1) Risk scores help identify patients with NSTE-ACS who are at higher risk of death and recurrent cardiac events in both the short and long term. 2) Studies have found reductions in mortality rates for NSTE-ACS patients in recent years, which is due in part to improvements in pharmacological and invasive coronary strategies. 3) The GRACE risk score is the most widely used and has been shown to accurately predict mortality in NSTE-ACS patients at both 30 days and 1 year. It helps guide clinical decision making regarding treatment strategies.

1. Dr. Vijay Yadav
DM Cardiology-1st Year
MCVTC, IOM
RISK SCORES IN NSTE-ACS

2. NSTE-ACS patients are a heterogeneous population with varying risk of
death and recurrent cardiac events in both short and long term follow up.
European Heart Journal (2005) 26, 865–872
There has been a global decline in rates of death following acute coronary
syndrome.
Heart Disease and Stroke Statistics-2018 Update
The use of pharmacological and invasive coronary strategies among
patients hospitalized with NSTEMI have provided evidence for reductions
in morbidity.
J Am Coll Cardiol. 2014;64 (24):e139-e228.
The detection of NSTEMI of lower clinical risk has increased with the
introduction of hs-TnI – improved clinical outcomes.
BMJ. 2015;350:g7873.

3. Epidemiology
• Overall ACS decreasing
• Incidence= 8 Lakhs in 2018 in USA
• Proportion of NSTEMI increasing; >70% in 2018 (STEMI
decreasing)
• ASA, Statin, Smoking cessation
• Aging with ↑prevalence of DM & CKD
• Use of troponin assays with higher sensitivity that shifts the
diagnosis from UA to NSTEMI
Heart Disease and Stroke Statistics-2018 Update

4. The decline in mortality at 30 &
180 days was greater for patients
who were at intermediate to high
GRACE risk than for patients at
lowest and low GRACE risk.
JAMA. 2016;316(10):1073–1082
All-cause mortality rates at
30days following hospital
discharge decreased from
2.6% to 2.0% and at
180 days from 10.8% to 7.6%

5. 1. Use of an invasive
coronary strategy
2. Not entirely related to a
decline in baseline clinical
risk or increased use of
pharmacological
therapies.
Improvements in all-
cause mortality between
2003 and 2013
JAMA. 2016;316(10):1073–1082

6. • Study Type: Retrospective
• Site: Manmohan Cardiothoracic Vascular and Transplant
Center (MCVTC)
• Study duration: November 1, 2017 to October 31, 2018
• Study Cohorts: 419
• STEMI - 60.1%
• NSTEMI - 23.4%
• UA - 16.5%
Shakya, A.; Jha, S.; Gajurel, R.; Poudel, C.; Sahi, R.; Shrestha, H.;
Devkota, S.; Thapa, S. Clinical Characteristics, Risk Factors and
Angiographic Profile of Acute Coronary Syndrome Patients in a Tertiary
Care Center of Nepal. NJH 2019, 16, 27-32.
NSTE-ACS: Scenario at our center

7. Risk in ACS refers to the probability of suffering a
major negative clinical outcome.
Recurrent ischemia, need for urgent coronary
revascularization, myocardial infarction, death, and
their combinations are the most frequently measured
outcomes in ACS risk analysis.
All patients with NSTE-ACS should undergo early and
late risk stratification.

8. VERY HIGH RISK PATIENTS
Cardiogenic shock
Severe LVSD
Refractory angina Coronary Angiography
Hemodynamic unstability
Ventricular arrhythmia

9. EARLY RISK STRATIFICATION TOOLS
 Who are not very high risk patients

10. Antman RM et al JAMA 2000, 284, 835
TIMI 11B
ESSENCE

13. WHAT OTHER
INFORMATION???
Enoxaparin was
associated with better
14-day and six-week
post-discharge
outcomes compared
to Unfractionated
heparin
These benefits were
primarily seen in high-
risk patients with risk
scores ≥4 and ≥5

14. PRISM-PLUS TRIAL
(N=1491)
Am Heart J. 2005;149(5):846.

15. The rate of the primary
end point was lower in the
invasive strategy group
than in the conservative-
strategy group.
TACTIS-TIMI
18 (2001)
Death, MI, Rehosp for ACS
at 6 Months

16. J Am Coll Cardiol. 2006;47(8):1553. TIME II study ,Lancet. 2001;358(9293):1

17. PURSUIT RISK SCORE
(PLATELET GLYCOPROTEIN IIB/IIIA IN UNSTABLE ANGINA: RECEPTOR
SUPPRESSION USING INTEGRILIN THERAPY)
• Developed in a multinational randomized clinical trial with 9,461
patients, comparing eptifibatide to placebo in the management
of NSTE-ACS.
Circulation 2000; 101: 2557-67.

18. • A Global Registry of ACS patients from 94 hospitals in 14 countries from
21,688 ACS patients and validated in subsequent GRACE and GUSTO
(Global Utilization of Streptokinase and Tissue Plasminogen Activator for
Occluded Coronary Arteries) IIb cohorts.
• Good predictive accuracy both for death (c-0.82) and death/MI (c-0.70) at 6
months
• Estimate the risk of in-hospital and six-month mortality among all patients
with an ACS
Arch Int Med 2003;163:2345-53. (In hospital mortality)
BMJ. 2006 Nov 25;333(7578):1091. Epub 2006 Oct 10 (six-month mortality)

20. http://www.outcomes-
umassmed.org/grace/acs_risk/acs_risk_content
.html

22. Earlier trials have shown that a routine invasive strategy
improves outcomes in patients with acute coronary syndromes
without ST-segment elevation.
However, the optimal timing of such intervention remained
unclear.

23. TIMACS – GRACE based Primary Outcomes
6.7
21.6
7.7
14.1
0
5
10
15
20
25
Death/MI/Strokeat6mo.(%)
Delayed
Early
HR 0.65
95% CI 0.48-0.88
P=0.005
Death, MI or Stroke at 6 months
Low/Int Risk
GRACE Score < 140
N=2070
High Risk
GRACE Score ≥ 140
N=961
HR 1.14
95% CI 0.82-1.58
P=0.43
NEJM, 2009 May 21;360(21):2165-75

25. 1 year mortality
(Fast Revascularization in Instabilty Coronary Disease FRISC II Trial)
1)Done in 2457 patients
2)Only risk score that focussed on the
treatment effect of early invasive strategies in ACS
3) early invasive strategies for patients with a
FRISC score ≥ 3.

27. 2014 ACC/AHA Guidelines

28. Comparison of Risk scores
European Heart Journal (2005) 26, 865–872

29. All 3 predicted 30-day mortality equally
All 3 predicted 1-year mortality well but GRACE score superior than others

30. Interaction between the admission score & the prognostic impact of myocardial
revascularization performed during initial hospital stay
1) For PURSUIT & GRACE scores, the interaction between the admission score & the
prognostic impact of myocardial revascularization was statistically significant.
2) For TIMI score, this interaction was not statistically significant.

32. Circulation. 2009;119:1873-1882

34. Take home message
0 Risk scores are simple prognostication scheme that categorize a
patient’s risk of death and ischemic events.
0 Risk scores allow accurate estimations of ischaemic and bleeding risk
for individual patients.
0 The faster we can identify the high-risk patients the more the benefit
can be achieved by administering the optimal treatment early.
0 The GRACE risk score is more advantageous and easier to use in
comparison with other available risk scores.
0 The GRACE risk score is considered to be the one with the highest
discriminative power.
0 The GRACE and CRUSADE score should be combined for better
outcomes.