array:26 [
  "pii" => "S0870255117302147"
  "issn" => "08702551"
  "doi" => "10.1016/j.repc.2017.03.007"
  "estado" => "S300"
  "fechaPublicacion" => "2017-09-01"
  "aid" => "1044"
  "copyright" => "Sociedade Portuguesa de Cardiologia"
  "copyrightAnyo" => "2017"
  "documento" => "simple-article"
  "crossmark" => 1
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "cor"
  "cita" => "Rev Port Cardiol. 2017;36:677-9"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 1727
    "formatos" => array:3 [
      "EPUB" => 163
      "HTML" => 1153
      "PDF" => 411
    ]
  ]
  "Traduccion" => array:1 [
    "en" => array:20 [
      "pii" => "S2174204917302489"
      "issn" => "21742049"
      "doi" => "10.1016/j.repce.2017.03.008"
      "estado" => "S300"
      "fechaPublicacion" => "2017-09-01"
      "aid" => "1044"
      "copyright" => "Sociedade Portuguesa de Cardiologia"
      "documento" => "simple-article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
      "subdocumento" => "cor"
      "cita" => "Rev Port Cardiol. 2017;36:677-9"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 1175
        "formatos" => array:3 [
          "EPUB" => 152
          "HTML" => 710
          "PDF" => 313
        ]
      ]
      "en" => array:11 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
        "titulo" => "Risk stratification in acute coronary syndromes&#58; Graced by a new score&#63;"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "677"
            "paginaFinal" => "679"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "pt" => array:1 [
            "titulo" => "Estratifica&#231;&#227;o de risco nas s&#237;ndromas coron&#225;rias agudas&#58; como poder&#225; o Grace ser destronado&#63;"
          ]
        ]
        "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" => 1645
                "Ancho" => 1587
                "Tamanyo" => 183499
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Receiver operating characteristic curve analysis for the prediction of in-hospital mortality using the ProACS and GRACE scores&#46; AUC&#58; area under the curve&#59; CI&#58; confidence interval&#59; SE&#58; standard error&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Lu&#237;s Paiva, S&#233;rgio Barra, Lino Gon&#231;alves"
            "autores" => array:3 [
              0 => array:2 [
                "nombre" => "Lu&#237;s"
                "apellidos" => "Paiva"
              ]
              1 => array:2 [
                "nombre" => "S&#233;rgio"
                "apellidos" => "Barra"
              ]
              2 => array:2 [
                "nombre" => "Lino"
                "apellidos" => "Gon&#231;alves"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S0870255117302147"
          "doi" => "10.1016/j.repc.2017.03.007"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117302147?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302489?idApp=UINPBA00004E"
      "url" => "/21742049/0000003600000009/v1_201709220127/S2174204917302489/v1_201709220127/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:20 [
    "pii" => "S0870255117305644"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2017.07.005"
    "estado" => "S300"
    "fechaPublicacion" => "2017-09-01"
    "aid" => "1049"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "simple-article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "cor"
    "cita" => "Rev Port Cardiol. 2017;36:681-2"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 1347
      "formatos" => array:3 [
        "EPUB" => 144
        "HTML" => 821
        "PDF" => 382
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
      "titulo" => "Response to Letter to the Editor &#8220;Risk stratification in acute coronary syndromes&#58; Graced by a new score&#63;&#8221;"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "681"
          "paginaFinal" => "682"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Resposta &#224; Carta ao Editor &#171;Estratifica&#231;&#227;o de risco nas s&#237;ndromas coron&#225;rias agudas&#58; como poder&#225; o Grace ser destronado&#63;&#187;"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ana Tim&#243;teo"
          "autores" => array:1 [
            0 => array:2 [
              "nombre" => "Ana"
              "apellidos" => "Tim&#243;teo"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2174204917302490"
        "doi" => "10.1016/j.repce.2017.09.003"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302490?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117305644?idApp=UINPBA00004E"
    "url" => "/08702551/0000003600000009/v1_201709150927/S0870255117305644/v1_201709150927/en/main.assets"
  ]
  "itemAnterior" => array:20 [
    "pii" => "S0870255117305693"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2016.09.023"
    "estado" => "S300"
    "fechaPublicacion" => "2017-09-01"
    "aid" => "1053"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2017;36:675-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 2813
      "formatos" => array:3 [
        "EPUB" => 164
        "HTML" => 2164
        "PDF" => 485
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Image in Cardiology</span>"
      "titulo" => "Vena cava filter migration after magnetic resonance imaging"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "675"
          "paginaFinal" => "676"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "pt" => array:1 [
          "titulo" => "Migra&#231;&#227;o de filtro de cava ap&#243;s resson&#226;ncia magn&#233;tica"
        ]
      ]
      "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" => 1793
              "Ancho" => 2500
              "Tamanyo" => 376077
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Echocardiogram showing hyperechoic linear images in the right chambers &#40;A&#41; and severe tricuspid regurgitation &#40;B&#41;&#59; chest computed tomography demonstrating intracardiac metallic fragments &#40;C&#41;&#59; thrombus and IVC filter fragments removed &#40;D&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Fernando Pivatto J&#250;nior, Diogo Silva Piardi, &#194;ngela Barreto Santiago Santos"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Fernando"
              "apellidos" => "Pivatto J&#250;nior"
            ]
            1 => array:2 [
              "nombre" => "Diogo Silva"
              "apellidos" => "Piardi"
            ]
            2 => array:2 [
              "nombre" => "&#194;ngela Barreto Santiago"
              "apellidos" => "Santos"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2174204917302477"
        "doi" => "10.1016/j.repce.2016.09.019"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302477?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117305693?idApp=UINPBA00004E"
    "url" => "/08702551/0000003600000009/v1_201709150927/S0870255117305693/v1_201709150927/en/main.assets"
  ]
  "asociados" => array:2 [
    0 => array:20 [
      "pii" => "S0870255116303778"
      "issn" => "08702551"
      "doi" => "10.1016/j.repc.2016.05.010"
      "estado" => "S300"
      "fechaPublicacion" => "2017-02-01"
      "aid" => "928"
      "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. 2017;36:77-83"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 2731
        "formatos" => array:3 [
          "EPUB" => 189
          "HTML" => 2013
          "PDF" => 529
        ]
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
        "titulo" => "ProACS risk score&#58; An early and simple score for risk stratification of patients with acute coronary syndromes"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "pt"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "77"
            "paginaFinal" => "83"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "pt" => array:1 [
            "titulo" => "<span class="elsevierStyleItalic">Score</span> de risco ProACS&#58; em <span class="elsevierStyleItalic">score</span> simples e precoce para estratifica&#231;&#227;o de risco em doentes com s&#237;ndromes coron&#225;rias agudas"
          ]
        ]
        "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" => "fig0010"
            "etiqueta" => "Figure 2"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr2.jpeg"
                "Alto" => 1270
                "Ancho" => 1608
                "Tamanyo" => 74518
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Fit of the final multivariate logistic regression model in the development cohort&#46; df&#58; degrees of freedom&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Ana Teresa Tim&#243;teo, S&#237;lvia Aguiar Rosa, Marta Afonso Nogueira, Adriana Belo, Rui Cruz Ferreira"
            "autores" => array:6 [
              0 => array:2 [
                "nombre" => "Ana Teresa"
                "apellidos" => "Tim&#243;teo"
              ]
              1 => array:2 [
                "nombre" => "S&#237;lvia"
                "apellidos" => "Aguiar Rosa"
              ]
              2 => array:2 [
                "nombre" => "Marta"
                "apellidos" => "Afonso Nogueira"
              ]
              3 => array:2 [
                "nombre" => "Adriana"
                "apellidos" => "Belo"
              ]
              4 => array:2 [
                "nombre" => "Rui"
                "apellidos" => "Cruz Ferreira"
              ]
              5 => array:1 [
                "colaborador" => "on behalf of the ProACS Investigators"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2174204917300259"
          "doi" => "10.1016/j.repce.2017.02.001"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300259?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116303778?idApp=UINPBA00004E"
      "url" => "/08702551/0000003600000002/v1_201702090011/S0870255116303778/v1_201702090011/en/main.assets"
    ]
    1 => array:20 [
      "pii" => "S0870255117305644"
      "issn" => "08702551"
      "doi" => "10.1016/j.repc.2017.07.005"
      "estado" => "S300"
      "fechaPublicacion" => "2017-09-01"
      "aid" => "1049"
      "copyright" => "Sociedade Portuguesa de Cardiologia"
      "documento" => "simple-article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
      "subdocumento" => "cor"
      "cita" => "Rev Port Cardiol. 2017;36:681-2"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 1347
        "formatos" => array:3 [
          "EPUB" => 144
          "HTML" => 821
          "PDF" => 382
        ]
      ]
      "en" => array:10 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
        "titulo" => "Response to Letter to the Editor &#8220;Risk stratification in acute coronary syndromes&#58; Graced by a new score&#63;&#8221;"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "681"
            "paginaFinal" => "682"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "pt" => array:1 [
            "titulo" => "Resposta &#224; Carta ao Editor &#171;Estratifica&#231;&#227;o de risco nas s&#237;ndromas coron&#225;rias agudas&#58; como poder&#225; o Grace ser destronado&#63;&#187;"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Ana Tim&#243;teo"
            "autores" => array:1 [
              0 => array:2 [
                "nombre" => "Ana"
                "apellidos" => "Tim&#243;teo"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2174204917302490"
          "doi" => "10.1016/j.repce.2017.09.003"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302490?idApp=UINPBA00004E"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117305644?idApp=UINPBA00004E"
      "url" => "/08702551/0000003600000009/v1_201709150927/S0870255117305644/v1_201709150927/en/main.assets"
    ]
  ]
  "en" => array:14 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
    "titulo" => "Risk stratification in acute coronary syndromes&#58; Graced by a new score&#63;"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "677"
        "paginaFinal" => "679"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Lu&#237;s Paiva, S&#233;rgio Barra, Lino Gon&#231;alves"
        "autores" => array:3 [
          0 => array:4 [
            "nombre" => "Lu&#237;s"
            "apellidos" => "Paiva"
            "email" => array:1 [
              0 => "luisvpaiva&#64;gmail&#46;com"
            ]
            "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">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "S&#233;rgio"
            "apellidos" => "Barra"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Lino"
            "apellidos" => "Gon&#231;alves"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Hospital Geral&#44; Centro Hospitalar e Universit&#225;rio de Coimbra&#44; Coimbra&#44; Portugal"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Universidade de Coimbra&#44; Coimbra&#44; Portugal"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Cardiology Department&#44; Papworth Hospital NHS Foundation Trust&#44; Cambridge&#44; UK"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "Estratifica&#231;&#227;o de risco nas s&#237;ndromas coron&#225;rias agudas&#58; como poder&#225; o Grace ser destronado&#63;"
      ]
    ]
    "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" => 1645
            "Ancho" => 1587
            "Tamanyo" => 183499
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Receiver operating characteristic curve analysis for the prediction of in-hospital mortality using the ProACS and GRACE scores&#46; AUC&#58; area under the curve&#59; CI&#58; confidence interval&#59; SE&#58; standard error&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with much interest the recently published paper by Tim&#243;teo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> This study makes an important contribution to the expanding field of risk stratification in myocardial infarction &#40;MI&#41;&#44; which is the cornerstone for patient management&#46; The authors developed a simple risk model from a large cohort of real-world MI patients&#44; comprising common and easily accessible clinical variables&#44; constructing a high-performing in-hospital mortality risk score&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several risk scores have been developed to predict outcomes in patients with acute coronary syndromes&#46; The GRACE score<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> is the most widely used and has been shown to outperform other previously developed mortality risk models&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> The ACHTUNG-Rule&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> based on clinical and laboratory parameters&#44; outperformed the GRACE score in its derivation and validation sets but&#44; in addition to requiring a calculator&#44; it still lacks calibration and validation in larger and external cohorts&#46; McNamara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> recently developed a novel in-hospital mortality risk score from a large contemporary cohort&#44; with calibration curves demonstrating its utility even in patients presenting with cardiac arrest&#44; a significant advantage in the context of MI given the difficulty in accurately predicting outcomes in this patient subgroup&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the GRACE and ProACS<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> scores share some variables&#44; the latter does have some advantages&#58; &#40;i&#41; it is simpler to use in clinical practice&#44; with fewer variables and no need for a calculator&#59; &#40;ii&#41; it uses the same cutoffs for ST-elevation &#40;STEMI&#41; and non-ST-elevation &#40;NSTEMI&#41; MI&#44; unlike GRACE&#59; and &#40;iii&#41; it is particularly useful in identifying truly low-risk patients&#44; as a score of 0 is associated with very low risk of in-hospital mortality &#40;0&#46;4&#37;&#41;&#46; In contrast&#44; the GRACE score predicts mortality risk as a continuum&#44; although low-risk strata have been proposed for STEMI and NSTEMI cases&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We validated the ProACS risk model in an independent and somewhat more contemporary &#40;2010-2013&#41; cohort of 1000 consecutive MI patients &#40;43&#46;5&#37; with STEMI&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> illustrates the performance of both GRACE and ProACS for predicting in-hospital mortality in our cohort&#46; Although the intermediate and high-risk strata of the ProACS score identified nearly 98&#37; of in-hospital deaths&#44; confirming the utility of the score in the stratification of ACS patients&#44; its discriminative power was significantly inferior to that reported in its internal and external validation cohorts&#46; Perhaps more importantly&#44; the discriminative performance of ProACS was significantly inferior to that of GRACE&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We believe that any new risk score should provide simplicity without significantly compromising accuracy of risk stratification&#46; Using a more intuitive approach with a measure of risk reclassification&#44; known as the integrated discrimination improvement &#40;IDI&#41; index&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> we noticed that compared with GRACE&#44; the ProACS score is indeed particularly useful in identifying truly low-risk patients who could potentially be considered for conservative management or early discharge &#40;a 56&#46;3&#37; improvement in prediction for patients who did not die during hospitalization&#41;&#46; However&#44; this comes at the expense of a significantly lower &#40;61&#46;8&#37;&#41; predictive ability in the identification of patients who eventually die during their hospitalization&#46; The relative IDI index was -5&#46;5&#37;&#46; We further expanded on this by using a category-based measure of risk reclassification known as net reclassification improvement &#40;NRI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> A positive and significant NRI index translates a net overall successful reclassification of subjects into more appropriate risk categories &#40;e&#46;g&#46; a patient who reaches the primary endpoint who is reclassified into a higher risk group with the new model or a subject who does not reach the primary endpoint who is reclassified into a lower risk category&#41;&#46; We used the same risk categories proposed by the GRACE and ProACS investigators&#46; As seen in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#44; altogether the ProACS score reclassified 26&#46;2&#37; of STEMI patients and 17&#46;7&#37; of NSTEMI patients into risk strata which were less accurate representations of their observed mortality risks&#46; However&#44; ProACS did reclassify low-risk NSTEMI patients into more appropriate &#40;lower&#41; risk categories &#40;partial NRI of &#43;9&#46;3&#37;&#41;&#46; The above observations suggest that the GRACE score is superior in identifying high-risk patients&#44; whereas ProACS may be more useful in identifying low-risk patients who present with NSTEMI &#40;but not STEMI&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Furthermore&#44; the ability to also estimate mortality during clinical follow-up and across different types of MI would surely improve the applicability of ProACS&#44; since risk models differ significantly in their predictive performance when applied to MI that arises from a primary coronary event &#40;type 1&#41; vs&#46; supply&#47;demand mismatch &#40;type 2&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In summary&#44; although the authors should be commended for their attempt to improve and simplify risk stratification of MI patients&#44; it remains to be determined whether the simplicity of this new score&#44; derived from a large Portuguese registry&#44; is offset by its inferior prognostic power compared to the gold standard ACS risk score&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</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
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1645
            "Ancho" => 1587
            "Tamanyo" => 183499
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Receiver operating characteristic curve analysis for the prediction of in-hospital mortality using the ProACS and GRACE scores&#46; AUC&#58; area under the curve&#59; CI&#58; confidence interval&#59; SE&#58; standard error&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">NRI&#58; net reclassification improvement&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">For patients with ST-elevation myocardial infarction &#40;STEMI&#41;&#44; a GRACE score below 126 was considered low risk&#44; a score between 126 and 154 was assigned to the intermediate risk category and above 154 was assigned to the high risk group&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col">In-hospital all-cause mortality</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GRACE &#40;STEMI&#41;</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Events &#40;n&#61;48&#41;</td><td class="td" title="table-entry  " rowspan="6" align="left" valign="middle">ProACS</td><td class="td" title="table-entry  " align="left" valign="top">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">NRI&#58; -26&#46;5&#37;<br>p&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Non-Events &#40;n&#61;387&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">146&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1514244.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Net reclassification improvement for in-hospital all-cause mortality&#44; comparing ProACS and GRACE scores for ST-elevation myocardial infarction&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">NRI&#58; net reclassification improvement&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">For patients with non-ST-segment elevation myocardial infarction &#40;NSTEMI&#41;&#44; a GRACE score below 109 was considered low risk&#44; while scores between 109 and 140 and above 140 were assigned to intermediate and high risk categories&#44; respectively&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " rowspan="2" align="center" valign="top" scope="col" colspan="3" style="border-bottom: 2px solid black">In-hospital all-cause mortality</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">GRACE &#40;NSTEMI&#41;</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Events &#40;n&#61;37&#41;</td><td class="td" title="table-entry  " rowspan="6" align="left" valign="middle">ProACS</td><td class="td" title="table-entry  " align="left" valign="top">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">NRI&#58; -17&#46;6&#37;<br>p&#61;0&#46;051</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Non-Events &#40;n&#61;528&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">213&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1514243.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Net reclassification improvement for in-hospital all-cause mortality&#44; comparing ProACS and GRACE scores for non-ST-elevation myocardial infarction&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:7 [
            0 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ProACS risk score&#58; 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&#46;T&#46; Tim&#243;teo"
                            1 => "S&#46; Aguiar Rosa"
                            2 => "M&#46; Afonso Nogueira"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.repc.2016.05.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol"
                        "fecha" => "2017"
                        "volumen" => "36"
                        "paginaInicial" => "77"
                        "paginaFinal" => "83"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28153630"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictors of hospital mortality in the global registry of acute coronary events"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Global Registry of Acute Coronary Events Investigators"
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46;B&#46; Granger"
                            1 => "R&#46;J&#46; Goldberg"
                            2 => "O&#46;H&#46; Dabbous"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archinte.163.19.2345"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2003"
                        "volumen" => "163"
                        "paginaInicial" => "2345"
                        "paginaFinal" => "2353"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14581255"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "TIMI&#44; PURSUIT&#44; and GRACE risk scores&#58; sustained prognostic value an interaction with revascularizatiton in NSTE-ACS"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; De Ara&#250;jo Gon&#231;alves"
                            1 => "J&#46; Ferreira"
                            2 => "C&#46; Aguiar"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehi187"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2015"
                        "volumen" => "26"
                        "paginaInicial" => "865"
                        "paginaFinal" => "872"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15764619"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "ACHTUNG-Rule&#58; a new and improved model for prognostic assessment in myocardial infarction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "S&#46; Barra"
                            1 => "R&#46; Providencia"
                            2 => "L&#46; Paiva"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/2048872612466536"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J Acute Cardiovasc Care"
                        "fecha" => "2012"
                        "volumen" => "1"
                        "paginaInicial" => "320"
                        "paginaFinal" => "334"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24062923"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predicting in-hospital mortality in patients with acute myocardial infarction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;L&#46; McNamara"
                            1 => "K&#46;F&#46; Kennedy"
                            2 => "D&#46;J&#46; Cohen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2016.05.049"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Am Coll Cardiol"
                        "fecha" => "2016"
                        "volumen" => "68"
                        "paginaInicial" => "626"
                        "paginaFinal" => "635"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27491907"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluating the added predictive ability of a new biomarker&#58; from area under the ROC curve to reclassification and beyond"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;J&#46; Pencina"
                            1 => "R&#46;B&#46;S&#46; D&#8217;Agostino"
                            2 => "R&#46;B&#46;J&#46; D&#8217;Agostino"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/sim.2929"
                      "Revista" => array:6 [
                        "tituloSerie" => "Stat Med"
                        "fecha" => "2008"
                        "volumen" => "27"
                        "paginaInicial" => "157"
                        "paginaFinal" => "172"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17569110"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Universal definition of myocardial infarction&#58; clinical insights"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "L&#46; Paiva"
                            1 => "R&#46; Provid&#234;ncia"
                            2 => "S&#46; Barra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000371739"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cardiology"
                        "fecha" => "2015"
                        "volumen" => "131"
                        "paginaInicial" => "13"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25831989"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/08702551/0000003600000009/v1_201709150927/S0870255117302147/v1_201709150927/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "29267"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Cartas ao Editor"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003600000009/v1_201709150927/S0870255117302147/v1_201709150927/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117302147?idApp=UINPBA00004E"
]
Partilhar
Informação da revista
Vol. 36. Núm. 9.
Páginas 677-679 (setembro 2017)
Partilhar
Partilhar
Baixar PDF
Mais opções do artigo
Vol. 36. Núm. 9.
Páginas 677-679 (setembro 2017)
Letter to the Editor
Open Access
Risk stratification in acute coronary syndromes: Graced by a new score?
Estratificação de risco nas síndromas coronárias agudas: como poderá o Grace ser destronado?
Visitas
4718
Luís Paivaa,b,
Autor para correspondência
luisvpaiva@gmail.com

Corresponding author.
, Sérgio Barrac, Lino Gonçalvesa,b
a Hospital Geral, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
b Universidade de Coimbra, Coimbra, Portugal
c Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge, UK
Conteúdo relacionado
Ana Teresa Timóteo, Sílvia Aguiar Rosa, Marta Afonso Nogueira, Adriana Belo, Rui Cruz Ferreira
Este item recebeu

Under a Creative Commons license
Informação do artigo
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (1)
Tabelas (2)
Table 1. Net reclassification improvement for in-hospital all-cause mortality, comparing ProACS and GRACE scores for ST-elevation myocardial infarction.
Table 2. Net reclassification improvement for in-hospital all-cause mortality, comparing ProACS and GRACE scores for non-ST-elevation myocardial infarction.
Mostrar maisMostrar menos
Texto Completo

We read with much interest the recently published paper by Timóteo et al.1 This study makes an important contribution to the expanding field of risk stratification in myocardial infarction (MI), which is the cornerstone for patient management. The authors developed a simple risk model from a large cohort of real-world MI patients, comprising common and easily accessible clinical variables, constructing a high-performing in-hospital mortality risk score.

Several risk scores have been developed to predict outcomes in patients with acute coronary syndromes. The GRACE score2 is the most widely used and has been shown to outperform other previously developed mortality risk models.3 The ACHTUNG-Rule,4 based on clinical and laboratory parameters, outperformed the GRACE score in its derivation and validation sets but, in addition to requiring a calculator, it still lacks calibration and validation in larger and external cohorts. McNamara et al.5 recently developed a novel in-hospital mortality risk score from a large contemporary cohort, with calibration curves demonstrating its utility even in patients presenting with cardiac arrest, a significant advantage in the context of MI given the difficulty in accurately predicting outcomes in this patient subgroup.

Although the GRACE and ProACS1 scores share some variables, the latter does have some advantages: (i) it is simpler to use in clinical practice, with fewer variables and no need for a calculator; (ii) it uses the same cutoffs for ST-elevation (STEMI) and non-ST-elevation (NSTEMI) MI, unlike GRACE; and (iii) it is particularly useful in identifying truly low-risk patients, as a score of 0 is associated with very low risk of in-hospital mortality (0.4%). In contrast, the GRACE score predicts mortality risk as a continuum, although low-risk strata have been proposed for STEMI and NSTEMI cases.

We validated the ProACS risk model in an independent and somewhat more contemporary (2010-2013) cohort of 1000 consecutive MI patients (43.5% with STEMI). Figure 1 illustrates the performance of both GRACE and ProACS for predicting in-hospital mortality in our cohort. Although the intermediate and high-risk strata of the ProACS score identified nearly 98% of in-hospital deaths, confirming the utility of the score in the stratification of ACS patients, its discriminative power was significantly inferior to that reported in its internal and external validation cohorts. Perhaps more importantly, the discriminative performance of ProACS was significantly inferior to that of GRACE.

Figure 1.

Receiver operating characteristic curve analysis for the prediction of in-hospital mortality using the ProACS and GRACE scores. AUC: area under the curve; CI: confidence interval; SE: standard error.

(0.17MB).

We believe that any new risk score should provide simplicity without significantly compromising accuracy of risk stratification. Using a more intuitive approach with a measure of risk reclassification, known as the integrated discrimination improvement (IDI) index,6 we noticed that compared with GRACE, the ProACS score is indeed particularly useful in identifying truly low-risk patients who could potentially be considered for conservative management or early discharge (a 56.3% improvement in prediction for patients who did not die during hospitalization). However, this comes at the expense of a significantly lower (61.8%) predictive ability in the identification of patients who eventually die during their hospitalization. The relative IDI index was -5.5%. We further expanded on this by using a category-based measure of risk reclassification known as net reclassification improvement (NRI).6 A positive and significant NRI index translates a net overall successful reclassification of subjects into more appropriate risk categories (e.g. a patient who reaches the primary endpoint who is reclassified into a higher risk group with the new model or a subject who does not reach the primary endpoint who is reclassified into a lower risk category). We used the same risk categories proposed by the GRACE and ProACS investigators. As seen in Tables 1 and 2, altogether the ProACS score reclassified 26.2% of STEMI patients and 17.7% of NSTEMI patients into risk strata which were less accurate representations of their observed mortality risks. However, ProACS did reclassify low-risk NSTEMI patients into more appropriate (lower) risk categories (partial NRI of +9.3%). The above observations suggest that the GRACE score is superior in identifying high-risk patients, whereas ProACS may be more useful in identifying low-risk patients who present with NSTEMI (but not STEMI).

Table 1.

Net reclassification improvement for in-hospital all-cause mortality, comparing ProACS and GRACE scores for ST-elevation myocardial infarction.

In-hospital all-cause mortalityGRACE (STEMI) 
      Low risk  Moderate risk  High risk   
Events (n=48)ProACSLow risk  NRI: -26.5%
p<0.001
Moderate risk 
High risk  36 
Non-Events (n=387)Low risk 
Moderate risk  81  86  56 
High risk  12  146 

NRI: net reclassification improvement.

For patients with ST-elevation myocardial infarction (STEMI), a GRACE score below 126 was considered low risk, a score between 126 and 154 was assigned to the intermediate risk category and above 154 was assigned to the high risk group.

Table 2.

Net reclassification improvement for in-hospital all-cause mortality, comparing ProACS and GRACE scores for non-ST-elevation myocardial infarction.

In-hospital all-cause mortalityGRACE (NSTEMI) 
Low risk  Moderate risk  High risk   
Events (n=37)ProACSLow risk  NRI: -17.6%
p=0.051
Moderate risk 
High risk  26 
Non-Events (n=528)Low risk  20  18  12 
Moderate risk  55  82  101 
High risk  27  213 

NRI: net reclassification improvement.

For patients with non-ST-segment elevation myocardial infarction (NSTEMI), a GRACE score below 109 was considered low risk, while scores between 109 and 140 and above 140 were assigned to intermediate and high risk categories, respectively.

Furthermore, the ability to also estimate mortality during clinical follow-up and across different types of MI would surely improve the applicability of ProACS, since risk models differ significantly in their predictive performance when applied to MI that arises from a primary coronary event (type 1) vs. supply/demand mismatch (type 2).7

In summary, although the authors should be commended for their attempt to improve and simplify risk stratification of MI patients, it remains to be determined whether the simplicity of this new score, derived from a large Portuguese registry, is offset by its inferior prognostic power compared to the gold standard ACS risk score.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
A.T. Timóteo, S. Aguiar Rosa, M. Afonso Nogueira, et al.
ProACS risk score: an early and simple score for risk stratification of patients with acute coronary syndromes.
Rev Port Cardiol, 36 (2017), pp. 77-83
[2]
C.B. Granger, R.J. Goldberg, O.H. Dabbous, Global Registry of Acute Coronary Events Investigators, et al.
Predictors of hospital mortality in the global registry of acute coronary events.
Arch Intern Med, 163 (2003), pp. 2345-2353
[3]
P. De Araújo Gonçalves, J. Ferreira, C. Aguiar, et al.
TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value an interaction with revascularizatiton in NSTE-ACS.
Eur Heart J, 26 (2015), pp. 865-872
[4]
S. Barra, R. Providencia, L. Paiva, et al.
ACHTUNG-Rule: a new and improved model for prognostic assessment in myocardial infarction.
Eur Heart J Acute Cardiovasc Care, 1 (2012), pp. 320-334
[5]
R.L. McNamara, K.F. Kennedy, D.J. Cohen, et al.
Predicting in-hospital mortality in patients with acute myocardial infarction.
J Am Coll Cardiol, 68 (2016), pp. 626-635
[6]
M.J. Pencina, R.B.S. D’Agostino, R.B.J. D’Agostino, et al.
Evaluating the added predictive ability of a new biomarker: from area under the ROC curve to reclassification and beyond.
Stat Med, 27 (2008), pp. 157-172
[7]
L. Paiva, R. Providência, S. Barra, et al.
Universal definition of myocardial infarction: clinical insights.
Cardiology, 131 (2015), pp. 13-21
Copyright © 2017. Sociedade Portuguesa de Cardiologia
Baixar PDF
Idiomas
Revista Portuguesa de Cardiologia
Opções de artigo
Ferramentas
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

Ao assinalar que é «Profissional de Saúde», declara conhecer e aceitar que a responsável pelo tratamento dos dados pessoais dos utilizadores da página de internet da Revista Portuguesa de Cardiologia (RPC), é esta entidade, com sede no Campo Grande, n.º 28, 13.º, 1700-093 Lisboa, com os telefones 217 970 685 e 217 817 630, fax 217 931 095 e com o endereço de correio eletrónico revista@spc.pt. Declaro para todos os fins, que assumo inteira responsabilidade pela veracidade e exatidão da afirmação aqui fornecida.