Hung J. Eur Heart J. 2021 Jul 8;42(26):2552-2561.
Patients with type 2 myocardial infarction are older and more frequently have comorbidities and are at greater risk of adverse results with as few as 30% of patients alive at 5 years. Regardless of a substantial increase in risk of non-cardiovascular death, patients with type 2 myocardial infarction show similar risk of future cardiovascular events as those with type 1 myocardial infarction. However, till date, there are no validated prognostic tools to measure all-cause mortality or future cardiovascular events in this population. Thus, Hung J, et al., conducted a study to analyse the performance of the Global Registry of Acute Coronary Events (GRACE) 2.0 score for the prediction of all-cause death in patients with type 1 and type 2 myocardial infarction.
In two groups of consecutive patients with suspected acute coronary syndrome from 10 hospitals in Scotland (n = 48,282) and a tertiary care hospital in Sweden (n = 22,589) were enrolled in the study. The GRACE 2.0 score was assessed to measure death at 1 year. The area under the receiver operating curve (AUC) was used to assess discrimination, and DeLong’s test was used to compare for those with an adjudicated diagnosis of type 1 and type 2 myocardial infarction. The primary outcome was all-cause death at 1 year, and the secondary outcome was all-cause death or type 1 myocardial infarction at 1 year.
4981 (10%) and 1080 (5%) patients were diagnosed with type 1 myocardial infarction in Scotland and Sweden, respectively. In patients with type 1 myocardial infarction, 15% (720/4981) and 10% (112/1080) patients died from any cause at 1 year in the Scottish and Swedish cohorts, respectively.
Patients with type 2 myocardial infarction showed higher GRACE 2.0 score as compared to type 1 myocardial infarction in both groups (Table 1) and showed good discriminative ability with an AUC of 0.83 [95% confidence interval (CI) 0.82–0.85] and 0.85 (95% CI 0.81–0.89), respectively (Figure 1). Scottish and Swedish groups had 23% (258/1121) and 23% (57/247) deaths resp. from any cause at 1 year in patients with type 2 myocardial infarction. The GRACE 2.0 score showed moderate discriminative ability, with an AUC of 0.73 (95% CI 0.70–0.77) and 0.73 (95% CI 0.66–0.81), respectively, in type 2 myocardial infarction and showed lower performance than patients with type 1 myocardial infarction (DeLong test, p<0.001 and p = 0.008 vs. type 1 myocardial infarction in Scottish and Swedish cohorts, respectively, Figure 1).
Table 1: Components of the GRACE 2.0 risk score in patients with type 1 and type 2 myocardial infarction.
Figure 1: Comparison of the discrimination of the GRACE score for the prediction of all-cause mortality in patients with type 1 (red) and type 2 (blue)myocardial infarction using the area under the receiver operator characteristic curve, in the Scottish and Swedish cohorts.
Take Home Figure: Performance of the GRACE 2.0 score in patients with type 1 and type 2 myocardial infarction.
It was concluded that the GRACE 2.0 score yielded convenient differentiation for all-cause death at 1 year in patients with type 1 myocardial infarction, and average differentiation for those with type 2 myocardial infarction. Clinicians should contemplate applying the GRACE 2.0 score till specific risk prediction tools are acquired and validated, to guide diagnosis and successive treatment in patients with type 2 myocardial infarction.