Scales for secondary prevention

Objectives

TIMI

• Assessing risk of mortality, recurrent MI of patients with acute coronary syndrome

GRACE

• Assessing risk of in-hospital death of patients with acute coronary syndrome

Pursuit

• Assessing risk of 30-day mortality or infarction of patients with acute coronary syndrome

Variables

TIMI (1 point for each)

• Age > 65
• >3 Risk factors for coronary artery disease (CAD)
  • Diabetes
  • Smoking
  • Hypertension
  • Low HDL
  • Family history
• Known CAD stenosis ¿ 50%
• Chest pain despite aspirin use in past 7days
• ¿ 2 episodes of severe angina within 24 hours
• ST changes ¿ 0.5mm
• Cardiac marker present

(Adapted from http://www.timi.org/)

GRACE

• Killip Class: system used to stratify risk after acute MI
  • Class I: no heart failure – 0 points
  • Class II: crackles in lung and/or raised JVP – 20 points
  • Class III: pulmonary oedema – 39 points
  • Class IV: cardiogenic shock – 59 points
• Systolic blood pressure (mmHg)
  • ¿ 80 – 58 points
  • 80-99 – 53 points
  • 100-119 – 43 points
  • 120-139 – 34 points
  • 140-159 – 24 points
  • 160-199 – 10 points
  • ¿ 200 – 0 points
• Heart rate (beats/min)
  • ¿ 50 – 0 points
  • 50-69 – 3 points
  • 70-89 – 9 points
  • 90-109 – 15 points
  • 110-149 – 24 points
  • 150-199 – 38 points
  • ¿ 200 – 46 points
• Age
  • ¿ 30 – 0 points
  • 30-39 – 8 points
  • 40-49 – 25 points
  • 50-59 – 41 points
  • 60-69 – 58 points
  • 70-79 – 75 points
  • 80-89 – 91 points
  • ¿ 90 – 100 points
• Creatinine level (mg/dL)
  • 0-0.39 – 1 points
  • 0.40-0.79 – 4 points
  • 0.80-1.19 – 7 points
  • 1.20-1.59 – 10 points
  • 1.60-1.99 – 13 points
  • 2.00-3.99 – 21 points
  • > 4.0 – 28 points
• Other risk factors
  • Cardiac Arrest at Admission – 39 points
  • ST-Segment deviation – 28 points
  • Elevated Cardiac Enzyme levels – 14 points

(Adapted from: Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003; 163: 2345-53.)

Pursuit

• Age
  • 50 – 0 points
  • 60 – 2 points
  • 70 – 4 points
  • 80 – 6 points
• Gender
  • Female – 0
  • Male – 1
• Worse CCS-class (Canadian Cardiovascular Society Angina Grading Scale) in previous 6 weeks
  • No angina; I or II – 0 points
  • III or IV – 2 points
• Heart rate (bpm)
  • 80 – 0 points
  • 100 – 1 points
  • 120 – 2 points
• Systolic blood pressure
  • 120 – 0 points
  • 100 – 1 points
  • 80 – 2 points
• Signs of heart failure
  • No – 0 points
  • Yes – 3 points
• ST-depression on presenting ECG
  • No – 0 points
  • Yes – 3 points

Stratification of other info

TIMI

• Score of 0-1 = 4.7% risk
• Score of 2 = 8.3% risk
• Score of 3 = 13.2% risk
• Score of 4 = 19.9% risk
• Score of 5 = 26.2% risk
• Score of 6-7 = at least 40.9% risk
• Data obtained from a US population

GRACE

• Score of ¿ 60 = ¿ 0.2% risk
• Score of 70 = 0.3% risk
• Score of 80 = 0.4% risk
• Score of 90 = 0.6% risk
• Score of 100 = 0.8% risk
• Score of 110 = 1.1% risk
• Score of 120 = 1.6% risk
• Score of 130 = 2.1% risk
• Score of 140 = 2.9% risk
• Score of 150 = 3.9% risk
• Score of 160 = 5.4% risk
• Score of 170 = 7.3% risk
• Score of 180 = 9.8% risk
• Score of 190 = 13% risk
• Score of 200 = 18% risk
• Score of 210 = 23% risk
• Score of 220 = 29% risk
• Score of 230 = 36% risk
• Score of 240 = 44% risk
• Score of ¿ 250 = ¿ 52% risk
• Data obtained from hospitals in North America, South America, Europe, Asia, Australia and New Zealand

Pursuit

Adapted from Boersma E, Pieper KS, Steyerberg EW et al. for the PURSUIT Investigators. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. Circulation 2000;101;2557-2567.

• Data obtained from 9461 patients in 726 hospitals in 28 countries in western and eastern Europe and North and South America

Comparison (adapted from De Araújo Gonçalves et. al.)

Description of trial

• Non-randomised, retrospective trial
• 460 consecutive patients admitted to a coronary care unit with acute coronary syndrome

Discriminatory Accuracy

• No significant differences in all 3 scores for the 30-day end point
• GRACE score was superior to that of the other two scores for the 1-year end point

Interaction between risk scores and prognostic impact of myocardial revascularization

• PURSUIT (36.7%) and GRACE (28.7%) scores reached statistical significance

Short term prognosis

• All three risk scores were able to discriminate patients with and without events at 30 days
• Performance of TIMI and GRACE scores was superior when the original follow-up time and composite end points used for their development were tested

Long term prognosis

• Best performance achieved by the GRACE score

Variables used

• TIMI is clearly different from the other two scores in terms of variables used.
• The main difference between GRACE and PURSUIT scores is based on the inclusion of renal function in the former.

Adapted from De Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R. TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. Eur Heart J 2005;26:865-72.