Letter to the Editor
Response to Letter to the Editor “Risk stratification in acute coronary syndromes: Graced by a new score?”
Resposta à Carta ao Editor «Estratificação de risco nas síndromas coronárias agudas: como poderá o Grace ser destronado?»
Ana Timóteo
Serviço de Cardiologia, CHLC, Hospital de Santa Marta, Lisboa, Portugal
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We appreciate their interest and their constructive comments on our article recently published in the <span class="elsevierStyleItalic">Journal</span> in which we develop and validate a simple risk stratification score (ProACS) for patients with acute coronary syndromes from a large nationwide registry.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> In our paper, the ProACS risk score showed a significantly lower discriminative power compared to the GRACE score in the external validation cohort, but slightly better compared to the development and internal validation cohorts. The Canada Acute Coronary Syndrome (C-ACS) risk score,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> developed with the same principles and objectives, yields similar discriminative power to our own score but is still considered adequate. Paiva et al. performed an additional external validation (highly recommended for any prediction model) in an independent contemporary cohort of 1000 consecutive myocardial infarction (MI) patients (43.5% with ST-elevation MI [STEMI]), fairly similar to the external validation cohort from our paper.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a> Their results showed that 98% of in-hospital deaths were accurately classified in the intermediate- or high-risk groups; however, the ProACS score's discriminative power was significantly lower than that of the GRACE score (and slightly lower than our results), which might compromise the accuracy of risk stratification. They also performed a risk reclassification study, which showed that ProACS is better at identifying low-risk patients, particularly in the non-ST-elevation MI (NSTEMI) cohort. GRACE is superior in identifying high-risk patients. We obviously agree with the authors’ concluding remark that it remains to be determined whether the simplicity of this new score is offset by its inferior prognostic power compared to the gold standard GRACE risk score.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our group also performed an external validation in patients from a single center, although with some different baseline characteristics, particularly a predominance of STEMI (62%) and with more cardiovascular risk factors.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Compared to GRACE, we also obtained a lower discriminative power, with an area under the curve (AUC) of 0.769 for in-hospital mortality, similar to that reported for C-ACS, and slightly superior in STEMI (0.77 vs. 0.74), albeit non-significant.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Also in an earlier study from our group in a STEMI cohort, we showed that a simple (reduced) score (not yet the ProACS score) led to significant improvement when reclassification was analyzed, particularly in patients without events, as was also demonstrated by Paiva et al.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">From a statistical point of view, dissatisfaction with AUC analysis has prompted proposals for new statistical metrics based on risk categories and reclassification.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Reclassification analysis with the use of net reclassification improvement (NRI) and integrated discrimination improvement (IDI) are particularly useful because they can help to clarify and quantify the degree of correct reclassification of predicted probabilities. However, for some authors NRI has many of the same problems as the AUC.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> It is sometimes difficult to be sure if the measure is clinically meaningful due to lack of experience with the index. Some authors recommend the use of category-free (or continuous) NRI, avoiding predefined risk categories, but this can also mislead investigators by overstating the incremental value of an additional biomarker. Furthermore, without proper attention to model fit, NRI can mislead researchers and it is recommended to use bootstrap methods for estimating the variance of NRI and constructing confidence intervals. For those reasons, some caution is advised when interpreting reclassification analysis. Also, in the presence of a fairly robust risk score, such as GRACE, the quantitative improvement in model performance is expected to be small or even negative.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Finally, from a clinical point of view, the fact that ProACS's predicted ability is lower than GRACE does not hinder its application, because an AUC ≥0.75 means that it is still valid. The ProACS risk score better identifies those who do not have events. This is clinically important, because identification of these “truly low-risk patients” may enable better patient selection, avoiding unnecessary interventions that can increase costs as well as the risk of intervention-related adverse events, and may help in the selection of patients for early discharge. As we stated in our paper, risk stratification is a dynamic process that requires risk recalculation after admission. ProACS can be used at the first medical contact, when it is important to decide whether to refer the patient directly to a tertiary hospital, and due to its simplicity, even healthcare professionals without advanced medical or cardiological training (in a pre-hospital setting or in emergency department triage) can use this simple score. However, when full clinical and laboratory data are available, clinicians should calculate the GRACE score, because it provides more accurate risk stratification, which is crucial to patient management decisions.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" 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 "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ProACS risk score: an early and simple score for risk stratification of patients with acute coronary syndromes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 4 | 13 |
| 2024 October | 27 | 22 | 49 |
| 2024 September | 41 | 26 | 67 |
| 2024 August | 33 | 27 | 60 |
| 2024 July | 29 | 27 | 56 |
| 2024 June | 26 | 19 | 45 |
| 2024 May | 23 | 20 | 43 |
| 2024 April | 27 | 21 | 48 |
| 2024 March | 25 | 15 | 40 |
| 2024 February | 30 | 15 | 45 |
| 2024 January | 19 | 19 | 38 |
| 2023 December | 32 | 32 | 64 |
| 2023 November | 26 | 23 | 49 |
| 2023 October | 22 | 19 | 41 |
| 2023 September | 20 | 12 | 32 |
| 2023 August | 19 | 17 | 36 |
| 2023 July | 21 | 12 | 33 |
| 2023 June | 24 | 11 | 35 |
| 2023 May | 37 | 23 | 60 |
| 2023 April | 15 | 4 | 19 |
| 2023 March | 36 | 22 | 58 |
| 2023 February | 27 | 15 | 42 |
| 2023 January | 19 | 13 | 32 |
| 2022 December | 31 | 21 | 52 |
| 2022 November | 35 | 28 | 63 |
| 2022 October | 25 | 16 | 41 |
| 2022 September | 30 | 29 | 59 |
| 2022 August | 21 | 24 | 45 |
| 2022 July | 23 | 34 | 57 |
| 2022 June | 24 | 14 | 38 |
| 2022 May | 16 | 36 | 52 |
| 2022 April | 23 | 23 | 46 |
| 2022 March | 34 | 42 | 76 |
| 2022 February | 34 | 37 | 71 |
| 2022 January | 20 | 20 | 40 |
| 2021 December | 17 | 36 | 53 |
| 2021 November | 29 | 31 | 60 |
| 2021 October | 68 | 36 | 104 |
| 2021 September | 26 | 28 | 54 |
| 2021 August | 14 | 28 | 42 |
| 2021 July | 14 | 30 | 44 |
| 2021 June | 14 | 18 | 32 |
| 2021 May | 26 | 32 | 58 |
| 2021 April | 28 | 30 | 58 |
| 2021 March | 46 | 19 | 65 |
| 2021 February | 34 | 12 | 46 |
| 2021 January | 17 | 13 | 30 |
| 2020 December | 35 | 11 | 46 |
| 2020 November | 23 | 14 | 37 |
| 2020 October | 14 | 15 | 29 |
| 2020 September | 30 | 11 | 41 |
| 2020 August | 13 | 7 | 20 |
| 2020 July | 36 | 7 | 43 |
| 2020 June | 15 | 6 | 21 |
| 2020 May | 22 | 6 | 28 |
| 2020 April | 19 | 7 | 26 |
| 2020 March | 18 | 9 | 27 |
| 2020 February | 50 | 13 | 63 |
| 2020 January | 5 | 7 | 12 |
| 2019 December | 18 | 4 | 22 |
| 2019 November | 19 | 5 | 24 |
| 2019 October | 9 | 4 | 13 |
| 2019 September | 15 | 6 | 21 |
| 2019 August | 12 | 6 | 18 |
| 2019 July | 17 | 8 | 25 |
| 2019 June | 15 | 11 | 26 |
| 2019 May | 19 | 11 | 30 |
| 2019 April | 12 | 11 | 23 |
| 2019 March | 36 | 13 | 49 |
| 2019 February | 11 | 5 | 16 |
| 2019 January | 5 | 4 | 9 |
| 2018 December | 10 | 8 | 18 |
| 2018 November | 23 | 9 | 32 |
| 2018 October | 42 | 14 | 56 |
| 2018 September | 27 | 12 | 39 |
| 2018 August | 21 | 3 | 24 |
| 2018 July | 13 | 5 | 18 |
| 2018 June | 24 | 5 | 29 |
| 2018 May | 40 | 7 | 47 |
| 2018 April | 44 | 9 | 53 |
| 2018 March | 46 | 8 | 54 |
| 2018 February | 36 | 8 | 44 |
| 2018 January | 14 | 5 | 19 |
| 2017 December | 25 | 15 | 40 |
| 2017 November | 15 | 15 | 30 |
| 2017 October | 41 | 18 | 59 |
| 2017 September | 7 | 6 | 13 |
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