GRACE: Late complicaties ACS nauwelijks herkend

GRACE: Late complications of acute coronary syndrome are poorly recognized

30 August 2010

Late risk factors associated with acute coronary syndrome (ACS) are often underestimated by clinicians despite adherence to recommended therapy guidelines and secondary prevention.

The survival and follow-up of over 3700 patients who presented at hospital with ACS were assessed 5 years after initiation of the Global Registry of Acute Coronary Events (GRACE) database. Professor Keith Fox (University of Edinburgh, UK) presented a substudy of patients from the UK (n=2065) and Belgium (n=1656) who could be accurately followed-up and matched to their original submissions on the GRACE central database; only four patients were not linked successfully.

The population demographics in this study were similar to those of the wider GRACE database, with the mean age for patients with ST elevated myocardial infarction (STEMI), non-STEMI and unstable angina (UA) being 63 years, 67 years and 66 years, respectively. Patients complied well to all medications at 6 months. After hospital discharge, the following patient outcomes were seen: recurrent MI (12.7%), strokes (7.7%), revascularizations (16.7%), and readmission for ACS (53.6%). There was no difference in survival between STEMI and non-STEMI/UA patients (p=0.65).

	Patients receiving PCI on initial discharge	Outcome at 5 years - death	Death following discharge
STEMI (n=1403)	68.9%	19%	66%
Non-STEMI (n=1107)	50.5%	22%	83%
Unstable angina (n=850)	34.6%	17%	95%

PCI, percutaneous coronary intervention.

Fox stated that “The late hazards [of ACS] are also predicted by the GRACE score. Now that is not to say that the GRACE score identifies the only factors that are predictive for long-term follow-up; clearly, it does not, but it was to find out whether it was helpful in identifying long-term risk.”

Study details

GRACE is a database of patients with ACS who present at hospital. 28 countries participate in this scheme, submitting the details and medication of approximately 10,000 patients per year. The treatment that the patients receive is determined by their clinician, reflecting real-life conditions. Fox stated that only 9% of patients included in the database are currently participating in a clinical trial. This database can help to improve our knowledge of effective treatments and to evaluate novel therapies and outcomes for patients with ACS around the world, in both the short- and the long-term.

Fox presented data on the long-term follow-up of patients from the UK and Belgium. It was found that late risk is often underestimated in patients presenting with ACS, and the greatest risk was for non-STEMI patients. A large proportion of deaths occurred following discharge from hospital, and there were several recurrent cardiovascular presentations, which has implications for the effectiveness of secondary prevention and on healthcare resources.

The investigators found that GRACE scores were a good predictor of ACS risk at ≥ 5 years, and could also accurately predict mortality, even at survival more than 6 months following ACS.