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Risk stratification in acute coronary syndromes: When less is more
Estratificação de risco nas síndromes coronárias agudas: quando o menos vale mais
Jorge Ferreira
Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Carnaxide, Portugal
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A: attention; EF: executive function; GF: global cognitive function; GI: globally impaired cluster; M: memory; MI: moderately impaired cluster; NI: non-impaired cluster; PS: processing speed; VC: visuoconstructive.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria Emília Areias, Bruno Peixoto, Ivone Santos, Lígia Cruz, Ana Regadas, Carolina Pinheiro, Helena Monteiro, Sara Araújo, Tânia Carvalho, Joana Miranda, Cláudia Moura, Joana Soares, Victor Viana, Jorge Quintas, José Carlos Areias" "autores" => array:15 [ 0 => array:2 [ "nombre" => "Maria Emília" "apellidos" => "Areias" ] 1 => array:2 [ "nombre" => "Bruno" "apellidos" => "Peixoto" ] 2 => array:2 [ "nombre" => "Ivone" "apellidos" => "Santos" ] 3 => array:2 [ "nombre" => "Lígia" "apellidos" => "Cruz" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Regadas" ] 5 => array:2 [ "nombre" => "Carolina" "apellidos" => "Pinheiro" ] 6 => array:2 [ "nombre" => "Helena" "apellidos" => "Monteiro" ] 7 => array:2 [ "nombre" => "Sara" "apellidos" => "Araújo" ] 8 => array:2 [ "nombre" => "Tânia" "apellidos" => "Carvalho" ] 9 => array:2 [ "nombre" => "Joana" "apellidos" => "Miranda" ] 10 => array:2 [ "nombre" => "Cláudia" "apellidos" => "Moura" ] 11 => array:2 [ "nombre" => "Joana" "apellidos" => "Soares" ] 12 => array:2 [ "nombre" => "Victor" "apellidos" => "Viana" ] 13 => array:2 [ "nombre" => "Jorge" "apellidos" => "Quintas" ] 14 => array:2 [ "nombre" => "José Carlos" "apellidos" => "Areias" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420491830391X?idApp=UINPBA00004E" "url" => "/21742049/0000003700000011/v1_201812150634/S217420491830391X/v1_201812150634/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204918303908" "issn" => "21742049" "doi" => "10.1016/j.repce.2018.03.020" "estado" => "S300" "fechaPublicacion" => "2018-11-01" "aid" => "1305" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2018;37:911-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1515 "formatos" => array:3 [ "EPUB" => 115 "HTML" => 1210 "PDF" => 190 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Left main and/or three-vessel disease in patients with non-ST-segment elevation myocardial infarction and low-risk GRACE score: Prevalence, clinical outcomes and predictors" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "911" "paginaFinal" => "919" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Doença do tronco comum e/ou doença arterial coronária de três vasos em doentes com enfarte agudo do miocárdio sem elevação do segmento ST e <span class="elsevierStyleItalic">Score</span> Grace de baixo risco: prevalência, prognóstico clínico e preditores" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2214 "Ancho" => 2167 "Tamanyo" => 283739 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flowchart of patient selection. ACS: acute coronary syndrome; GRACE: Global Registry of Acute Coronary Events; LM/3VD: left main and/or three-vessel disease; MI: myocardial infarction; NSTE-ACS: non-ST-segment elevation acute coronary syndrome; NSTEMI: non-ST-segment elevation acute myocardial infarction; STEMI: ST-segment elevation myocardial infarction.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "João Filipe Carvalho, Adriana Belo, Kisa Congo, David Neves, Ana Rita Santos, Bruno Piçarra, Ana Filipa Damásio, José Aguiar" "autores" => array:9 [ 0 => array:2 [ "nombre" => "João Filipe" "apellidos" => "Carvalho" ] 1 => array:2 [ "nombre" => "Adriana" "apellidos" => "Belo" ] 2 => array:2 [ "nombre" => "Kisa" "apellidos" => "Congo" ] 3 => array:2 [ "nombre" => "David" "apellidos" => "Neves" ] 4 => array:2 [ "nombre" => "Ana Rita" "apellidos" => "Santos" ] 5 => array:2 [ "nombre" => "Bruno" "apellidos" => "Piçarra" ] 6 => array:2 [ "nombre" => "Ana Filipa" "apellidos" => "Damásio" ] 7 => array:2 [ "nombre" => "José" "apellidos" => "Aguiar" ] 8 => array:1 [ "colaborador" => "on behalf of the investigators of the Portuguese Registry on Acute Coronary Syndromes (ProACS)" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918303908?idApp=UINPBA00004E" "url" => "/21742049/0000003700000011/v1_201812150634/S2174204918303908/v1_201812150634/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Risk stratification in acute coronary syndromes: When less is more" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "921" "paginaFinal" => "922" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Jorge Ferreira" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Jorge" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "jorge_ferreira@netcabo.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Carnaxide, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Estratificação de risco nas síndromes coronárias agudas: quando o menos vale mais" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with acute coronary syndrome (ACS) are a heterogeneous population in terms of both diagnosis and prognosis, and therefore risk stratification is an essential element in the therapeutic approach.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In non-ST-elevation ACS (NSTE-ACS), early identification of patients at high ischemic risk enables immediate measures to be taken that have a positive impact on outcome, such as an invasive strategy to assess coronary anatomy with a view to revascularization.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Risk stratification at the time of initial diagnostic assessment is a class I recommendation, level of evidence A, in the guidelines for NSTE-ACS from both the European Society of Cardiology and the American College of Cardiology/American Heart Association.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Stratification is based on clinical and demographic variables, the electrocardiogram (ECG), and laboratory tests. Older age, diabetes, renal dysfunction, hemodynamic instability, signs of heart failure, ischemic changes on the ECG and elevated biomarkers of myocardial necrosis, inflammation and neurohormonal activation are all indicators of worse prognosis. Risk scores, which combine and integrate these variables, improve the accuracy of ischemic risk stratification and thus prediction of cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The GRACE score has the best performance in quantifying ischemic risk at admission and in selecting patients for revascularization.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">However, even patients initially classified as low risk may have a complicated clinical course, and identification of these individuals is a challenge for ongoing risk stratification. The development of signs of heart failure after admission, or detection of dynamic ischemic ST-segment changes on continuous ECG monitoring or of left ventricular dysfunction, will significantly change the level of risk in a patient initially classified as low or intermediate risk.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> This is also the case for patients who are subsequently found to have severe coronary artery disease (CAD) on coronary angiography, including left main and/or three-vessel disease (LM/3VD).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Carvalho et al. assess the prevalence, clinical outcomes and predictors of LM/3VD in patients included in the Portuguese Registry of Acute Coronary Syndromes and classified as low risk on admission on the basis of a GRACE score of ≤108.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> These accounted for around 20% of all patients with NSTE-ACS in the registry, which is a slightly lower figure than in another Portuguese study.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Coronary angiography identified LM/3VD in 18% of low-risk patients, meaning that 3.5% of patients with NSTE-ACS classified as low risk had severe CAD. Not surprisingly, the prevalence of severe CAD in such low-risk patients is much lower than that reported in observational studies.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In the study by Carvalho et al., LM/3VD was associated with higher mortality (0.9% vs. 0.0%), more major adverse cardiac and cerebrovascular events (4.1% vs. 2.5%), and higher one-year mortality (2.4% vs. 0.5%) than in those without LM/3VD. However, these differences did not reach statistical significance, which may in part be due to the fact that most patients underwent coronary angiography within 24 hours of admission, and therefore early revascularization following detection of LM/3VD may have reduced the absolute risk associated with severe CAD.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The independent predictors of LM/3VD identified by the authors were age (OR 1.03; 95% confidence interval [CI] 1.01–1.05, p=0.003 for each 10-year increase in age), male gender (OR 2.56; 95% CI 1.56–4.17, p<0.001), heart rate (1.02; 95% CI 1.01–1.03, p<0.001 for each 10-bpm increase in heart rate), and previous peripheral arterial disease (OR 3.21; 95% CI 1.47–7.00, p<0.001) and heart failure (OR 3.38; 95% CI 1.02–11.15, p=0.046). It is interesting to note that age and heart rate are among the variables of the GRACE score, which identified these patients as low risk. This apparent paradox may be related to the fact that both these variables are numerical, which affects continuous risk. Otherwise, the performance of the GRACE score was adequate, since the absolute risk of in-hospital death in patients with LM/3VD (<1%) was within the range estimated by the score for low-risk patients.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Previous heart failure and peripheral arterial disease are also risk markers in ACS and are commonly associated with more severe CAD.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">However, the presence of any of these predictors of CAD severity will be unlikely to prompt selection of the patient for early coronary angiography, since in daily clinical practice it is low-risk patients who more often undergo an invasive strategy. This reversal of a risk-guided therapeutic approach has in fact been observed in a range of studies, including the GRACE registry, in which angiography was performed in 72% of low-risk patients, 68% of intermediate-risk patients and only 51% of high-risk patients.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> This is a problem that needs to be addressed. Risk stratification should be carried out in all NSTE-ACS patients with a view to referring those at highest risk for coronary angiography, as stipulated in the guidelines.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" 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: Ferreira J. Estratificação de risco nas síndromes coronárias agudas: quando o menos vale mais. Rev Port Cardiol. 2018;37:921–922.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "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)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Roffi" 1 => "C. Patrono" 2 => "J.P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 3 | 11 |
| 2024 October | 54 | 24 | 78 |
| 2024 September | 51 | 24 | 75 |
| 2024 August | 57 | 27 | 84 |
| 2024 July | 45 | 27 | 72 |
| 2024 June | 26 | 20 | 46 |
| 2024 May | 30 | 27 | 57 |
| 2024 April | 28 | 23 | 51 |
| 2024 March | 29 | 22 | 51 |
| 2024 February | 21 | 21 | 42 |
| 2024 January | 23 | 23 | 46 |
| 2023 December | 19 | 31 | 50 |
| 2023 November | 27 | 31 | 58 |
| 2023 October | 17 | 10 | 27 |
| 2023 September | 20 | 20 | 40 |
| 2023 August | 18 | 13 | 31 |
| 2023 July | 21 | 9 | 30 |
| 2023 June | 25 | 19 | 44 |
| 2023 May | 34 | 26 | 60 |
| 2023 April | 20 | 2 | 22 |
| 2023 March | 39 | 19 | 58 |
| 2023 February | 24 | 17 | 41 |
| 2023 January | 18 | 10 | 28 |
| 2022 December | 30 | 24 | 54 |
| 2022 November | 34 | 22 | 56 |
| 2022 October | 22 | 18 | 40 |
| 2022 September | 21 | 36 | 57 |
| 2022 August | 22 | 23 | 45 |
| 2022 July | 29 | 35 | 64 |
| 2022 June | 19 | 22 | 41 |
| 2022 May | 20 | 20 | 40 |
| 2022 April | 25 | 26 | 51 |
| 2022 March | 20 | 42 | 62 |
| 2022 February | 31 | 34 | 65 |
| 2022 January | 16 | 26 | 42 |
| 2021 December | 18 | 24 | 42 |
| 2021 November | 22 | 31 | 53 |
| 2021 October | 25 | 34 | 59 |
| 2021 September | 16 | 22 | 38 |
| 2021 August | 20 | 29 | 49 |
| 2021 July | 12 | 20 | 32 |
| 2021 June | 20 | 19 | 39 |
| 2021 May | 40 | 35 | 75 |
| 2021 April | 26 | 57 | 83 |
| 2021 March | 30 | 18 | 48 |
| 2021 February | 32 | 12 | 44 |
| 2021 January | 25 | 11 | 36 |
| 2020 December | 23 | 12 | 35 |
| 2020 November | 16 | 10 | 26 |
| 2020 October | 16 | 10 | 26 |
| 2020 September | 18 | 9 | 27 |
| 2020 August | 13 | 6 | 19 |
| 2020 July | 14 | 13 | 27 |
| 2020 June | 21 | 7 | 28 |
| 2020 May | 12 | 6 | 18 |
| 2020 April | 12 | 15 | 27 |
| 2020 March | 24 | 6 | 30 |
| 2020 February | 13 | 11 | 24 |
| 2020 January | 16 | 5 | 21 |
| 2019 December | 16 | 4 | 20 |
| 2019 November | 10 | 6 | 16 |
| 2019 October | 17 | 5 | 22 |
| 2019 September | 9 | 4 | 13 |
| 2019 August | 13 | 7 | 20 |
| 2019 July | 12 | 6 | 18 |
| 2019 June | 18 | 16 | 34 |
| 2019 May | 17 | 6 | 23 |
| 2019 April | 13 | 15 | 28 |
| 2019 March | 10 | 14 | 24 |
| 2019 February | 13 | 13 | 26 |
| 2019 January | 13 | 7 | 20 |
| 2018 December | 20 | 16 | 36 |
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