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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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 11 | 4 | 15 |
| 2024 Outubro | 31 | 28 | 59 |
| 2024 Setembro | 51 | 21 | 72 |
| 2024 Agosto | 44 | 24 | 68 |
| 2024 Julho | 49 | 29 | 78 |
| 2024 Junho | 27 | 18 | 45 |
| 2024 Maio | 34 | 25 | 59 |
| 2024 Abril | 38 | 23 | 61 |
| 2024 Maro | 29 | 18 | 47 |
| 2024 Fevereiro | 30 | 17 | 47 |
| 2024 Janeiro | 18 | 26 | 44 |
| 2023 Dezembro | 33 | 26 | 59 |
| 2023 Novembro | 29 | 27 | 56 |
| 2023 Outubro | 23 | 11 | 34 |
| 2023 Setembro | 21 | 23 | 44 |
| 2023 Agosto | 17 | 25 | 42 |
| 2023 Julho | 22 | 12 | 34 |
| 2023 Junho | 22 | 14 | 36 |
| 2023 Maio | 28 | 25 | 53 |
| 2023 Abril | 19 | 7 | 26 |
| 2023 Maro | 23 | 21 | 44 |
| 2023 Fevereiro | 24 | 16 | 40 |
| 2023 Janeiro | 8 | 16 | 24 |
| 2022 Dezembro | 33 | 22 | 55 |
| 2022 Novembro | 29 | 27 | 56 |
| 2022 Outubro | 22 | 23 | 45 |
| 2022 Setembro | 24 | 30 | 54 |
| 2022 Agosto | 30 | 29 | 59 |
| 2022 Julho | 27 | 38 | 65 |
| 2022 Junho | 17 | 25 | 42 |
| 2022 Maio | 23 | 35 | 58 |
| 2022 Abril | 18 | 27 | 45 |
| 2022 Maro | 25 | 39 | 64 |
| 2022 Fevereiro | 20 | 24 | 44 |
| 2022 Janeiro | 25 | 25 | 50 |
| 2021 Dezembro | 15 | 34 | 49 |
| 2021 Novembro | 25 | 29 | 54 |
| 2021 Outubro | 29 | 50 | 79 |
| 2021 Setembro | 24 | 31 | 55 |
| 2021 Agosto | 24 | 31 | 55 |
| 2021 Julho | 16 | 19 | 35 |
| 2021 Junho | 19 | 25 | 44 |
| 2021 Maio | 18 | 36 | 54 |
| 2021 Abril | 24 | 36 | 60 |
| 2021 Maro | 59 | 24 | 83 |
| 2021 Fevereiro | 71 | 24 | 95 |
| 2021 Janeiro | 33 | 15 | 48 |
| 2020 Dezembro | 26 | 19 | 45 |
| 2020 Novembro | 28 | 14 | 42 |
| 2020 Outubro | 16 | 14 | 30 |
| 2020 Setembro | 54 | 17 | 71 |
| 2020 Agosto | 13 | 5 | 18 |
| 2020 Julho | 39 | 8 | 47 |
| 2020 Junho | 31 | 14 | 45 |
| 2020 Maio | 30 | 4 | 34 |
| 2020 Abril | 32 | 10 | 42 |
| 2020 Maro | 21 | 11 | 32 |
| 2020 Fevereiro | 45 | 18 | 63 |
| 2020 Janeiro | 33 | 11 | 44 |
| 2019 Dezembro | 26 | 8 | 34 |
| 2019 Novembro | 18 | 6 | 24 |
| 2019 Outubro | 18 | 6 | 24 |
| 2019 Setembro | 13 | 4 | 17 |
| 2019 Agosto | 31 | 5 | 36 |
| 2019 Julho | 26 | 16 | 42 |
| 2019 Junho | 21 | 16 | 37 |
| 2019 Maio | 31 | 15 | 46 |
| 2019 Abril | 14 | 12 | 26 |
| 2019 Maro | 18 | 10 | 28 |
| 2019 Fevereiro | 14 | 12 | 26 |
| 2019 Janeiro | 12 | 4 | 16 |
| 2018 Dezembro | 23 | 8 | 31 |
| 2018 Novembro | 25 | 2 | 27 |
| 2018 Outubro | 62 | 14 | 76 |
| 2018 Setembro | 27 | 12 | 39 |
| 2018 Agosto | 22 | 9 | 31 |
| 2018 Julho | 8 | 5 | 13 |
| 2018 Junho | 24 | 9 | 33 |
| 2018 Maio | 20 | 10 | 30 |
| 2018 Abril | 24 | 9 | 33 |
| 2018 Maro | 47 | 16 | 63 |
| 2018 Fevereiro | 18 | 5 | 23 |
| 2018 Janeiro | 19 | 10 | 29 |
| 2017 Dezembro | 36 | 26 | 62 |
| 2017 Novembro | 49 | 25 | 74 |
| 2017 Outubro | 58 | 41 | 99 |
| 2017 Setembro | 48 | 36 | 84 |
| 2017 Agosto | 4 | 9 | 13 |
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