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Coronary artery disease
Original research article
Left ventricular ejection fraction adds value over the GRACE score in prediction of 6-month mortality after ACS: the MADDEC study
  1. Nina Syyli1,
  2. Markus Hautamäki1,
  3. Kari Antila2,
  4. Shadi Mahdiani2,
  5. Markku Eskola3,
  6. Terho Lehtimäki1,4,5,
  7. Kjell Nikus1,3,5,
  8. Leo-Pekka Lyytikäinen1,3,4,5,
  9. Niku Oksala1,5,6 and
  10. Jussi Hernesniemi1,3,5
  1. 1Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
  2. 2VTT Technical Research Centre of Finland, Tampere, Finland
  3. 3Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
  4. 4Department of Clinical Chemistry, Fimlab Laboratories, Tampere University Hospital, Tampere, Finland
  5. 5Finnish Cardiovascular Research Center Tampere, Tampere, Finland
  6. 6Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
  1. Correspondence to Nina Syyli; nina.syyli{at}tuni.fi

Abstract

Background Reduced left ventricular ejection fraction (LVEF) is a risk marker for mortality after an acute coronary syndrome (ACS). Global Registry of Acute Coronary Events (GRACE) risk score, developed almost two decades ago, is the preferred scoring system for risk stratification in ACS. The aim of this study was to validate the GRACE score and evaluate whether LVEF has incremental predictive value over the GRACE in predicting 6-month mortality after ACS in a contemporary setting.

Methods A retrospective analysis of all 1576 consecutive patients who were admitted to Tays Heart Hospital and underwent coronary angiography for a first episode of ACS (2015–2016). Clinical risk factors were extensively recorded. Adjusted Cox regression analysis was used to analyse the associations between LVEF and the GRACE score with 6-month all-cause mortality. The incremental predictive value was assessed by the change in C-statistic by Delong’s method for paired samples and by index of discrimination improvement (IDI).

Results In univariable analysis, both LVEF and the GRACE were associated with 6-month mortality, and after applying both variables into the same model, the results remained significant (GRACE score: HR: 1.036, 95% CI 1.030 to 1.042; LVEF: HR: 0.965, 95% CI 0.948 to 0.982, both HRs corresponding to a one unit change in the exposure variable). The GRACE score demonstrated good discrimination for mortality (C-statistic: 0.833, 95% CI 0.795 to 0.871). Adding LVEF to the model with the GRACE score improved model performance significantly (C-statistic: 0.848, 95% CI 0.813 to 0.883, p=0.029 for the improvement and IDI 0.0171, 95% CI 0.0016 to 0.0327, p=0.031).

Conclusions Adding LVEF to the GRACE score significantly improves risk prediction of 6-month mortality after ACS.

  • acute coronary syndrome
  • mortality
  • prediction
  • left ventricular ejection fraction

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/openhrt-2019-001007

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    Footnotes

    • Contributors All authors have made substantial contributions to the manuscript by drafting the work or revising it critically for important intellectual content and by participating to the design of the work, or the acquisition, analysis or interpretation of the data. The authors take full responsibility of the integrity and accuracy of the data and all authors have given their approval for the final version of the manuscript.

    • Funding The study was supported by the Business Finland (the Finnish Funding Agency for Technology and Innovation).

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement No data are available.