Comparison of clinical and angiographic prognostic risk scores in elderly patients presenting with acute coronary syndrome and referred for percutaneous coronary intervention
BACKGROUND: Multiple risk prediction models have been validated in all-age patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI); however, they have not been validated specifically in the elderly.
METHODS: We calculated the GRACE (Global Registry of Acute Coronary Events) score, the logistic EuroSCORE, the AMIS (Acute Myocardial Infarction Swiss registry) score, and the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in a consecutive series of 114 patients ≥75 years presenting with ACS and treated with PCI within 24 hours of hospital admission.
Patients were stratified according to score tertiles and analysed retrospectively by comparing the lower/mid tertiles as an aggregate group with the higher tertile group. The primary endpoint was 30-day mortality. Secondary endpoints were the composite of death and major adverse cardiovascular events (MACE) at 30 days, and 1-year MACE-free survival. Model discrimination ability was assessed using the area under receiver operating characteristic curve (AUC).
RESULTS: Thirty-day mortality was higher in the upper tertile compared with the aggregate lower/mid tertiles according to the logistic EuroSCORE (42% vs 5%; odds ratio [OR] = 14, 95% confidence interval [CI] = 4–48; p <0.001; AUC = 0.79), the GRACE score (40% vs 4%; OR = 17, 95% CI = 4–64; p <0.001; AUC = 0.80), the AMIS score (40% vs 4%; OR = 16, 95% CI = 4–63; p <0.001; AUC = 0.80), and the SYNTAX score (37% vs 5%; OR = 11, 95% CI = 3–37; p <0.001; AUC = 0.77).
CONCLUSIONS: In elderly patients presenting with ACS and referred to PCI within 24 hours of admission, the GRACE score, the EuroSCORE, the AMIS score, and the SYNTAX score predicted 30 day mortality. The predictive value of clinical scores was improved by using them in combination.
- Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG, et al.; FIR Collaboration. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: a meta-analysis of individual patient data. J Am Coll Cardiol. 2010;55(22):2435–45.
- De Luca G, Suryapranata H, van ’t Hof AW, de Boer MJ, Hoorntje JC, Dambrink JH, et al. Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: implications for early discharge. Circulation. 2004;109(22):2737–43.
- Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, et al.; GRACE Investigators. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6–month postdischarge death in an international registry. JAMA. 2004;291(22):2727–33.
- Morrow DA, Antman EM, Charlesworth A, Cairns R, Murphy SA, de Lemos JA, et al. TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation. 2000;102(17):2031–7.
- Addala S, Grines CL, Dixon SR, Stone GW, Boura JA, Ochoa AB, et al. Predicting mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PAMI risk score). Am J Cardiol. 2004;93(5):629–32.
- Halkin A, Singh M, Nikolsky E, Grines CL, Tcheng JE, Garcia E, et al. Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score. J Am Coll Cardiol. 2005;45(9):1397–405.
- Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al.; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction); American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association of Cardiovascular and Pulmonary Rehabilitation; Society for Academic Emergency Medicine. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Am Coll Cardiol. 2007;50(7):e1–157.
- Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R; EuroSCORE study group. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardio-thoracic Surg. 1999;16(1):9–13.
- Sukiennik A, Ostrowska-Nowak J, Wiśniewska-Szmyt J, Radomski M, Rychter M, Jabłoński M, et al. Predicted and observed in-hospital mortality after left main coronary artery stenting in 204 patients. Cardiol J. 2008;15(3):268–76.
- Rodés-Cabau J, Deblois J, Bertrand OF, Mohammadi S, Courtis J, Larose E, et al. Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians. Circulation. 2008;118(23):2374–81.
- Min SY, Park DW, Yun SC, Kim YH, Lee JY, Kang SJ, et al. Major predictors of long-term clinical outcomes after coronary revascularization in patients with unprotected left main coronary disease: analysis from the MAIN-COMPARE study. Circ Cardiovasc Interv. 2010;3(2):127–33.
- Lehmann R, Fichtlscherer S, Schächinger V, Held L, Hobler C, Baier G, et al. Favorable long-term survival in patients undergoing multivessel-PCI compared to predicted prognosis of CABG estimated by EuroSCORE: procedural and clinical determinants of long-term outcome. J Interv Cardiol. 2009;22(6):511–9.
- Radovanovic D, Erne P. AMIS Plus: Swiss registry of acute coronary syndrome. Heart. 2010;96(12):917–21.
- Kurz DJ, Bernstein A, Hunt K, Radovanovic D, Erne P, Siudak Z, Bertel O. Simple point-of-care risk stratification in acute coronary syndromes: the AMIS model. Heart. 2009;95(8):662–8.
- Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. Eurointervention. 2005;1(2):219–27.
- Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al.; SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.
- Valgimigli M, Serruys PW, Tsuchida K, Vaina S, Morel MA, van den Brand MJ, et al.; ARTS II. Cyphering the complexity of coronary artery disease using the syntax score to predict clinical outcome in patients with three-vessel lumen obstruction undergoing percutaneous coronary intervention. Am J Cardiol. 2007;99(8):1072–81.
- Serruys PW, Onuma Y, Garg S, et al. 5–Year clinical outcomes of the ARTS II (Arterial Revascularization Therapies Study II) of the sirolimus-eluting stent in the treatment of patients with multivessel de novo coronary artery lesions. J Am Coll Cardiol. 2010;55(11):1093–101.
- Capodanno D, Capranzano P, Di Salvo ME, Caggegi A, Tomasello D, Cincotta G, et al. Usefulness of SYNTAX score to select patients with left main coronary artery disease to be treated with coronary artery bypass graft. J Am Coll Cardiol Cardiovasc Intervent. 2009;2(8):731–8.
- Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J, et al. Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization. Am J Cardiol. 2011;107(3):360–6.
- Chen SL, Chen JP, Mintz G, Xu B, Kan J, Ye F, et al. Comparison between the NERS (New Risk Stratification) score and the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score in outcome prediction for unprotected left main stenting.J Am Coll Cardiol Cardiovasc Intervent. 2010;3(6):632–41.
- Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ, et al. Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. J Am Coll Cardiol Cardiovasc Intervent. 2010;3(6):612–23.
- Wykrzykowska J, Garg S, Girasis C, de Vries T, Morel MA, van Es GA, et al. Value of the Syntax Score (SX) for risk assessment in the “Allcomers” Population of the Randomized Multicenter Leaders Trial. J Am Coll Cardiol. 2010;56(4):272–7.
- Garg S, Sarno G, Serruys PW, Rodriguez AE, Bolognese L, Anselmi M, et al.; STRATEGY and MULTISTRATEGY Investigators. Prediction of 1–year clinical outcomes using the SYNTAX score in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a substudy of the STRATEGY (Single High-Dose Bolus Tirofiban and Sirolimus-Eluting Stent Versus Abciximab and Bare-Metal Stent in Acute Myocardial Infarction) and MULTISTRATEGY (Multicenter Evaluation of Single High-Dose Bolus Tirofiban Versus Abciximab With Sirolimus-Eluting Stent or Bare-Metal Stent in Acute Myocardial Infarction Study) trials.J Am Coll Cardiol Cardiovasc Intervent. 2011;4(1):66–75.
- Magro M, Nauta S, Simsek C, Onuma Y, Garg S, van der Heide E, et al. Value of the SYNTAX score in patients treated by primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: The MI SYNTAXscore study. Am Heart J. 2011;161(4):771–81.
- Palmerini T, Genereux P, Caixeta A, Cristea E, Lansky A, Mehran R, et al. Prognostic value of the SYNTAX score in patients with acute coronary syndromes undergoing percutaneous coronary intervention: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage StrategY) trial. J Am Coll Cardiol. 2011;57(24):2389–97.
- Vrints CJ. Acute coronary syndrome in the elderly. Eur Heart J. 2008;29(10):1213–4.
- Scherff F, Vassalli G, Sürder D, Mantovani A, Corbacelli C, Pasotti E, et al. The SYNTAX score predicts early mortality risk in the elderly with acute coronary syndrome having primary PCI. J Interv Cardiol. 2011;23(12):505–10.
- Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology, Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A, Fernández-Avilés F, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J. 2007;28(13):1598–660.
- Van de Werf F, Ardissino D, Betriu A, Cokkinos DV, Falk E, Fox KA, et al.; Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Management of acute myocardial infarction in patients presenting with ST-segment elevation. The Task Force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2003;24(1):28–66.
- Müller C: New ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Swiss Med Wkly. 2012;142:w13514.
- Devlin G, Gore JM, Elliott J, Wijesinghe N, Eagle KA, Avezum A, et al.; GRACE Investigators. Management and 6–month outcomes in elderly and very elderly patients with high-risk non-ST elevation acute coronary syndromes: the Global Registry of Acute Coronary Events. Eur Heart J. 2008;29(10):1275–82.
- Bauer T, Möllmann H, Weidinger F, Zeymer U, Seabra-Gomes R, Eberli F, et al. Predictors of hospital mortality in the elderly undergoing percutaneous coronary intervention for acute coronary syndromes and stable angina. Int J Cardiol. 2011;151(2):164–9.
- Otten AM, Maas AH, Ottervanger JP, Kloosterman A, van ’t Hof AW, Dambrink JH, et al.; Zwolle Myocardial Infarction study Group. Is the difference in outcome between men and women treated by primary percutaneous coronary intervention age dependent? Gender difference in STEMI stratified on age. Eur Heart J Acute Cardiovasc Care. 2013;2(4):334–41.
- Garg S, Sarno G, Garcia-Garcia HM, Girasis C, Wykrzykowska J, Dawkins KD, Serruys PW; ARTS-II Investigators. A new tool for the risk stratification of patients with complex coronary artery disease. The Clinical SYNTAX Score. Circ Cardiovasc Interv. 2010;3(4):317–26.
- Palmerini T, Caixeta A, Genereux P, Cristea E, Lansky A, Mehran R, et al. Comparison of clinical and angiographic prognostic risk scores in patients with acute coronary syndromes: Analysis from the Acute Catheterization and Urgent Intervention Triage StrategY (ACUITY) trial. Am Heart J. 2012;163(3):383–91,391.e1–5.
- Farooq V, Vergouwe Y, Räber L, Vranckx P, Garcia-Garcia H, Diletti R, et al. Combined anatomical and clinical factors for the long-term risk stratification of patients undergoing percutaneous coronary intervention: the Logistic Clinical SYNTAX score. Eur Heart J. 2012;33(24):3098–104.
- Farooq V, van Klaveren D, Steyerberg EW, Meliga E, Vergouwe Y, Chieffo A, et al. Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013;381(9867):639–50.
- Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–M156.
- Singh M, Rihal CS, Lennon RJ, Spertus JA, Nair KS, Roger VL. Influence of frailty and health status on outcomes in patients with coronary disease undergoing percutaneous revascularization. Circ Cardiovasc Qual Outcomes. 2011; 4(5):496–502.