Elsevier

American Heart Journal

Volume 163, Issue 3, March 2012, Pages 383-391.e5
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
Comparison of clinical and angiographic prognostic risk scores in patients with acute coronary syndromes: Analysis from the Acute Catheterization and Urgent Intervention Triage StrategY (ACUITY) trial

https://doi.org/10.1016/j.ahj.2011.11.010Get rights and content

Background

Several prognostic risk scores have been developed for patients with coronary artery disease, but their comparative use in patients with non–ST-segment elevation acute coronary syndromes (NSTEACS) undergoing percutaneous coronary intervention (PCI) has not been examined. We therefore investigated the accuracy of the Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score, Clinical Synergy Between PCI With Taxus and Cardiac Surgery score (CSS), New Risk Stratification (NERS) score (NERS), Age, Creatinine, Ejection Fraction (ACEF) score, Global Registry for Acute Coronary Events (GRACE) score, and Thrombolysis in Myocardial Infarction (TIMI) score for risk assessment of 1-year mortality, cardiac mortality, myocardial infarction, target vessel revascularization, and stent thrombosis in patients with NSTEACS undergoing PCI.

Methods

The 6 scores were determined in 2,094 patients with NSTEACS treated with PCI enrolled in the angiographic substudy of the ACUITY trial. The prognostic accuracy of the 6 scores was assessed using the c statistic for discrimination and the Hosmer-Lemeshow test for calibration. The index of separation and net reclassification improvement (NRI) were also determined.

Results

Scores incorporating clinical and angiographic variables (CSS and NERS) showed the best tradeoff between discrimination and calibration for most end points, with the best discrimination for all end points and good calibration for most of them. The CSS had the best index of separation for most ischemic endpoints and displayed an NRI for cardiac death and myocardial infarction (MI) compared to the other scores, whereas NERS displayed an NRI for all-cause death and target vessel revascularization. The 3 scores—CSS, NERS, and SYNTAX—were the only scores to have both good discrimination and calibration for cardiac mortality.

Conclusions

In patients with NSTEACS undergoing PCI, risk scores incorporating clinical and angiographic variables had the highest predictive accuracy for a broad spectrum of ischemic end points.

Section snippets

Study protocol

The ACUITY trial design has been previously reported in detail.12 Briefly, ACUITY was a large, international, multicenter, prospective randomized trial of patients with moderate- and high-risk NSTEACS undergoing an early invasive strategy. Patients were randomly assigned before coronary angiography to heparin (unfractionated or enoxaparin) plus a glycoprotein IIb/IIIa inhibitor, bivalirudin plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin monotherapy. Coronary angiography was performed in

Results

The study flow diagram is shown in Figure 1. A total of 2,094 patients with NSTEACS undergoing PCI were included, in whom a 1-year follow-up was available in 2,001 patients (96%). Clinical and angiographic characteristics of patients included vs those not included in this study are shown in the online Appendix Supplemental Table 1. Descriptive statistics for the 6 scores are reported in the online Appendix Supplemental Table 2.

Discussion

Assessing the performance of prediction models is a complex process that requires the evaluation of several performance measures.22 Traditional measures for survival outcomes include discrimination, usually expressed as c statistic, and calibration, usually measured with the Hosmer-Lemeshow test.17 Discrimination is a measure of how well the prognostic model can separate cases from controls, whereas calibration is a measure of how well predicted probabilities fit actual risks. Typically,

Disclosures

Conflict of interest: Dr Mehran is a consultant for Abbott Vascular, AstraZeneca, Ortho-McNeil, and Regado Biosciences and has received research grant from Sanofi/Bristol Myers Squibb. Dr Dangas has received honoraria from The Medicines Company. Martin Fahy, Ke Xu, Dr Cristea, Dr Lazar, and Dr Sanchez are employed by the Cardiovascular Research Foundation. Dr Stone is a consultant to Abbott Vascular, Boston Scientific, The Medicines Company, and Medtronic.

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