List of Authors:
Keith A.A. Fox, MB, ChB, FMed Sci, Kathryn F Carruthers MPhil, Donald R Dunbar PhD, Catriona Graham MSc, Jonathan R Manning PhD, Herbert De Raedt MD, Ian Buysschaert MD, PhD, Diether Lambrechts PhD, Frans Van de Werf MD, PhD
To define the long-term outcome of patients presenting with acute coronary syndrome (ST elevation myocardial infarction (STEMI), and non-STEMI and unstable angina (ACS without biomarker elevation) and to test the hypothesis that the GRACE risk score predicts mortality and death/MI at 5 years.
Methods and Results:
In the GRACE (Global Registry of Acute Coronary Events) long-term study, UK and Belgian centres prospectively recruited and followed ACS patients for a median of 5 years (1570 days). Primary outcome events: deaths, cardiovascular deaths (CVD) and MIs. Secondary events: stroke and re-hospitalisation for ACS. There were 736 deaths, 19.8% (532 CV deaths, 14.3%) and 347 (9.3%) MIs, (>24hours), 261 strokes (7.7%), and 452 (17%) subsequent revascularisations. Rehospitalisation was common: average 1.6 per patient; 31.2% had >1 admission, 9.2% had 5+ admissions). These events were despite high rates of guideline indicated therapies.
The GRACE score was highly predictive of all cause death, cardiovascular death (CVD), and CVD/MI at 5 years (death: Chi Squared Likelihood Ratio 477.1; Wald 352.6, p<0.0001, C statistic 0.77; for CVD C statistic 0.75, p<0.0001; CVD/MI C statistic 0.68, p<0.0001). Compared with the low risk GRACE stratum, (ESC Guideline criteria), those with intermediate (OR 2.49, 95%CI 1.73, 3.58) and those with high risk (OR 10.09, 95%CI 7.21, 14.13) had a 2.5 and 10-fold higher risk of later death. A landmark analysis after 6-months confirmed that the GRACE score predicted long-term death (Log-Rank=210.8, df =2, p<0.0001). Although in-hospital rates of death and MI are higher following STEMI, the cumulative rates of death (and CVD) were not different, by class of ACS, over the duration of follow-up (Wilcoxon = 1.5597, df=1, p=0.21). At 5yrs after STEMI 269/1403 (19%) died; after non-STEMI 262/1107, (22%) after UA 148/850, (17%). About half (55%) of STEMI deaths occurred after initial hospital discharge, but this was 81% for non-STEMI and 94% for UA.
Conclusions: The GRACE risk score predicts early and 5-year death and CVD/MI. 5-year morbidity and mortality are as high in patients following non-ST MI and UA as seen following STEMI. Their morbidity burden is high (MI, stroke, readmissions) and the substantial late mortality in non-STE ACS is under-recognised. The findings highlight the importance of pursuing novel approaches to diminish long-term risk.
5-year morbidity and mortality are as high in patients following non-ST MI and UA as seen following STEMI. Their morbidity burden is high (MI, stroke, readmissions) and the substantial late mortality in non-STE ACS is under-recognised. The findings highlight the importance of pursuing novel approaches to diminish long-term risk.
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