|Year : 2021 | Volume
| Issue : 3 | Page : 106-111
Comparison of global registry of acute coronary events and thrombolysis in myocardial infarction risk scores in non-ST-elevation acute coronary syndrome
Satyanarayan Routray DM , Chhabi Satpathy DM , Nirmal Kumar Mohanty DM , Bijay Kumar Dash DM , Rajendra Prasad Satapathy DM
Department of Cardiology, SCB Medical College and Hospital, Cuttack, Odisha, India
|Date of Submission||23-Apr-2021|
|Date of Decision||19-Jun-2021|
|Date of Acceptance||23-Jun-2021|
|Date of Web Publication||23-Sep-2021|
Dr. Rajendra Prasad Satapathy
Room No-100, SR Hostel, SCB Medical College and Hospital, Cuttack, Odisha
Source of Support: None, Conflict of Interest: None
Context: The Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores in predicting coronary disease severity in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) have not been proved. Aims: We aimed to compare the GRACE score with TIMI risk score for prediction of the angiographic severity of coronary artery disease (CAD) in patients with NSTE-ACS. Settings and Design: This was an observational cross-sectional study. Subjects and Methods: Total 202 NSTE-ACS (NSTE myocardial infarction and unstable angina) patients were included. The GRACE and TIMI scores were estimated. Coronary angiogram was done and the Gensini score and vessel score were used to assess the severity of CAD. Statistical Analysis Used: SPSS software version 27.0 was used for statistical analysis. For comparison of two means, independent sample t-test/Mann–Whitney U-test was used, while for more than two means, one-way ANOVA/Kruskal–Wallis test was used. The receiver operating characteristic (ROC) curve was applied for the predictability of GRACE and TIMI scores for severity of disease. Results: A positive association between the Gensini score and vessel score was observed with both the GRACE (P = 0.001) and TIMI (P = 0.001) scores. The area under the ROC curve for the GRACE score was 0.765 (95% confidence interval [CI] = 0.676–0.854), significantly superior to the area under the ROC curve of the TIMI score (0.715; 95% CI = 0.618–0.812). Risk factors such as higher age, hypertension, smoking history, dyslipidemia, ECG changes such as ST deviation and T inversion, and Killip classification showed a statistically significant association with severity of disease. Conclusions: Both the GRACE and TIMI risk scores were a good predictor of angiographic severity of CAD in patients with NSTE-ACS, and the GRACE score was found to be superior to the TIMI risk score.
Keywords: Coronary angiography, coronary artery disease, non-ST-elevation acute coronary syndrome
|How to cite this article:|
Routray S, Satpathy C, Mohanty NK, Dash BK, Satapathy RP. Comparison of global registry of acute coronary events and thrombolysis in myocardial infarction risk scores in non-ST-elevation acute coronary syndrome. J Clin Prev Cardiol 2021;10:106-11
|How to cite this URL:|
Routray S, Satpathy C, Mohanty NK, Dash BK, Satapathy RP. Comparison of global registry of acute coronary events and thrombolysis in myocardial infarction risk scores in non-ST-elevation acute coronary syndrome. J Clin Prev Cardiol [serial online] 2021 [cited 2022 Nov 28];10:106-11. Available from: https://www.jcpconline.org/text.asp?2021/10/3/106/326471
| Introduction|| |
Cardiovascular diseases are currently the leading cause of mortality and morbidity in industrialized countries. Among these, coronary artery disease (CAD) is the most common and is associated with high rate of mortality and morbidity. Ischemic heart disease contributed to 17.8% of total deaths and 8.7% of total disability-adjusted life years in India.
Unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) constitutes a clinical syndrome subset of the acute coronary syndrome (ACS) that is usually, but not always, caused by atherosclerotic CAD and is associated with an increased risk of cardiac death and subsequent myocardial infarction. NSTEMI is defined by Electrocardiography (ECG) ST-segment depression or prominent T-wave inversion with positive biomarkers of necrosis in the absence of persistent (<20 min) ST-segment elevation. Patients without typical symptoms and serial negative biomarkers of necrosis are diagnosed as UA.
The number of patients with non ST elevation acute coronary syndrome (NSTE ACS) as compared to ST elevation myocardial infarction is increasing. This may be due to change in the demography of population, growing number of aging population, and increase incidence of obesity and diabetes mellitus. NSTE-ACS causes 2–2.5 million annual worldwide hospitalizations. According to Kerala and Himachal Pradesh ACS registries, NSTE-ACS accounts for 63% and 54.5% of ACS, respectively.,
Several risk scores are used to assess the prognosis in patients with NSTE-ACS that integrate clinical variables, findings on ECG, and from serum biomarkers have been developed. The Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores are most commonly used for risk stratification, and the prognostic value of each score has been established by several studies., Vessel score and Gensini score are widely used in the assessment of the severity of CAD.
Though both the scores correlate directly with mortality and recurrent ischemia,however are not meant to identify the angiographic severity of CAD. A positive correlation of GRACE and TIMI risk scores with the severity of CAD has been reported by several studies, but which score is higher in predicting the severity of CAD has not yet been established. Patients with high GRACE and TIMI risk scores before performing coronary angiography may change the therapeutic decisions and the timing or intensity of treatment. In this study, we aimed to predict the angiographic severity of CAD in patients with NSTE-ACS by GRACE and TIMI risk scores and to compare the GRACE score with TIMI risk score in patients with NSTE-ACS for their accuracy in predicting the angiographic severity of coronary disease.
| Subjects and Methods|| |
This observational cross-sectional study was carried out after the study protocol was approved by the Institutional Ethics Committee. A total of 202 patients with NSTE-ACS who gave consent for undergoing coronary angiography were included in the study. Patients with a history of prior myocardial infarction, valvular heart diseases, congenital heart diseases, cardiomyopathy, suspected myocarditis, or pericarditis and who underwent prior percutaneous coronary intervention or coronary artery bypass grafting were not included in the study.
After enrollment, all patients were evaluated clinically at the first presentation. Risk factors including diabetes, smoking, hypertension, dyslipidemia, and family history of premature CAD were noted. A 12-lead resting ECG was done on admission and looked for any ST segment depression, T wave inversion. Cardiac troponin T, serum creatinine, fasting, postprandial blood sugar, and lipid profile were measured.
The GRACE and TIMI scores were calculated during hospital admission. GRACE score has eight parameters (age, heart rate, systolic blood pressure (SBP), Killip class of heart failure, cardiac arrest at admission, serum creatinine, ST-segment deviation on ECG, and elevated cardiac biomarker) with the score from 1 to 372. Each variable has different points. The patients were divided into low-risk (≤108), intermediate-risk (109–140), and high-risk (>140) groups in accordance with the GRACE score.
TIMI score has seven criteria (age >65, prior CAD stenosis >50%, risk factors [hypertension, diabetes, smoking, hyperlipidemia, and family history], history of angina episodes in 24 h, history of aspirin intake in the last 7 days, ST-segment deviation on ECG, and elevated cardiac biomarker) with the score from 1 to 7. Each criterion consists of score 1. After calculation of TIMI score, the patients were also divided into low-risk (0–2), intermediate-risk (3–4), and high-risk (5–7) groups.
In a fasting state, coronary angiography was performed through the femoral or radial artery approach. The Gensini score and vessel score were used to assess the severity of CAD. Modified Gensini score was calculated by taking three factors of coronary lesion, severity coefficient, multiplying factor for region, and collateral adjustment factor. Severity coefficients were 1, 2, 4, 8, 16, and 32 for obstruction 1%–25%, 26%–50%, 51%–75%, 76%–90%, 91%–99%, and 100%, respectively. Multiplying factor for each lesion depends on its location in coronary anatomy and functional significance of the area; it supplies and ranges from 0.5 to 5. When there was 99% or 100% obstruction and receiving collaterals, an adjustment factor for collateral was used. Gensini score of each segment was calculated by multiplying severity coefficient and multiplying factor. The points of all segments were added to get the total Gensini score of the patient. Patients were divided into absent or mild CAD and moderate-to-severe CAD. Absent or mild CAD is defined as a Gensini score of ≤20 and moderate-to-severe CAD is defined as a Gensini score of >20.
Vessel score defines ≥70% stenosis in any major epicardial coronary arteries or ≥50% stenosis in the left main coronary artery as significant CAD.
All the data were entered in Microsoft Excel software version 2007 and analyzed in the SPSS software version 27.0 (IBM corporation, Armonk, New York, USA). All the categorical variables were expressed in terms of numbers and percentages. All the continuous variables were expressed in terms of mean and standard deviation. A comparison of two categorical variables was carried out using Chi-square/Fisher's exact test. For comparison of two means, independent sample t-test/Mann–Whitney U-test was used, while for more than two means, one-way ANOVA/Kruskal–Wallis test was used. The receiver operating characteristic (ROC) curve was applied to find out the predictability of GRACE and TIMI scores for severity of disease in terms of area under the curve. A P value of < 0.05 was considered statistically significant.
| Results|| |
A total of 202 patients were enrolled, out of which 26 (13%) were UA and 176 (87%) were NSTEMI. The mean age of the study participants was 59.28 ± 9.19 years, and the age ranged from a minimum of 39 years to a maximum of 78 years. The majority of the patients were male 144 (71.5%) compared to females 58 (28.5%). One hundred and twenty-three (60.8%) patients were hypertensive while only seventy (34.6%) were diabetic. Smoking history was found in 47 (23.3%) participants while family history was present in 41 (20.3%) patients. Dyslipidemia was found in 62 (31.7%). Among GRACE score, the mean heart rate was 89 ± 14.2, mean SBP was 130 ± 17, and mean serum creatinine was 1.04 ± 0.3. Majority of the subjects belonged to Killip Class I 152 (75%), followed by Class II 42 (21%) and Class III 8 (4%). Based on the parameters of TIMI score, 78 (38.7%) had a history of aspirin intake, 120 (59%) had two episodes of angina in the last 24 h, ST deviation was found in 105 (52%), while T wave inversion 133 (66%), mean troponin T was 1.47 ± 1.6.
In our study 43 (21.5%) had triple vessel disease, 53(26%) had double vessel disease, while the majority were found to have single vessel disease 85 (42%). [Table 1] shows mean Gensini score,GRACE score,TIMI score of our study.
|Table 1: Distribution of different scoring system among the study participants (n=202)|
Click here to view
[Table 2] shows that the moderate-to-severe CAD score according to Gensini score was found in 166 (82%) participants. According to the GRACE score, 98 (48.5%) belonged to a high-risk group, while according to the TIMI score, only 33 (16.3%) belonged to high risk.
|Table 2: Classification of participants according to different scores (n=202)|
Click here to view
[Table 3] shows that the mean GRACE score in a patient without any vessel involvement was 105.43 which increased steadily with an increase in the number of vessels involved with a statistically significant P = 0.001. The mean TIMI score in a patient without any vessel involvement was 1.95 which increased steadily with an increase in the number of vessels involved. This change in the TIMI score for the number of vessels involved was also statistically significant (P = 0.004).
|Table 3: Association of Global Registry of Acute Coronary Events and Thrombolysis in Myocardial Infarction score with number of vessels involved (n=202)|
Click here to view
[Table 4] shows that the mean Gensini score increased steadily from low-risk GRACE and TIMI scores to high-risk GRACE and TIMI scores with significant P = 0.001.
|Table 4: Association between Global Registry of Acute Coronary Events and Thrombolysis in Myocardial Infarction score with Gensini score (n=202)|
Click here to view
The mean GRACE score in patients with none/mild CAD severity according to Gensini score was 106.22 ± 34.95 while the value was 142.76 ± 37.94 in a patient with moderate-to-severe CAD. This increase in GRCE score was significant (P < 0.001). The mean TIMI score in patients with none/mild CAD severity according to Gensini score was 2.11 ± 1.56 while the value was 3.18 ± 1.42 in a patient with moderate-to-severe CAD. This difference was statistically significant (P < 0.001) [Table 5].
|Table 5: Mean Global Registry of Acute Coronary Events and Thrombolysis in Myocardial Infarction score according to severity category of Gensini score (n=202)|
Click here to view
[Table 6] shows the association of different risk factors with the severity of the disease. We found that higher age, hypertension, smoking history, dyslipidemia, ECG changes such as ST deviation and T inversion, and Killip classification showed a statistically significant association with severity of disease.
|Table 6: Association of different risk factors with the severity (n=202)|
Click here to view
| Discussion|| |
Persons admitted due to NSTE-ACS have a large array in their disease severity, which ranges according to clinical features and laboratory variables. Every patient of NSTEMI should undergo risk stratification during hospitalization, and those patients with high-risk scores have improved outcomes if early coronary intervention was done.
The GRACE and TIMI scores are the two widely used risk scores for risk stratification in patients with NSTE-ACS. Many studies have shown a positive correlation between the GRACE and TIMI risk scores with angiographic severity in patients of NSTE-ACS.[17.18]
In our study, angiographic severity was determined by vessel score and Gensini score. Mean GRACE score and TIMI score steadily increased from a patient without any vessel involvement to triple-vessel disease and were statistically significant. Similar results were found in a study done by Roy et al. and Mahmood et al.,
Mean Gensini score steadily increased from low-risk GRACE and TIMI score to high-risk GRACE and TIMI score with P < 0.001. These findings suggest the tendency toward severe CAD according to mean GRACE and mean TIMI scores, similar to the results of Roy et al. and Barbosa et al. study.,
This study showed the superiority of the GRACE score to the TIMI score in assessing the angiographic extension of CAD in NSTE-ACS. In our study, both GRACE and TIMI scores showed a high predictive capacity for severity of CAD with an area under the ROC curve of 0.765 (95% confidence interval [CI] = 0.676–0.854) and 0.715 (95% CI = 0.618–0.812), respectively, at a significance level of P < 0.001. The area under the curve difference was 0.05 between the two scores, which was statistically significant to establish that the GRACE score was better than TIMI score in assessing the severity of CAD in patients with NSTE-ACS, similar to the results of Roy et al.
Barbosa et al. suggested that the TIMI and GRACE scores were not accurate in predicting the CAD extension in patients with NSTE ACS [Figure 1] and [Figure 2], but the results of our study showed that these two scores had a high predictive capacity for severity of CAD with the GRACE score as a better predictor.
|Figure 1: Receiver operating characteristic curve showing predictive ability of Global Registry of Acute Coronary Events score for severity|
Click here to view
|Figure 2: Receiver operating characteristic curve showing predictive ability of Thrombolysis in Myocardial Infarction score for severity|
Click here to view
Mahmood et al. showed that GRACE score was superior to TIMI risk score in predicting extent of CAD in NSTE-ACS which was similar to the result of our study.
Bekler et al. found that there was a positive significant correlation between the GRACE and the syntax score (r = 0.427, P < 0.001) but not with TIMI score. However, in our study, we compared these scores with the Gensini score and vessel score.
Hammami et al. found in their study that both GRACE and TIMI scores can predict obstructive CAD moderately well but not severity of CAD.
Ascenzo et al., a meta-analysis of 40 derivation studies on 216,552 patients and 42 validation studies on 31,625 patients, showed that TIMI and GRACE are the risk scores that up until now have been most extensively investigated, with GRACE score superior in predicting the severity compared to TIMI score.
For prognostication, the GRACE score is better than TIMI risk score in patients of NSTE-ACS., However, TIMI risk score may be a better predictor of severity of CAD. This is explained by variables such as prior CAD stenosis >50%, use of aspirin, and risk factors (hypertension, diabetes, family history, and dyslipidemia). Age, heart rate, blood pressure, heart failure class, cardiac arrest at presentation, and serum creatinine are not included in TIMI score. However, these parameters are included in the GRACE score. TIMI score consists of dichotomous variables. Age, heart rate, blood pressure, serum creatinine are continuous variables which make the GRACE score better predictor of severity of CAD than the TIMI score in patients of NSTE-ACS.,
According to ESC guidelines, early invasive strategy (< 24 hour) was adopted for patients with GRACE score >140 and delayed invasive strategy (24–72 h) implemented for patients with GRACE score 109–140, and TIMI score ≥2. An ischemia guided strategy recommended for patients with GRACE score < 109 and TIMI score ≤1., Angiographic severity is an independent predictor of major cardiovascular events. We found a good association between high GRACE score and high TIMI score with angiographic severity. Hence, patients with high scores may get benefit from early invasive therapy.
This evaluation was based on a small number of patients involving only one center. Normal coronaries were prespecified by angiogram without any IVUS evaluation.
| Conclusions|| |
Both the GRACE and TIMI risk scores had a high predictive capacity for angiographic severity of CAD in patients with NSTE-ACS, and the GRACE score was found to be better in assessing the severity than TIMI score. Patients with high-risk GRACE and TIMI scores at admission may get benefit from an early intervention approach to treatment.
We are indebted to all residents, nurses, technicians, and paramedical staffs of our department and catheterization laboratory for their immense contribution for our patient treatment and clinical care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet 1997;349:1498-504.
India State-Level Disease Burden Initiative CVD Collaborators. The changing patterns of cardiovascular diseases and their risk factors in the states of India: The Global Burden of Disease Study 1990-2016. Lancet Glob Health 2018;6:e1339-51.
Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr., et al.
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: A report of the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With UA/NSTEMI):developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007;116:e148-304.
Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr., Ganiats TG, Holmes DR Jr., et al.
2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e139-228.
Braunwald E, Antman EM, Beasley JW. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina). J Am Coll Cardiol 2000;36:970-2.
Padinhare PM, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph H, et al.
Presentation, management and outcomes of 25748 acute coronary syndrome admissions in Kerala, India: Results from Kerala ACS Registry. Eur Heart J 2013;34:121-9.
Negi PC, Merwaha R, Panday D, Chauhan V, Guleri R. Multicenter HP ACS registry. Indian Heart J 2015;68:118-27.
Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al.
The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284:835-42.
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.
Sun L, Lü SZ. Association between non-alcoholic fatty liver disease and coronary artery disease severity. Chin Med J (Engl) 2011;124:867-72.
Roy SS, Abu Azam STM, Khalequzzaman M, Ullah M, Arifur Rahman M. GRACE and TIMI risk scores in predicting the angiographic severity of non-ST elevation acute coronary syndrome. Indian Heart J 2018;70 Suppl 3:S250-3.
Huang G, Zhao JL, Du H, Lan XB, Yin YH. Coronary score adds prognostic information for patients with acute coronary syndrome. Circ J 2010;74:490-5.
Chen ZW, Chen YH, Qian JY, Ma JY, Ge JB. Validation of a novel clinical prediction score for severe coronary artery diseases before elective coronary angiography. PLoS One 2014;9:e94493.
Chaitman BR, Bourassa MG, Davis K, Rogers WJ, Tyras DH, Berger R, et al.
Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation 1981;64:360-7.
Barbosa CE, Viana M, Brito M, Sabino M, Garcia G, Maraux M, et al.
Accuracy of the GRACE and TIMI scores in predicting the angiographic severity of acute coronary syndrome. Arq Bras Cardiol 2012;99:818-24.
Santos ES, Aguiar Filho Lde F, Fonseca DM, Londero HJ, Xavier RM, Pereira MP, et al.
Correlation of risk scores with coronary anatomy in non-ST-elevation acute coronary syndrome. Arq Bras Cardiol 2013;100:511-7.
Cakar MA, Sahinkus S, Aydin E, Vatan MB, Keser N, Akdemir R, et al.
Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome. J Cardiol 2014;63:24-8.
Lakhani MS, Qadir F, Hanif B, Farooq S, Khan M. Correlation of thrombolysis in myocardial infarction (TIMI) risk score with extent of coronary artery disease in patients with acute coronary syndrome. J Pak Med Assoc 2010;60:197-200.
Mahmood M, Achakzai AS, Akhtar P, Zaman KS. Comparison of the TIMI and the GRACE risk scores with the extent of coronary artery disease in patients with non-ST-elevation acute coronary syndrome. J Pak Med Assoc 2013;63:691-5.
Bekler A, Altun B, Gazi E, Temiz A, Barucu A, Gungor O, et al
. Comparison of the GRACE risk score and the TIMI risk index in predicting the extent and severity of coronary artery disease in patients with acute coronary syndrome. Anatol J Cardiol 2015;15:801-6.
Hammami R, Jdidi J, Mroua F, Kallel R, Hentati M, Abid L, et al.
Accuracy of the TIMI and GRACE scores in predicting coronary disease in patients with non-ST-elevation acute coronary syndrome. Rev Port Cardiol (Engl Ed) 2018;37:41-9.
Ascenzo FD, Biondi-Zoccai G, Moretti C, Bollati M, Omede P, Sciuto F, et al
. TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: A meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients Contemp Clin Trials 2012;33:507-14.
Khot UN, Jia G, Moliterno DJ, Lincoff AM, Khot MB, Harrington RA, et al.
Prognostic importance of physical examination for heart failure in non-ST-elevation acute coronary syndromes: The enduring value of Killip classification. JAMA 2003;290:2174-81.
Yan AT, Yan RT, Tan M, Casanova A, Labinaz M, Sridhar K, et al.
Risk scores for risk stratification in acute coronary syndromes: Useful but simpler is not necessarily better. Eur Heart J 2007;28:1072-8.
Correia LC, Freitas R, Bittencourt AP, Souza AC, Almeida MC, Leal J, et al.
Prognostic value of GRACE scores versus TIMI score in acute coronary syndromes. Arq Bras Cardiol 2010;94:613-9.
Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al.
2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019;40:87-165.
Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al.
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267-315.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]