Editorial comment
Risk stratification after acute coronary syndromes: Scores, scores and yet another score
Estratificação de risco após síndromes coronárias agudas. Scores, scores e mais (um) score
Daniel Ferreira
Cardiovascular Centre, Hospital da Luz Lisboa, Lisbon, Portugal
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array:1 [ 0 => "dferreira@hospitaldaluz.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiovascular Centre, Hospital da Luz Lisboa, Lisbon, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Estratificação de risco após síndromes coronárias agudas. <span class="elsevierStyleItalic">Scores</span>, <span class="elsevierStyleItalic">scores</span> e mais (um) <span class="elsevierStyleItalic">score</span>" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Identification of high-risk patients soon after an acute coronary syndrome (ACS) event has been a challenge for clinicians in the past two or three decades. Numerous studies have clearly demonstrated that more intensive, even aggressive, management of these patients results in significantly better outcomes, in particular in the reduction of major adverse cardiac events.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Both ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients have been the subject of risk stratification studies and a number of risk scores have been proposed. Some of these scores were tested in populations of clinical trials (of which the TIMI scores<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> are the best known), but others (such as the GRACE score<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a>) were derived from large registries, with the obvious advantages of reflecting real-life patients, including older and sicker patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Identifying high-risk patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">ACS risk scores aim to identify high-risk patients who should be managed with the best available care, in the shortest possible timeframe. This is in contrast with, for example, the CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> for non-valvular atrial fibrillation, which aims to identify very low-risk patients who do not need to be anticoagulated, since the risk of cerebral or peripheral embolism is minimal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Early referral of these high-risk ACS patients to reference centers with percutaneous coronary intervention (PCI) capabilities and cardiac intensive care units has been shown to result in better short- and long-term outcomes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Risk stratification can be particularly useful to identify high-risk NSTEMI patients who should be referred for more intensive management at an earlier stage of their ACS episode.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Low-risk patients should be properly treated too</span><p id="par0030" class="elsevierStylePara elsevierViewall">A word of caution for the management of patients stratified as low-risk on presentation shortly after an ACS episode, who should also be referred for the best care possible, particularly those presenting with STEMI. Emergency response services should be ready to provide immediate referral to a PCI center, provided it is available in the timeframe defined by the ACS and PCI guidelines.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Do we need yet another score?</span><p id="par0035" class="elsevierStylePara elsevierViewall">All existing risk stratification scores have their strengths and weaknesses. The TIMI scores have been used for some time now but they were derived from clinical trials and their application to real-world patients has been the subject of debate.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The robust GRACE score<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> has the advantage of being based on a large registry, but the disadvantage of including variables that are not available on admission (such as some laboratory results), meaning that it is not applicable for immediate stratification after presentation in the pre-hospital or emergency room environments.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A more immediately applicable score was proposed in 2013 by Huynh et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> based on a Canadian population registry. The Canada Acute Coronary Syndrome (C-ACS) risk score is a simple-to-use score with only four variables (age, Killip class, systolic blood pressure and heart rate) that the investigators have shown enables rapid identification of high-risk patients with ACS, even before biological markers can be obtained.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The question then arises: if we already have good and reliable scores for ACS risk stratification, why would we want yet another score?</p><p id="par0055" class="elsevierStylePara elsevierViewall">The main reason is concern about the applicability of scores derived from populations from North America (US and Canada) to European ACS patients. There are a number of reasons to question this extrapolation. There are relevant epidemiological, genetic, environmental and cultural differences as well as differences in organizational aspects of healthcare systems. Also, ACS management differs considerably between countries on opposite sides of the ocean.</p><p id="par0060" class="elsevierStylePara elsevierViewall">To resolve this question, in this issue of the <span class="elsevierStyleItalic">Journal</span> Timóteo et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> propose a new score derived from the Portuguese Registry on Acute Coronary Syndromes (ProACS), a multicenter nationwide ACS registry. It is a prospective, continuous, and observational registry that includes more than 40<span class="elsevierStyleHsp" style=""></span>000 patients from 33 participating cardiology departments in Portugal.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Thus, this study has the advantage of being based on a large, continuous, national ACS registry, that likely reflects local real-world practice. The validation (both internal and external) was well designed, the score's performance was similar when comparing patients with STEMI and NSTEMI, and its predictive ability was only slightly lower than that of the robust GRACE risk score. The external validation of the score has been previously published in this journal.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Creating a new ACS risk score? Keep it simple</span><p id="par0070" class="elsevierStylePara elsevierViewall">Having learned the lessons of the C-ACS score, Timóteo et al. designed the ProACS score to be simple to use and without the need for laboratory results.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Simplicity is a key factor for widespread applicability of a risk score. As the authors mention in the discussion, the need to wait for laboratory results has led to the underuse of the GRACE score in daily clinical practice.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The proposed ProACS score can be easily calculated with clinical variables only, and has nonetheless showed good discriminatory ability in the identification of high-risk ACS patients (both STEMI and NSTEMI).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Could we make it even simpler?</span><p id="par0085" class="elsevierStylePara elsevierViewall">As mentioned above, one of the major advantages of the C-ACS score is its simplicity, as it has only four variables to consider, 1 point for each variable and clear cut-off values (age ≥75 years, Killip class >1, systolic blood pressure <100 mm Hg, and heart rate >100 beats/min). Huynh et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> could justifiably point out in their conclusions “Because this risk score is simple and easy to memorize and calculate, it can be rapidly applied by health care professionals without advanced medical training.”</p><p id="par0090" class="elsevierStylePara elsevierViewall">The ProACS score is also simple to calculate, but the cut-off values for some of the variables are not so easy to memorize. We may wonder if the score's discriminatory value would decrease significantly if more straightforward numbers were used as cut-offs, e.g. 70 (or 75) instead of 72 years for age and/or 115 mmHg instead of 116 mmHg for systolic blood pressure.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The exact transposition of the multivariate statistical analysis is understandable, but sometimes some loss of discriminatory value (as long as it is only marginal) can be compensated by more user-friendly cut-off variables.</p><p id="par0100" class="elsevierStylePara elsevierViewall">That being said, the authors of the ProACS score are to be congratulated for their work, which deserves the attention of other investigators in this research area. Validation of their proposed score by other groups in other European countries would be most welcome.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Identifying high-risk patients" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Low-risk patients should be properly treated too" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Do we need yet another score?" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Creating a new ACS risk score? Keep it simple" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Could we make it even simpler?" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The TIMI risk score for unstable angina/non-ST-elevation MI. A method for prognostication and therapeutic decision making" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E.M. Antman" 1 => "M. Cohen" 2 => "P.J. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 6 | 2 | 8 |
| 2024 Outubro | 49 | 33 | 82 |
| 2024 Setembro | 57 | 23 | 80 |
| 2024 Agosto | 40 | 30 | 70 |
| 2024 Julho | 49 | 31 | 80 |
| 2024 Junho | 38 | 25 | 63 |
| 2024 Maio | 40 | 21 | 61 |
| 2024 Abril | 44 | 26 | 70 |
| 2024 Maro | 51 | 20 | 71 |
| 2024 Fevereiro | 37 | 19 | 56 |
| 2024 Janeiro | 23 | 30 | 53 |
| 2023 Dezembro | 30 | 36 | 66 |
| 2023 Novembro | 29 | 26 | 55 |
| 2023 Outubro | 24 | 13 | 37 |
| 2023 Setembro | 22 | 22 | 44 |
| 2023 Agosto | 27 | 27 | 54 |
| 2023 Julho | 23 | 13 | 36 |
| 2023 Junho | 36 | 13 | 49 |
| 2023 Maio | 39 | 24 | 63 |
| 2023 Abril | 25 | 3 | 28 |
| 2023 Maro | 35 | 27 | 62 |
| 2023 Fevereiro | 31 | 24 | 55 |
| 2023 Janeiro | 20 | 27 | 47 |
| 2022 Dezembro | 32 | 23 | 55 |
| 2022 Novembro | 36 | 27 | 63 |
| 2022 Outubro | 23 | 14 | 37 |
| 2022 Setembro | 21 | 33 | 54 |
| 2022 Agosto | 31 | 24 | 55 |
| 2022 Julho | 25 | 39 | 64 |
| 2022 Junho | 23 | 24 | 47 |
| 2022 Maio | 22 | 33 | 55 |
| 2022 Abril | 24 | 17 | 41 |
| 2022 Maro | 28 | 39 | 67 |
| 2022 Fevereiro | 23 | 30 | 53 |
| 2022 Janeiro | 32 | 27 | 59 |
| 2021 Dezembro | 28 | 26 | 54 |
| 2021 Novembro | 27 | 38 | 65 |
| 2021 Outubro | 41 | 39 | 80 |
| 2021 Setembro | 32 | 27 | 59 |
| 2021 Agosto | 33 | 36 | 69 |
| 2021 Julho | 35 | 24 | 59 |
| 2021 Junho | 19 | 14 | 33 |
| 2021 Maio | 39 | 30 | 69 |
| 2021 Abril | 66 | 53 | 119 |
| 2021 Maro | 46 | 12 | 58 |
| 2021 Fevereiro | 51 | 21 | 72 |
| 2021 Janeiro | 42 | 10 | 52 |
| 2020 Dezembro | 30 | 18 | 48 |
| 2020 Novembro | 53 | 19 | 72 |
| 2020 Outubro | 35 | 18 | 53 |
| 2020 Setembro | 63 | 17 | 80 |
| 2020 Agosto | 44 | 6 | 50 |
| 2020 Julho | 64 | 9 | 73 |
| 2020 Junho | 55 | 14 | 69 |
| 2020 Maio | 80 | 4 | 84 |
| 2020 Abril | 71 | 8 | 79 |
| 2020 Maro | 55 | 10 | 65 |
| 2020 Fevereiro | 88 | 13 | 101 |
| 2020 Janeiro | 37 | 7 | 44 |
| 2019 Dezembro | 55 | 10 | 65 |
| 2019 Novembro | 40 | 9 | 49 |
| 2019 Outubro | 54 | 14 | 68 |
| 2019 Setembro | 64 | 8 | 72 |
| 2019 Agosto | 33 | 9 | 42 |
| 2019 Julho | 36 | 17 | 53 |
| 2019 Junho | 24 | 8 | 32 |
| 2019 Maio | 41 | 15 | 56 |
| 2019 Abril | 34 | 19 | 53 |
| 2019 Maro | 43 | 12 | 55 |
| 2019 Fevereiro | 61 | 13 | 74 |
| 2019 Janeiro | 38 | 5 | 43 |
| 2018 Dezembro | 39 | 9 | 48 |
| 2018 Novembro | 87 | 13 | 100 |
| 2018 Outubro | 116 | 17 | 133 |
| 2018 Setembro | 35 | 11 | 46 |
| 2018 Agosto | 36 | 14 | 50 |
| 2018 Julho | 16 | 5 | 21 |
| 2018 Junho | 47 | 7 | 54 |
| 2018 Maio | 48 | 12 | 60 |
| 2018 Abril | 57 | 4 | 61 |
| 2018 Maro | 83 | 13 | 96 |
| 2018 Fevereiro | 34 | 5 | 39 |
| 2018 Janeiro | 23 | 8 | 31 |
| 2017 Dezembro | 44 | 5 | 49 |
| 2017 Novembro | 63 | 13 | 76 |
| 2017 Outubro | 29 | 11 | 40 |
| 2017 Setembro | 19 | 8 | 27 |
| 2017 Agosto | 36 | 12 | 48 |
| 2017 Julho | 19 | 11 | 30 |
| 2017 Junho | 29 | 18 | 47 |
| 2017 Maio | 50 | 24 | 74 |
| 2017 Abril | 19 | 12 | 31 |
| 2017 Maro | 30 | 16 | 46 |
| 2017 Fevereiro | 77 | 41 | 118 |
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