Editorial comment
Is a GRACE 3.0 needed?
Será necessário um GRACE 3.0?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "393" "paginaFinal" => "394" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Manuel de Sousa Almeida" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Manuel" "apellidos" => "de Sousa Almeida" "email" => array:1 [ 0 => "almeidams@sapo.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidade de Intervenção Cardiovascular, Hospital de Santa Cruz, CHLO, Carnaxide, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Fisiopatologia, Nova Medical School, Universidade Nova de Lisboa, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Será necessário um GRACE 3.0?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Sergio Raposeiras-Roubín et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> present an original study that identifies the Global Registry of Acute Coronary Events (GRACE) risk score as an independent predictor of 30-day mortality and major cardiovascular events in patients with acute coronary syndrome (ACS).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The ability to identify patients at risk for clinical events that endanger their lives or worsen their prognosis is one of the most important goals in medicine. But this goal makes more sense if identifying at-risk patients leads to therapeutic strategies that reduce the risk. This is the rationale behind risk scores, diagnostic tools that improve physicians’ ability not only to identify high-risk patients but to select the most appropriate strategies to reduce risk.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Of the available scores for estimating risk associated with ACS, the GRACE score appears to be the best.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> It has been validated for identifying ACS patients at risk of in-hospital<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> and six-month<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> mortality, and according to Raposeiras-Roubín et al., it can also be used to identify ACS patients at risk of death and cardiovascular events within 30 days.</p><p id="par0020" class="elsevierStylePara elsevierViewall">First of all, the authors are to be congratulated on the low event rate in their study; in an all-comer population admitted and treated between 2004 and 2010, 30% (n=1332) of whom had ST-segment elevation myocardial infarction and 15.5% were in Killip class >2, 30-day mortality was 0.7%; the combined event rate was 2.7%, including 1% reinfarction, 1.3% heart failure, and 0.2% stroke. These numbers reflect not only the excellence of the center, but also the impact of recent developments in treatment options, which are more effective and safer than those available in the GRACE registry five years previously in the era of glycoprotein IIb/IIIa inhibitors and before the advent of drug-eluting stents. As an example, the incidence of percutaneous coronary intervention in Raposeiras-Roubín et al.’s series was 64.5%, compared to only 28% in the GRACE registry,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> which would partly explain the difference in clinical outcomes during hospitalization and after discharge. The point I want to make is that the circumstances that gave rise to the GRACE score no longer apply. It is easier to identify an event with an incidence of 6–7% than one that is 10 times less frequent (0.7%); a tool designed to be applied in the former context may fail in the latter.</p><p id="par0025" class="elsevierStylePara elsevierViewall">When applied by the authors, the GRACE score identified 1601 patients (37.9%) as being at high risk of death, but this occurred in only 11 (0.7%), giving a positive predictive value of 5.3%, which is too low to be useful for the selection of more aggressive therapeutic strategies that involve greater risks and higher costs.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is a need for scores that can more accurately identify patients at high risk for major cardiovascular events for whom more aggressive treatment would be more effective in prevention, and thus justify the higher risks and costs. This may mean a more complex score that better reflects the current situation, with the possible drawback of it being used less by physicians.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A magnifying glass is a simple instrument that is adequate for examining a macroscopic object but is clearly useless for the microscopic world, for which more powerful and accurate instruments are required, even if they are more complex. A GRACE 3.0 is needed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de Sousa Almeida M. Será necessário um GRACE 3.0?. Rev Port Cardiol. 2015;34:393–394.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mortality and cardiovascular morbidity within 30 days of acute coronary syndrome in a contemporary European cohort of patients: how can early risk prediction be improved? The six-month GRACE risk score" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Raposeiras-Roubín" 1 => "E. Abu-Assi" 2 => "C. Cambeiro-González" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2015" "volumen" => "34" "paginaInicial" => "383" "paginaFinal" => "391" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. de Araujo Goncalves" 1 => "J. Ferreira" 2 => "C. Aguiar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehi187" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2005" "volumen" => "26" "paginaInicial" => "865" "paginaFinal" => "872" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15764619" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.T. Yan" 1 => "R.T. Yan" 2 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 5 | 12 |
| 2024 October | 33 | 25 | 58 |
| 2024 September | 50 | 23 | 73 |
| 2024 August | 38 | 27 | 65 |
| 2024 July | 26 | 25 | 51 |
| 2024 June | 28 | 32 | 60 |
| 2024 May | 31 | 26 | 57 |
| 2024 April | 20 | 29 | 49 |
| 2024 March | 19 | 19 | 38 |
| 2024 February | 17 | 23 | 40 |
| 2024 January | 24 | 23 | 47 |
| 2023 December | 19 | 30 | 49 |
| 2023 November | 15 | 21 | 36 |
| 2023 October | 20 | 14 | 34 |
| 2023 September | 22 | 21 | 43 |
| 2023 August | 13 | 17 | 30 |
| 2023 July | 20 | 18 | 38 |
| 2023 June | 15 | 13 | 28 |
| 2023 May | 24 | 28 | 52 |
| 2023 April | 10 | 12 | 22 |
| 2023 March | 18 | 21 | 39 |
| 2023 February | 21 | 24 | 45 |
| 2023 January | 14 | 15 | 29 |
| 2022 December | 15 | 29 | 44 |
| 2022 November | 26 | 23 | 49 |
| 2022 October | 15 | 18 | 33 |
| 2022 September | 25 | 50 | 75 |
| 2022 August | 20 | 32 | 52 |
| 2022 July | 25 | 36 | 61 |
| 2022 June | 12 | 25 | 37 |
| 2022 May | 15 | 21 | 36 |
| 2022 April | 21 | 23 | 44 |
| 2022 March | 20 | 32 | 52 |
| 2022 February | 19 | 26 | 45 |
| 2022 January | 15 | 22 | 37 |
| 2021 December | 15 | 28 | 43 |
| 2021 November | 21 | 30 | 51 |
| 2021 October | 25 | 33 | 58 |
| 2021 September | 15 | 31 | 46 |
| 2021 August | 22 | 28 | 50 |
| 2021 July | 14 | 25 | 39 |
| 2021 June | 8 | 10 | 18 |
| 2021 May | 30 | 36 | 66 |
| 2021 April | 43 | 34 | 77 |
| 2021 March | 30 | 11 | 41 |
| 2021 February | 40 | 8 | 48 |
| 2021 January | 19 | 14 | 33 |
| 2020 December | 22 | 6 | 28 |
| 2020 November | 19 | 13 | 32 |
| 2020 October | 12 | 7 | 19 |
| 2020 September | 55 | 9 | 64 |
| 2020 August | 20 | 9 | 29 |
| 2020 July | 21 | 3 | 24 |
| 2020 June | 29 | 8 | 37 |
| 2020 May | 28 | 7 | 35 |
| 2020 April | 33 | 12 | 45 |
| 2020 March | 32 | 9 | 41 |
| 2020 February | 27 | 28 | 55 |
| 2020 January | 20 | 5 | 25 |
| 2019 December | 20 | 5 | 25 |
| 2019 November | 27 | 6 | 33 |
| 2019 October | 25 | 6 | 31 |
| 2019 September | 19 | 5 | 24 |
| 2019 August | 32 | 6 | 38 |
| 2019 July | 22 | 8 | 30 |
| 2019 June | 15 | 8 | 23 |
| 2019 May | 31 | 11 | 42 |
| 2019 April | 15 | 13 | 28 |
| 2019 March | 14 | 8 | 22 |
| 2019 February | 27 | 10 | 37 |
| 2019 January | 16 | 6 | 22 |
| 2018 December | 38 | 9 | 47 |
| 2018 November | 48 | 13 | 61 |
| 2018 October | 68 | 14 | 82 |
| 2018 September | 37 | 15 | 52 |
| 2018 August | 29 | 3 | 32 |
| 2018 July | 20 | 6 | 26 |
| 2018 June | 34 | 5 | 39 |
| 2018 May | 40 | 9 | 49 |
| 2018 April | 51 | 1 | 52 |
| 2018 March | 61 | 7 | 68 |
| 2018 February | 26 | 4 | 30 |
| 2018 January | 23 | 6 | 29 |
| 2017 December | 56 | 7 | 63 |
| 2017 November | 45 | 3 | 48 |
| 2017 October | 31 | 9 | 40 |
| 2017 September | 37 | 9 | 46 |
| 2017 August | 48 | 10 | 58 |
| 2017 July | 34 | 13 | 47 |
| 2017 June | 38 | 10 | 48 |
| 2017 May | 44 | 11 | 55 |
| 2017 April | 34 | 5 | 39 |
| 2017 March | 36 | 29 | 65 |
| 2017 February | 28 | 14 | 42 |
| 2017 January | 41 | 8 | 49 |
| 2016 December | 28 | 6 | 34 |
| 2016 November | 27 | 3 | 30 |
| 2016 October | 29 | 16 | 45 |
| 2016 September | 18 | 14 | 32 |
| 2016 August | 7 | 7 | 14 |
| 2016 July | 14 | 5 | 19 |
| 2016 June | 13 | 2 | 15 |
| 2016 May | 16 | 5 | 21 |
| 2016 April | 25 | 1 | 26 |
| 2016 March | 34 | 15 | 49 |
| 2016 February | 54 | 24 | 78 |
| 2016 January | 32 | 27 | 59 |
| 2015 December | 35 | 13 | 48 |
| 2015 November | 43 | 15 | 58 |
| 2015 October | 40 | 12 | 52 |
| 2015 September | 53 | 23 | 76 |
| 2015 August | 99 | 35 | 134 |
| 2015 July | 162 | 61 | 223 |
| 2015 June | 62 | 29 | 91 |
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