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Our mission is to promote excellence in research, practice, education and policy in cardiovascular health, primary and secondary prevention.
Our mission is to reduce the burden of cardiovascular disease in Europe through percutaneous cardiovascular interventions.
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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
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.
© 2017 European Society of Cardiology. All rights reserved