The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. ...Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.
Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base ...has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.
Le traitement antiplaquettaire (TAP) constitue désormais un outil important dans le traitement et la prévention des événements athérosclérotiques, particulièrement ceux qui sont associés à la coronaropathie. Le vaste corpus de données scientifiques a évolué sur la relation entre l’ordonnance de TAP dans les divers contextes cliniques et les rapports bénéfices/risques. Le comité des lignes directrices de la Société canadienne de cardiologie et de l’Association canadienne de cardiologie d’intervention actualise et publie régulièrement ses recommandations en tenant compte des données probantes cliniques les plus récentes. La mise à jour des lignes directrices sur le TAP de la Société canadienne de cardiologie de 2011 et 2013 intègre de nouvelles données probantes sur la façon d’optimiser l’utilisation du TAP, particulièrement dans les situations où il existait peu ou pas de données. La mise à jour des recommandations porte principalement sur les sujets suivants : 1) la durée du double TAP (DTAP) chez les patients qui subissent l’intervention coronarienne percutanée (ICP) en raison d’un syndrome coronarien aigu ou d’un syndrome coronarien non aigu ; 2) la prise en charge du DTAP chez les patients qui subissent une intervention chirurgicale non cardiaque ; 3) la prise en charge du DTAP chez les patients qui subissent un pontage aortocoronarien non urgent ou semi-urgent ; 4) le moment et la façon de passer d’un traitement antiplaquettaire par voie orale à un autre ; 5) la prise en charge du TAP et de l’anticoagulothérapie chez les patients qui subissent une ICP. Chez les patients qui subissent l’ICP, nous analysons notamment les considérations particulières chez les patients qui souffrent de fibrillation auriculaire, qui portent des valves mécaniques ou bioprothétiques (y compris ceux qui ont subi un remplacement valvulaire aortique par cathéter), qui souffrent d’une maladie thrombo-embolique veineuse et dont le diagnostic de thrombus ventriculaire gauche est établi ou dont le diagnostic de thrombus ventriculaire gauche avec fraction d’éjection réduite après l’infarctus du myocarde avec sus-décalage du segment ST est possible. En plus des recommandations particulières, nous donnons des valeurs, des préférences et des conseils pratiques pour aider le clinicien praticien dans l’utilisation quotidienne de ces importants agents.
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute ...hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
Ticagrelor was shown to reduce mortality in patients who underwent coronary artery bypass grafting (CABG), but its effect on graft patency is unknown.
We performed a prospective, randomised, ...double-blind, placebo-controlled trial, comparing ticagrelor 90 mg twice daily versus placebo for 3 months added to aspirin 81 mg/day, following isolated CABG. Aspirin was started within 12 h, and study medication within 72 h after CABG. Primary outcome was graft occlusion on CT angiography (CTA) performed 3 months post CABG. Patients were followed to 12 months for death, myocardial infarction, stroke, repeat revascularisation and bleeding.
The study was terminated prematurely after randomising 70 patients between September 2011 and August 2014 because of slow recruitment. CTA was performed in 56 patients who completed >1 month of study drug. Graft occlusion occurred in 7/25 (28.0%) patients on ticagrelor and 17/31 (48.3%) on placebo, p=0.044. Of 207 analysable grafts, graft occlusion occurred in 9/87 (10.3%) with ticagrelor and 22/120 (18.3%) with placebo, p=0.112. Graft occlusion or stenosis ≥50% occurred in 10/87 (11.5%) ticagrelor vs 32/120 (26.7%) placebo, p=0.007. There was no major bleeding, but minor bleeding was higher with ticagrelor (31.4% vs 2.9%, p=0.003). In univariate analysis, ticagrelor use reduced graft occlusion (OR 0.32, 95% CI 0.10 to 0.97, p=0.047), which remained significant on multivariable analysis (OR 0.25, 95% CI 0.073 to 0.873, p=0.03).
Ticagrelor added to aspirin after CABG reduced the proportion of patients with graft occlusion, and was a significant univariate and multivariable predictor of graft occlusion. These results are hypothesis-generating and should be confirmed in larger studies.
NCT01373411: Results.
Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada’s geography presents unique challenges for ...timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.
La reperfusion rapide de l’artère responsable de l’infarctus est la pierre angulaire thérapeutique de la prise en charge de l’infarctus aigu du myocarde avec élévation du segment ST (STEMI). Les caractéristiques géographiques du Canada posent des défis particuliers pour prodiguer aux patients victimes d’un STEMI une reperfusion dans les délais requis. Les lignes directrices sur l’STEMI de la Société canadienne de cardiologie et de l’Association canadienne de cardiologie d’intervention ont été élaborées pour formuler des recommandations sur la prise en charge aiguë optimale des patients victimes d’un STEMI sans égard à l’endroit où l’infarctus a été initialement constaté, que ce soit à l’extérieur ou dans un établissement en mesure ou incapable de pratiquer une intervention coronarienne percutanée. Nous avions prévu d’évaluer également et d’intégrer la prise en compte du sexe et du genre dans l’élaboration de nos recommandations. Malheureusement, le nombre insuffisant de femmes recrutées dans les essais avec répartition aléatoire, le manque de publications sur les critères d’évaluation principaux stratifiés en fonction du sexe et l’omission fréquente du sexe à titre de variable de l’étude dans la littérature limitaient la faisabilité d’une telle approche. Le système GRADE (« Grading Recommendations, Assessment, Development, and Evaluation ») a été utilisé pour formuler des recommandations précises, fondées sur des données probantes, pour le repérage précoce des patients victimes d’un STEMI, les aspects pratiques concernant le transport des patients, la prise de décision au sujet de la reperfusion au niveau régional, les interventions d’appoint préhospitalières (oxygène, opioïdes, traitement antiplaquettaire), ainsi que les aspects procéduraux de la reperfusion mécanique (voie d’accès, thrombectomie, traitement antithrombotique, étendue de la revascularisation). Une importance particulière est accordée à l’intégration de ces recommandations à un réseau régional structuré de prise en charge du STEMI et à l’élaboration de parcours appropriés de reperfusion et de transport dans chaque région. On s’attend à ce que ces lignes directrices servent de modèle pratique pour l’élaboration de systèmes de soins permettant d’offrir un traitement optimal à un large éventail de patients victimes d’un STEMI.
Among patients with out-of-hospital cardiac arrest (OHCA), the influence of pre- and in-hospital factors on long-term survival, readmission, and resource utilization is ill-defined, mainly related to ...challenges combining disparate data sources.
Adult nontraumatic OHCA from the British Columbia Cardiac Arrest Registry (January 2009 to December 2016) were linked to provincial datasets comprising comorbidities, medications, cardiac procedures, mortality, and hospital admission and discharge. Among hospital-discharge survivors, the 3-year end point of mortality or mortality and all-cause readmission was examined with the use of the Kaplan-Meier method and multivariable Cox regression model for predictors. The use of publicly funded home care and community services within 1 year after discharge also was evaluated.
Of the 10,674 linked, emergency medical services–treated adult OHCAs, 3230 were admitted to hospital and 1325 survived to hospital discharge. At 3 years after discharge, the estimated Kaplan-Meier survival rate was 84.1% (95% CI 81.7%-86.1%) and freedom from death or all-cause readmission was 31.8% (29.0%-34.7%). After exclusions, 26.6% (n = 315/1186) accessed residential or home care services within 1 year. Independent predictors of long-term outcomes included age and comorbidities, but also favourable arrest characteristics and in-hospital factors such as revascularization or receipt of an intracardiac defibrillator before discharge.
Among OHCA hospital survivors, the long-term death or readmission risk persists and is modulated by both pre- and in-hospital factors. However, only 1 in 4 survivors required residential or home care after discharge. These results support efforts to improve care processes to increase survival to hospital discharge.
Chez les patients qui subissent un arrêt cardiaque extrahospitalier (ACEH), l’influence des facteurs préhospitaliers et des facteurs liés au séjour hospitalier sur la survie à long terme, la réadmission et l’utilisation de ressources est mal comprise, principalement en raison des difficultés à agencer des renseignements provenant de sources disparates.
Les données au sujet des ACEH non traumatiques chez des adultes figurant au British Columbia Cardiac Arrest Registry (pour la période allant de janvier 2009 à décembre 2016) ont été associées aux ensembles de données de niveau provincial, notamment les données liées aux troubles concomitants, aux médicaments, aux interventions cardiaques, à la mortalité, à l’admission en hôpital et au congé de l’hôpital. Chez les patients ayant survécu jusqu’à leur congé, la mortalité au cours des trois années suivant le congé ainsi que la combinaison de la mortalité et de la réadmission toutes causes confondues au cours des trois années suivant le congé ont été analysées par la méthode de Kaplan-Meier, et les facteurs prédictifs ont été mod-élisés par une régression multivariée de Cox. Le recours à des soins à domicile financés par le système public et à des services de proximité dans la première année après le congé a également été évalué.
Parmi les 10 674 patients qui ont subi un ACEH et pour lesquels les services d’urgence ont été requis, 3 230 patients ont été admis à l’hôpital et 1 325 d’entre eux ont survécu jusqu’à leur congé de l’hôpital. Trois ans après le congé, le taux de survie estimé par la méthode de Kaplan-Meier s’élevait à 84,1 % (IC à 95 % : de 81,7 % à 86,1 %) et l’absence de décès ou d’hospitalisation toutes causes confondues touchait 31,8 % des patients (29,0 % à 34,7 %). Parmi les patients inclus dans l’analyse, 26,6 % (n = 315/1 186) ont eu recours à des services de soins en milieu résidentiel ou à domicile au cours de l’année suivant leur congé. Les facteurs prédictifs indépendants des résultats de santé à long terme comprenaient l’âge des patients et la présence de troubles concomitants, mais également des caractéristiques favorables relatives à l’arrêt cardiaque et des facteurs liés à l’hospitalisation comme la revascularisation ou l’implantation d’un défibrillateur cardiaque avant le congé.
Parmi les patients ayant survécu à un ACEH et ayant nécessité une hospitalisation, le risque de décès ou de réadmission hospitalière persiste à long terme, et ce risque est modulé par des facteurs préhospitaliers et des facteurs liés à l’hospitalisation. Toutefois, seulement un patient sur quatre requiert des soins en milieu résidentiel ou à domicile après le congé. Ces résultats viennent appuyer les efforts visant l’amélioration des processus de soins permettant d’accroître la survie jusqu’au congé de l’hôpital.
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Background Cardiac intensive care units were originally created in the prerevascularization era for the early recognition of ventricular arrhythmias following a myocardial infarction. Many patients ...with stable ST‐segment–elevation myocardial infarction (STEMI) are still routinely triaged to cardiac intensive care units after a primary percutaneous coronary intervention (pPCI), independent of clinical risk or the provision of critical care therapies. The aim of this study was to determine factors associated with in‐hospital adverse events in a hemodynamically stable, postreperfusion population of patients with STEMI. Methods and Results Between April 2012 and November 2019, 2101 consecutive patients with STEMI who received pPCI in the Vancouver Coastal Health Authority were evaluated. Patients were stratified into those with and without subsequent adverse events, which were defined as cardiogenic shock, in‐hospital cardiac arrest, stroke, re‐infarction, and death. Multivariable logistic regression models were used to determine predictors of adverse events. After excluding patients presenting with cardiac arrest, cardiogenic shock, or heart failure, the final analysis cohort comprised 1770 stable patients with STEMI who had received pPCI. A total of 94 (5.3%) patients developed at least one adverse event: cardiogenic shock 55 (3.1%), in‐hospital cardiac arrest 42 (2.4%), death 28 (1.6%), stroke 21 (1.2%), and re‐infarction 5 (0.3%). Univariable predictors of adverse events were older age, female sex, prior stroke, chronic kidney disease, and atrial fibrillation. There was no significant difference in reperfusion times between those with and without adverse events. Following multivariable adjustment, moderate to severe chronic kidney disease (creatinine clearance <44 mL/min; 13% of cohort) was associated with adverse events (odds ratio 2.24 95% CI, 1.12–4.48) independent of reperfusion time, age, sex, smoking status, hypertension, diabetes, and prior myocardial infarction/PCI/coronary artery bypass grafting. Conclusions Only 1 in 20 initially stable patients with STEMI receiving pPCI developed an in‐hospital adverse event. Moderate to severe chronic kidney disease independently predicted the risk of future adverse events. These results indicate that the majority of patients with STEMI who receive pPCI may not require routine admission to a cardiac intensive care unit following reperfusion.
There are concerns of delays in ST-segment elevation myocardial infarction (STEMI) care during the COVID-19 pandemic. It is unclear whether the care and outcomes of STEMI patients differ between ...COVID-19 waves and compared with historical periods.
Consecutive patients in the Vancouver Coastal Health Authority STEMI database were included to compare care during 3 distinct waves of the COVID-19 pandemic (9 months; March 2020 to January 2021) with an historical non–COVID-19 cohort. We compared STEMI incidence, baseline characteristics, and outcomes between groups. We also examined time from first medical contact (FMC) to reperfusion, symptom to FMC, and FMC to STEMI diagnosis, as well as predictors of delays.
The incidence of STEMI was similar during COVID-19 (n = 305; mean 0.93/day) and before COVID-19 (n = 949; 0.97/day; P = 0.80). The COVID-19 cohort showed significant delay in FMC-to-reperfusion (median 116 min vs 102 min; P < 0.001) and FMC-to-STEMI diagnosis (median 17 mins vs 11 min; P < 0.001). Delays in FMC-to-device times worsened across the 3 COVID-19 waves (FMC-to-device time ≤ 90 min in wave 1: 32.9%; in wave 2: 25.6%; in wave 3: 16.3%; P = 0.045 47.5% before COVID-19; P < 0.001). There were no significant predictors of delay were unique to the COVID-19 cohort.
This study demonstrates delays in reperfusion during the COVID-19 pandemic compared with the historical control, with delays increasing during subsequent waves within the pandemic. It is critical to further understand these care gaps to improve STEMI care for future waves of the current and future pandemics.
On s'inquiète des retards dans la prise en charge des infarctus du myocarde avec élévation du segment ST (STEMI) pendant la pandémie COVID-19. Il n'est pas clair si les soins et les pronostics des patients STEMI diffèrent entre les vagues COVID-19 et par rapport aux périodes antérieures.
Des patients consécutifs issus de la base de données STEMI de la Vancouver Coastal Health Authority ont été inclus pour comparer les soins apportés au cours de trois vagues distinctes de la pandémie COVID-19 (neuf mois; de mars 2020 à janvier 2021) avec ceux d'une cohorte historique non-COVID-19. Nous avons comparé l'incidence des STEMI, les caractéristiques de base et les pronostics entre les groupes. Nous avons également examiné le délai entre le premier contact médical (PCM) et la reperfusion, entre l'apparition de symptôme et le PCM, et entre le PCM et le diagnostic de STEMI, ainsi que les prédicteurs des délais.
L'incidence du STEMI était similaire pendant la COVID-19 (n = 305; moyenne de 0,93/jour) et avant COVID-19 (n = 949; 0,97/jour; P = 0,80). La cohorte COVID-19 a montré un retard significatif entre le PCM et la reperfusion (médiane 116 min vs 102 min; P < 0,001), et entre le PCM et le diagnostic de STEMI (médiane 17 min vs 11 min; P < 0,001). Les retards dans les délais entre le PCM et l'installation du dispositif se sont aggravés au cours des trois vagues de COVID-19 (délai PCM-dispositif ≤ 90 min durant la vague 1 : 32,9 % ; durant la vague 2 : 25,6 % ; durant la vague 3 : 16,3 % ; P = 0,045 47,5 % avant COVID-19; P < 0,001). Aucun prédicteur de retard significatif n'était propre à la cohorte COVID-19.
Cette étude met en lumière des retards dans la reperfusion pendant la pandémie COVID-19 par rapport à la période historique servant de contrôle, les retards augmentant pendant les vagues successives de la pandémie. Il est essentiel de mieux comprendre ces lacunes en matière de soins afin d'améliorer les soins STEMI pour les vagues futures des pandémies actuelles et futures.
Atrial fibrillation (AF) is a progressive chronic disease characterized by exacerbations and periods of remission. It is estimated that up to 20% to 30% of those with AF also have coronary artery ...disease (CAD), and 5% to 15% will require percutaneous coronary intervention (PCI). In patients with concomitant AF and CAD, management remains challenging and requires a careful and balanced assessment of the risk of bleeding against the anticipated impact on ischemic outcomes (AF-related stroke and systemic embolism, as well as ischemic coronary events). Oral anticoagulation (OAC) is indicated for the prevention of AF-related stroke and systemic embolism, whereas antiplatelet therapy is indicated for the prevention of coronary events. Each offers a relative efficacy benefit (dual antiplatelet therapy DAPT is more effective than OAC alone in reducing cardiovascular death, myocardial infarction, stent thrombosis, and ischemic coronary events in a population with acute coronary syndromes ACS), but with a relative compromise (DAPT is significantly inferior to OAC for the prevention of stroke/systemic embolism in an AF population at increased risk of stroke). The purpose of this review is to explore the current evidence and rationale for antithrombotic treatment strategies in patients with both AF and CAD. Specifically, there is a focus on how to best tailor the therapeutic choices (OAC and antiplatelet therapy) to individual patients based on their underlying coronary presentation.
La fibrillation auriculaire (FA) est une maladie chronique évolutive qui est caractérisée par des périodes d’exacerbation et de rémission. On estime que de 20 % à 30 % des patients atteints de FA ont aussi une maladie coronarienne (MC) et que de 5 % à 15 % auront besoin d’une intervention coronarienne percutanée (ICP). Chez les patients atteints d’une FA et d’une MC concomitantes, la prise en charge est difficile et exige une évaluation prudente et équilibrée du risque d’hémorragie par rapport aux répercussions anticipées sur les événements ischémiques (par ex., l’accident vasculaire cérébral (AVC) lié à la FA, l’embolie systémique et les événements ischémiques coronariens). L’anticoagulation orale (ACO) est indiquée dans la prévention de l'AVC lié à la FA et l’embolie systémique, tandis que le traitement antiplaquettaire est indiqué dans la prévention des événements coronariens. Chacun offre un avantage relatif en matière d’efficacité (par ex., la bithérapie antiplaquettaire BTAP est plus efficace que l’ACO seule dans la réduction de la mortalité cardiovasculaire, l’infarctus du myocarde, la thrombose de l’endoprothèse et les événements ischémiques coronariens dans une population atteinte d’un syndrome coronarien aigu), néanmoins, selon un compromis relatif (par ex., la BTAD est significativement inférieure à l’ACO dans la prévention de l'AVC et de l’embolie systémique dans une population atteinte de FA chez qui le risque d'AVC est accru). L’objectif de la présente revue est d’examiner les données probantes actuelles et les raisons qui justifient les stratégies de traitement antithrombotique chez les patients atteints de FA et de MC. En particulier, on se penche sur la meilleure façon d’adapter les choix thérapeutiques (ACO et traitement antiplaquettaire) aux patients en tenant compte de leur tableau clinique individuel de MC sous-jacente.
Background The Global Registry of Acute Coronary Event (GRACE) risk score was developed in a large multinational registry to predict in-hospital mortality across the broad spectrum of acute coronary ...syndromes (ACS). Because of the substantial regional variation and temporal changes in patient characteristics and management patterns, we sought to validate this risk score in a contemporary Canadian population with ACS. Methods The main GRACE and GRACE2 registries are prospective, multicenter, observational studies of patients with ACS (June 1999 to December 2007). For each patient, we calculated the GRACE risk score and evaluated its discrimination and calibration by the c statistic and the Hosmer-Lemeshow goodness-of-fit test, respectively. To assess the impact of temporal changes in management on the GRACE risk score performance, we evaluated its discrimination and calibration after stratifying the study population into prespecified subgroups according to enrollment period, type of ACS, and whether the patient underwent coronary angiography or revascularization during index hospitalization. Results A total of 12,242 Canadian patients with ACS were included; the median GRACE risk score was 127 (25th and 75th percentiles were 103 and 157, respectively). Overall, the GRACE risk score demonstrated excellent discrimination ( c statistic 0.84, 95% CI 0.82-0.86, P < .001) for in-hospital mortality. Similar results were seen in all the subgroups (all c statistics ≥0.8). However, calibration was suboptimal overall (Hosmer-Lemeshow P = .06) and in various subgroups. Conclusions GRACE risk score is a valid and powerful predictor of adverse outcomes across the wide range of Canadian patients with ACS. Its excellent discrimination is maintained despite advances in management over time and is evident in all patient subgroups. However, the predicted probability of in-hospital mortality may require recalibration in the specific health care setting and with advancements in treatment.
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