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Risk stratification in acute coronary syndromes – When perfect is the enemy of good
Estratificação de risco nas síndromes coronárias agudas – quando o ótimo é inimigo do bom
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] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Risk stratification in acute coronary syndromes – When perfect is the enemy of good" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "329" "paginaFinal" => "330" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Pedro de Araújo Gonçalves" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Pedro" "apellidos" => "de Araújo Gonçalves" "email" => array:1 [ 0 => "paraujogoncalves@yahoo.co.uk" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital da Luz, Luz-Saúde, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Nova Medical School, Universidade Nova de Lisboa, Lisboa, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Estratificação de risco nas síndromes coronárias agudas – quando o ótimo é inimigo do bom" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute coronary syndrome (ACS) is a clinical entity that affects a heterogeneous group of patients, and thus risk stratification is essential for decisions on the treatment approach to adopt. The aggressiveness of the strategy should be proportional to the risk of cardiovascular events and take into account the risk of complications, particularly bleeding and renal dysfunction. Two factors make this stratification difficult. Firstly, the decision whether to adopt an invasive or a conservative strategy is taken before assessment of the coronary anatomy, but this is crucial to establishing the patient's risk level. Secondly, many variables – risk factors, clinical presentation, and demographic, electrocardiographic and laboratory data, among others – may affect prognosis. There have therefore been efforts in recent years to develop scoring systems that use multiple variables to provide an overall estimate of risk, not only for cardiovascular events (such as the Thrombolysis in Myocardial Infarction [TIMI]<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> and Global Registry of Acute Coronary Events [GRACE]<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> scores), but also for complications, like the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) Bleeding Score.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is against this background that the article by Timóteo et al.,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> which aimed to perform an external validation of the ProACS risk score developed on the basis of ProACS, the Portuguese national ACS registry,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> is published in this issue of the <span class="elsevierStyleItalic">Journal</span>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The ProACS score enables early risk stratification; it is simple to calculate, since it includes only four dichotomized variables (age, systolic blood pressure, Killip class at admission and ST-segment elevation). It had previously been validated for in-hospital mortality, but in this study the authors compared its performance with the GRACE score, which has been widely validated and is recommended in the European Society of Cardiology (ESC) guidelines<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> and a score recently developed by a Canadian group, the Canada Acute Coronary Syndrome (C-ACS) risk score.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> The authors showed that in their external validation cohort, composed of 3170 ACS patients from a single center, the ProACS score had reasonable discriminative ability, not only for in-hospital mortality (area under the receiver operating characteristic curve [AUC] 0.769) but also for 30-day (AUC 0.755) and one-year (AUC 0.748) mortality, similar to C-ACS, but lower than the GRACE risk score (AUCs of 0.857, 0.829 and 0.804 for in-hospital, 30-day and one-year mortality, respectively). Timóteo et al., as well as the group who originally developed the ProACS score, deserve recognition for their work, and the performance of the score should be evaluated in light of the small number of variables used (four) and the fact that they are weighted on a dichotomized basis, making it easy to calculate and thus more likely to be adopted in clinical practice. The complexity of a risk score with multiple variables and relative weightings can be inversely proportional to its ease of application, which may explain why many references to the TIMI score continue to be seen, even though its performance is clearly inferior to that of the GRACE score,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> as has been shown by our group in a study cited in the latest ESC guidelines on ACS.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The other advantage of the ProACS score is that it reflects efforts to develop and validate a risk stratification system based on the clinical characteristics of patients in the Portuguese national ACS registry, and may therefore identify genetic factors or aspects of management that are specific to Portugal.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, the usefulness and applicability of risk stratification scores may vary across the spectrum of ACS patients. While in non-ST-elevation ACS the considerable heterogeneity of patients and of therapeutic options, together with the recommendation for an immediate invasive strategy (<2 h) for very high risk patients in the latest ESC guidelines,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> make risk stratification imperative, in patients with ST-elevation myocardial infarction (STEMI) this is less important for initial decision-making and choice of strategy, since in these patients the indication for percutaneous coronary intervention is almost universal and depends more on logistical considerations (such as availability of a catheterization laboratory) than on the level of clinical risk. In view of this difference, it is worth noting that the prevalence of STEMI in the external validation cohort was significantly higher than in the original development cohort from the ProACS registry (62.2% vs. 43.6%), which may have affected the AUCs reported in the study and may limit generalization of these findings to other centers, although the authors found no significant difference in the performance of the ProACS score in different clinical contexts (with or without ST elevation). Comparison between the ProACS and GRACE scores clearly reflects the dilemma of risk stratification in ACS, in which there is a delicate balance between complexity and performance, with complexity directly proportional to performance but inversely proportional to adoption in clinical practice – an example of when perfect is the enemy of good.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has 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 Araújo Gonçalves P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 6 | 9 |
| 2024 October | 36 | 31 | 67 |
| 2024 September | 48 | 21 | 69 |
| 2024 August | 41 | 26 | 67 |
| 2024 July | 31 | 34 | 65 |
| 2024 June | 28 | 15 | 43 |
| 2024 May | 30 | 26 | 56 |
| 2024 April | 20 | 19 | 39 |
| 2024 March | 32 | 28 | 60 |
| 2024 February | 26 | 39 | 65 |
| 2024 January | 16 | 40 | 56 |
| 2023 December | 21 | 26 | 47 |
| 2023 November | 32 | 23 | 55 |
| 2023 October | 22 | 17 | 39 |
| 2023 September | 21 | 24 | 45 |
| 2023 August | 22 | 11 | 33 |
| 2023 July | 23 | 6 | 29 |
| 2023 June | 23 | 11 | 34 |
| 2023 May | 31 | 20 | 51 |
| 2023 April | 22 | 2 | 24 |
| 2023 March | 41 | 18 | 59 |
| 2023 February | 23 | 15 | 38 |
| 2023 January | 15 | 8 | 23 |
| 2022 December | 38 | 23 | 61 |
| 2022 November | 37 | 20 | 57 |
| 2022 October | 22 | 15 | 37 |
| 2022 September | 18 | 28 | 46 |
| 2022 August | 26 | 21 | 47 |
| 2022 July | 24 | 26 | 50 |
| 2022 June | 21 | 19 | 40 |
| 2022 May | 18 | 29 | 47 |
| 2022 April | 28 | 24 | 52 |
| 2022 March | 21 | 29 | 50 |
| 2022 February | 20 | 24 | 44 |
| 2022 January | 22 | 24 | 46 |
| 2021 December | 19 | 26 | 45 |
| 2021 November | 36 | 32 | 68 |
| 2021 October | 37 | 34 | 71 |
| 2021 September | 19 | 21 | 40 |
| 2021 August | 28 | 33 | 61 |
| 2021 July | 19 | 24 | 43 |
| 2021 June | 22 | 11 | 33 |
| 2021 May | 37 | 35 | 72 |
| 2021 April | 28 | 45 | 73 |
| 2021 March | 50 | 25 | 75 |
| 2021 February | 46 | 15 | 61 |
| 2021 January | 37 | 16 | 53 |
| 2020 December | 22 | 10 | 32 |
| 2020 November | 23 | 13 | 36 |
| 2020 October | 20 | 16 | 36 |
| 2020 September | 41 | 6 | 47 |
| 2020 August | 18 | 6 | 24 |
| 2020 July | 48 | 13 | 61 |
| 2020 June | 40 | 7 | 47 |
| 2020 May | 32 | 13 | 45 |
| 2020 April | 33 | 7 | 40 |
| 2020 March | 38 | 3 | 41 |
| 2020 February | 49 | 49 | 98 |
| 2020 January | 27 | 7 | 34 |
| 2019 December | 21 | 5 | 26 |
| 2019 November | 33 | 10 | 43 |
| 2019 October | 43 | 4 | 47 |
| 2019 September | 13 | 8 | 21 |
| 2019 August | 30 | 5 | 35 |
| 2019 July | 33 | 7 | 40 |
| 2019 June | 20 | 8 | 28 |
| 2019 May | 28 | 8 | 36 |
| 2019 April | 30 | 15 | 45 |
| 2019 March | 21 | 12 | 33 |
| 2019 February | 49 | 5 | 54 |
| 2019 January | 28 | 11 | 39 |
| 2018 December | 39 | 13 | 52 |
| 2018 November | 156 | 8 | 164 |
| 2018 October | 307 | 13 | 320 |
| 2018 September | 111 | 14 | 125 |
| 2018 August | 69 | 6 | 75 |
| 2018 July | 40 | 8 | 48 |
| 2018 June | 56 | 9 | 65 |
| 2018 May | 76 | 16 | 92 |
| 2018 April | 98 | 15 | 113 |
| 2018 March | 135 | 15 | 150 |
| 2018 February | 57 | 12 | 69 |
| 2018 January | 124 | 9 | 133 |
| 2017 December | 98 | 12 | 110 |
| 2017 November | 56 | 15 | 71 |
| 2017 October | 38 | 13 | 51 |
| 2017 September | 31 | 12 | 43 |
| 2017 August | 38 | 17 | 55 |
| 2017 July | 32 | 14 | 46 |
| 2017 June | 35 | 15 | 50 |
| 2017 May | 33 | 8 | 41 |
| 2017 April | 11 | 9 | 20 |
| 2017 March | 22 | 5 | 27 |
| 2017 February | 22 | 6 | 28 |
| 2017 January | 32 | 2 | 34 |
| 2016 December | 39 | 1 | 40 |
| 2016 November | 30 | 4 | 34 |
| 2016 October | 37 | 12 | 49 |
| 2016 September | 32 | 10 | 42 |
| 2016 August | 15 | 2 | 17 |
| 2016 July | 49 | 16 | 65 |
| 2016 June | 6 | 34 | 40 |
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