What is the clinical significance of the difference between a 6-month GRACE (Global Registry of Acute Coronary Events) score of 2 and a GRACE 2.0 score of 2.2-2.6 in terms of risk assessment?

From the Guidelines

The difference between a 6-month GRACE score of 2 and a GRACE 2.0 score of 2.2-2.6 suggests we may be underestimating cardiovascular risk in some patients, and clinicians should consider using the more contemporary GRACE 2.0 model for risk stratification and treatment decisions. The original GRACE score predicts 6-month mortality after acute coronary syndrome, while GRACE 2.0 is an updated version that incorporates additional risk factors and provides more granular risk assessment. When a patient has a higher GRACE 2.0 score compared to their original GRACE score, it indicates that newer risk factors or more precise calculations are identifying additional risk not captured by the original model. This discrepancy means some patients might not receive appropriately aggressive treatment based on the older scoring system. Some key points to consider include:

• The GRACE risk score is used to stratify patients with acute coronary syndrome into different risk categories, with higher scores indicating a higher risk of adverse outcomes 1.
• The TIMACS trial suggested that early intervention is beneficial in patients with high-risk features, as defined by a GRACE risk score greater than 140 1.
• The ABOARD trial found no evidence of incremental benefit derived by a strategy of immediate angiography and intervention for UA/NSTEMI 1.
• The advantage of early intervention was achieved in the context of intensive background antithrombotic therapy 1.
• Clinicians should consider using the more contemporary GRACE 2.0 model for risk stratification and treatment decisions, including appropriate intensity of antiplatelet therapy, statin dosing, and follow-up intervals 1. The difference occurs because medical understanding of cardiovascular risk factors has evolved, and GRACE 2.0 incorporates improved statistical methods and additional variables like renal function that better predict outcomes in contemporary practice. Overall, the use of the GRACE 2.0 score can help clinicians to better assess cardiovascular risk and make more informed treatment decisions, which can lead to improved patient outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Clinical Significance of GRACE Score Difference

The clinical significance of the difference between a 6-month GRACE score of 2 and a GRACE 2.0 score of 2.2-2.6 in terms of risk assessment can be understood by examining the predictive value of these scores for patient outcomes.

• The GRACE risk score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome (ACS) 2, 3, 4.
• The GRACE 2.0 risk score has been shown to have better discrimination and is easier to use than the previous score based on linear associations 2.
• A study comparing the performance of the GRACE 2.0 risk model with other risk models found that modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort 5.
• The GRACE risk score has been demonstrated to provide accurate risk assessment, regardless of the initial diagnostic impression, and has been shown to be highly predictive of all-cause mortality at 2 years 4, 6.

Risk Assessment and Prediction

The difference between a GRACE score of 2 and a GRACE 2.0 score of 2.2-2.6 may reflect differences in the predictive value of these scores for patient outcomes, such as:

• In-hospital mortality: The GRACE 2.0 risk model has been shown to have a c-index of 0.79 for predicting in-hospital mortality, while the NCDR model performed best with a c-index of 0.89 5.
• Long-term mortality: The GRACE risk score has been demonstrated to be highly predictive of all-cause mortality at 2 years, with a c-statistic of 0.80 4.
• The GRACE risk score has been shown to provide excellent discrimination for in-hospital mortality in both patients with "definite" ACS and those with "possible" ACS 6.

Clinical Implications

The clinical implications of the difference between a GRACE score of 2 and a GRACE 2.0 score of 2.2-2.6 are:

• The choice of risk model may impact the accuracy of risk assessment and prediction of patient outcomes 5.
• The GRACE risk score can be used to guide management decisions and provide accurate risk assessment, regardless of the initial diagnostic impression 2, 6.
• The use of modern NCDR and ACTION risk models may provide superior performance in prediction of in-hospital mortality compared to the GRACE model 5.