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Estimating the Risk of 6-Month Postdischarge Death in an International Registry

Kim A. Eagle, MD; Michael J. Lim, MD; Omar H. Dabbous, MD, MPH; Karen S. Pieper, MS; Robert J. Goldberg, PhD; Frans Van de Werf, MD, PhD; Shaun G. Goodman, MD, MSc; Christopher B. Granger, MD; P. Gabriel Steg, MD; Joel M. Gore, MD; Andrzej Budaj, MD, PhD; Álvaro Avezum, MD, PhD; Marcus D. Flather, MBBS, FRCP; Keith A. A. Fox, MB, ChB, FRCP; for the GRACE Investigators

JAMA. 2004;291:2727-2733.

Context  Accurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy.

Objective  To develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS.

Design, Setting, and Patients  A multinational registry, involving 94 hospitals in 14 countries, that used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months postdischarge. From 17 142 patients presenting with an ACS from April 1, 1999, to March 31, 2002, and discharged alive, 15 007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients admitted from April 1, 2002, to December 31, 2003.

Main Outcome Measure  All-cause mortality during 6 months postdischarge after admission for an ACS.

Results  The 6-month mortality rates were similar in the development (n = 717; 4.8%) and validation cohorts (n = 331; 4.7%). The risk-prediction tool for all forms of ACS identified 9 variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram, and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively.

Conclusions  The GRACE 6-month postdischarge prediction model is a simple, robust tool for predicting mortality in patients with ACS. Clinicians may find it simple to use and applicable to clinical practice.

Author Affiliations: Department of Internal Medicine, University of Michigan Health System, Ann Arbor (Drs Eagle and Lim); Department of Medicine, University of Massachusetts Medical School, Worcester (Drs Dabbous, Goldberg, and Gore); Department of Medicine, Duke University Medical Center, Durham, NC (Dr Granger and Ms Pieper); Department of Cardiology, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium (Dr Van de Werf); Canadian Heart Research Centre and Terrence Donnelly Heart Centre, and Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario (Dr Goodman); Cardiology, Hôpital Bichat, Paris, France (Dr Steg); Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland (Dr Budaj); Clinical Research Center, Education, and Research Institute Hospital Albert Einstein, São Paulo, Brazil (Dr Avezum); Royal Brompton and Harefield NHS Trust, London, England (Dr Flather); and The University and The Royal Infirmary of Edinburgh, Edinburgh, Scotland (Dr Fox).

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