.• The criteria for ACS as defined below must be met, with one exception:• Patients hospitalized for < 1 day that die and do not meet the criteria maybe enrolled provided that the cause of death is confirmed to be due to

ACS.• Patients who meet eligibility criteria and who die shortly after admissione.g. in the emergency room should also be included.

Acute Coronary Syndromes(Including Unstable or Intermediate Coronary Syndromes AND/OR AcuteMyocardial Infarction):GRACE Variable Definitions

– Version of March 2006Page2Eligible patients should have symptoms considered as consistent withacute cardiac ischemia within 24 hours of hospital presentation.


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They should also have at least one of the following:• ECG Changes−

Transient ST segment elevations of≥ 1 mm∗ − ST segment depressions of≥ 1mm− New T wave inversions of≥ 1mm∗ − Pseudo-normalization of previously inverted T waves∗ − New Q-waves (1/3 the height of the R wave or≥ 0.04 seconds)∗ − New R wave > S wave in lead V1

(posterior MI)− New left bundle branch block∗ Changes should be seen in two or more contiguous leads.

• Documentation of Coronary Artery Disease− History of MI, angina, CHF felt to be due to ischemia or resuscitatedsudden cardiac death− History of, or new positive stress test, with or without imaging− Prior, or new, cardiac catheterization documenting coronary arterydisease

− Prior, or new, percutaneous coronary intervention or coronary artery


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bypass surgery• Increase in Cardiac Enzymes−

CK-MB > 2x upper limit of the hospital’s normal range or if no CK -MBavailable, then total CPK > 2x upper limit of the hospital’s normal range.− Positive troponin I− Positive troponin TNOTE: Patients with unstable or intermediate coronary syndromes whoare hospitalized for < 1 day cannot qualify for GRACE based onsymptoms and history alone (i.e., they must have one of the ECG

changes or new documentation of CAD as listed above).MEDICAL HISTORY - SELECTED DEFINITIONSSmokerHistory of cigarette smoking (pipe and cigar smoking is excluded).Smoker Codes• Former smoker – defined as previous smoker who reports having quitsmoking cigarettes >1 month prior to admission.• Current smoker – defined as person who reports active smoking ofcigarettes within one month prior to this admission.• Smoking status not recorded i.e. no information in case notes availableon the patient’s smoking status.DiabetesPrevious diagnosis of diabetes mellitus regardless of duration of disease orneed for anti-diabetic agents. Patient may have been treated with diet, oralhypoglycemic agents or insulin at any time prior to hospitalization. RecordGRACE Variable Definitions

– Version of March 2006Page3the patient’scurrent treatment at presentationusing the following treatmenttypes:Diabetes Treatment Types• Diet controlled•


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Oral hypoglycemics• Insulin-dependent•

No treatment or diet regimen being used• Type not recordedRenalInsufficiency

Any documented history of renal compromise.MEDICATION CONTRAINDICATIONS

ASA• patients with true allergy to aspirin

• patient with active bleeding on admission• patient admitted on warfarin (coumadin)• patient refuses aspirin• taking other antiplatelet medication• taking nonsteroidal anti-inflammatory agents (NSAID)• other documented reasonBeta Blockers• allergy or intolerance to beta blockers• bradycardia (heart rate < 60 bpm) while not on a beta blocker• symptomatic heart failure

• systolic blood pressure less than 100mmHg• PR intervals greater than 0.24 seconds on electrocardiogram (ECG)• second or third degree heart block on ECG• asthma

ACE Inhibitors• allergy or intolerance to ACE Inhibitors


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• patients on an angiotensin receptor blocking agent (ARB)• moderate or severe aortic stenosis

• bilateral renal artery stenosis• history of angioedema, hives, or rash with ACEI use other reasons, such ashyperkalemia, symptomatic hypotension, severe renal dysfunction

ARB• allergy or intolerance to ARB• patients on ACE Inhibitors

• bilateral renal artery stenosis• severe CHF• hepatic insufficiencyGRACE Variable Definitions

– Version of March 2006Page4Statins• acute liver disease• hypersensitivity to HMG-CoA reductase inhibitors• alcohol abuse• history of, or suspected rhabdomolysis

LMWH• major bleeding disorders• thrombocytopenia• active gastric or duodenal ulceration• recent ischemic CVA• any patient with increased risk of hemorrhage


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• uncontrolled severe hypertension• hypersensitivity to LMWH

UnfractionatedHeparin• major bleeding disorders• thrombocytopenia• peptic ulcer• recent cerebral hemorrhage

• severe hypertension• severe liver disease• renal failure• recent trauma (including surgery)• hypersensitivity to heparinIN-HOSPITAL EVENTSCHF/PulmonaryEdemaCHF=CongestiveHeart Failure.Criteria same as Killip Class II: Bibasilar rales in50% or lessof lung fields,or

an S3 heart sound.Pulmonary Edema = Criteria same as Killip Class III: Bibasilar rales inmorethan 50%of lung fields.CardiogenicShockCriteria same asKillip Class IV: Pulmonary edema and hypo perfusioncharacterized by systolic BP < 80mmHg.Cardiac


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Arrest/VF (afterpresentation)Ventricular Fibrillation, Rapid ventricular tachycardia with hemodynamicinstability, asystole, or EMD (Electrical-Mechanical Dissociation) requiring

CPR. AtrialFib/FlutterDocumented in physician’s note or by ECG documentation.Sustained VT(after presentation)SustainedVT (Ventricular Tachycardia): Documented in physician’s note orby ECG documentation and requiring intervention.Thrombocyto-

peniaThrombocytopenia - any etiology.Defined as documented platelet levels < the lower limit of normal for thelocallaboratory.GRACE Variable Definitions

– Version of March 2006Page5HITHIT = Heparin Induced Thrombocytopenia defined asThrombocytopenia occurring≥ to 4 days post initiation of heparin withplatelets < 100,000 or≥ 50% drop from baseline AND one of the (HIT)following:1. Associated with venous or arterial thrombotic event,

OR2. Positive assay for heparin associated antibodies (C-serotonin, ELISA,platelet aggregation study, etc.)OR3. If only clinical diagnosis of HIT, thrombocytopenia promptingdiscontinuation of heparin product.VenousThrombo-embolism

Any documented evidence of acute deep vein thrombosis (DVT) and/orpulmonary embolism (PE) during index hospitalization.

Acute Renal


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Failure Acute renal failure with oliguriaandelevation of creatinine > 2.0 mg/dl or

177 μmol/l. AV Block(Mobitz II, 3rddegree)

Atrio-ventricular block: as shown on ECG:Mobitz II 2 degree (second degree), 3 degree (third degree) or complete

AVblock.MechanicalComplication

Ventricular Septal DefectMitral RegurgitationFree Wall RuptureMI > 24 hoursafter hospitalpresentation/Re-infarctionMI is documented by positive markers with the time of the first positivemarkerdetermining the time of diagnosis.1. Patients with an admission diagnosis of unstable angina who develop anMI> 24 hours after presentation.Note: The biomarker (troponin, CPK or CKMB) confirming the MI should bedrawn beyond the first 24 hours of presentation to hospital.2. Patients who are diagnosed with an MI after CABG or a PCI (and > 24hours after presentation) as long as they qualified forGRACEprior to the

CABG or PCI.Post CABG or PCI Myocardial Infarction Criteria• Following PCI, CK-MB (or CPK) elevation must be > 3 X ULN• Following CABG, CK-MB (or CPK) must be > 5 X ULN3. Patients who are diagnosed as having had a recurrent MI confirmed byECG changes or elevation of cardiac markers.Criteria for patients with an initial diagnosis of MI as the qualifying eventwho subsequently reinfarct.GRACE Variable Definitions


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– Version of March 2006Page6In patients with acute MI as the qualifying event, marker criteria for

recurrentinfarction are: A.re-elevationof the CK-MB to above the ULN and increased by at least50% over the previous value.B. If CK-MB is not available, thenre-elevationof total CPK must be either> 2 X ULN and increased by 25% over the previous value, or > 1.5 X

ULN and increased by at least 50% over the previous value.C. Following PCI, CK-MB (or CK) elevation must be > 3 X ULN andincreased by at least 50% over previous value.D. Following CABG, the criteria for recurrent infarction requirebothenzyme criteria in C. above and ECG changes consistent with MI.StrokeStroke-related neurological signs or symptoms, e.g., loss or slurring ofspeech, altered state of consciousness.Confirmed by either computed tomography or magnetic resonanceimaging.Stroke type:Embolic/IschemicEmbolic w/Hemorrhagic ConversionHemorrhagic/ Subdural HematomaOtherMajor Bleeding(excepthemorrhagic

stroke)Life-threatening bleeding requiring a transfusion of 2 or more units ofpackedred cells or resulting in an absolute decrease in Hematocrit of≥ 10% orresulting in death. (Excludes bleeding post CABG surgery)OUTCOMES (6-MONTH FOLLOW-UP)DeathRecordNo


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, if the patient was alive at the time of the 6-month follow-up.RecordYes,if the patient died during the 6 months following discharge from

the hospital. IfYes, record the day, month, and year that the patient died. Ifyou are unable to determine the exact day of death, please report theapproximate day or even justthe month and year of death.Indicate the main cause of death as one of the following:CardiacTraumaSuicide

Pulmonary EmbolismOther Non-CardiacIf the patient died in the 6-month follow-up period, please endeavor tocomplete all information on unscheduled re-hospitalization, MI, stroke andprocedures.GRACE Variable Definitions

– Version of March 2006Page7MIRecordYes,if a Myocardial Infarction was diagnosed (or if the patientreported that an MI was diagnosed) at any time during period postdischargeup to 6-month follow-up point.If a patient was re-admitted into thehospital with a clinical syndrome of suspected acute ischemia, with apositive rise in troponin, or CKMB, then record this event as a

Myocardial Infarction even if the discharge diagnosis in the patient chartwas either unstable angina, or acute coronary syndrome.(This is based on the current ACC/ESC guidelines regarding thedefinition of MI).If Myocardial Infarction was reported asYes,record date ofmyocardial infarction. If more than one myocardial infarction occurred,recordthe date of the first myocardial infarction. RecordNo,


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ifnoMyocardialInfarction was diagnosed.

REFERENCES

1. Murray CJ, Lopez AD. Alternative projections of mortality and disabilityby cause 1990-2020: Global Burden of Disease Study. Lancet 1997;349:1498-1504.

2. Bassand JP, Hamm CW, et al. Guidelines for the diagnosis and treatmentof non-ST-segment elevation acute coronary syndromes. Eur Heart J2007;28:1598-1660.

3. Yeh RW,Sidney S,Chandra M, et al. Population trends in the Incidenceand outcomes of acute myocardial infarction. N Eng J Med 2010;362:2155-65.

4. Braunwald E, Antman EM, Beasley JW, et al: ACC/AHA Guideline updatefor the management of patients with unstable angina and NSTEMI2002.Circulation 106:1893-900.2002.

5. The Task Force for Diagnosis & Treatment NSTE-Acute CoronarySyndrome of the European Society of Cardiology, 2007

6. Antman EM , Cohen M, Bernink PJ et al. The TIMI risk score for unstableangina/NSTEMI: a method for prognostification and therapeutic decisionmaking.JAMA 2000;284:83

Comparison of the Prognostic PredictiveValue of the TIMI, PAMI, CADILLAC, andGRACE Risk Scores in STEACSUndergoing Primary or Rescue PCI


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Elizabet Méndez-Eirín a, Xacobe Flores-Ríos a, , Fernando García-López a, Alberto J. Pérez-Pérez a,Rodrigo Estévez-Loureiro a, Pablo Piñón-Esteban a, Guillermo Aldama-López a, Jorge Salgado-Fernández a, Ramón A. Calviño-Santos a, José M. Vázquez Rodríguez a, Nicolás Vázquez-González a,Alfonso Castro-Beiras

Rev Esp Cardiol. 2012;65:227-33. - Vol. 65 Num.03 DOI: 10.1016/j.rec.2011.10.021

The risk of death and cardiovascular events after ACS varies widely .2 Accurateidentification of patients with the highest clinical risk will make it possible tohelp those who may benefit from closer follow-up and more aggressivetreatment and, in general, improve the prognosis of ACS. Consequently, riskstratification is a key component of ACS management.

Various scores based on multivariate statistical models have been developed to

predict ACS risk, and several risk models are available for ST-segmentelevation ACS (STEACS): Thrombolysis In Myocardial Infarction (TIMI) ,3 theControlled Abciximab and Device Investigation to Lower Late AngioplastyComplications (CADILLAC) ,4 and the Primary Angioplasty in MyocardialInfarction (PAMI) .5 In non-STEACS, the risk model most widely used is theGlobal Registry for Acute Coronary Events (GRACE) .6 However, there is a

paucity of data on the comparative prognostic value of these risk models inSTEACS .7

The purpose of this paper is to compare the prognostic predictive value of these4 scores in STEACS in our setting, in which percutaneous coronary intervention(PCI) is the reperfusion strategy of choice.

CONCLUSIONS

The TIMI, PAMI, CADILLAC, and GRACE clinical models are an excellent tool for thestratification of mortality risk in patients who undergo primary or rescue PCI. The TIMI,CADILLAC, and GRACE scores have a greater predictive capacity for 30-day and 365-daymortality than the PAMI score. In contrast with previously published studies, the usefulnessof these risk models in STEACS undergoing PCI for the prediction of re-AMI and TVR is

questionable, given the poor predictive capacity in our series.
mailto:[email protected]://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib2http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib2http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib2http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib3http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib3http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib3http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib4http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib4http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib4http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib5http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib5http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib5http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib6http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib6http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib6http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib7http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib7http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib7mailto:[email protected]://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib7http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib6http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib5http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib4http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib3http://www.revespcardiol.org/en/comparison-of-the-prognostic-predictive/articulo/90098388/#bib2

2.1 Risk Score for UA NSTEMI - dr. Rukma Sp.JP.pdf

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