ABOUT THIS COLLECTION

The Global Registry of Acute Coronary Events (GRACE) (1999-2009) was an international registry designed to track in-hospital and long-term outcomes of patients presenting with acute coronary syndrome (ACS). With nearly 250 hospitals in 30 countries, GRACE enrolled over 102,000 patients. The GRACE risk score has been developed into an app and it has been integrated into electronic medical records systems used in daily clinical management of ACS patients worldwide. The United Kingdom national Institute for Health and Clinical Excellence (NICE) guideline has recommended employing the GRACE risk score since 2010. This collection showcases publications about the project and project research.

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Recently Published

  • Performance of the GRACE Risk Score 2.0 Simplified Algorithm for Predicting 1-Year Death After Hospitalization for an Acute Coronary Syndrome in a Contemporary Multiracial Cohort

    Huang, Wei; FitzGerald, Gordon; Goldberg, Robert J.; Gore, Joel M.; McManus, Richard H.; Awad, Hamza H.; Waring, Molly E.; Allison, Jeroan J.; Saczynski, Jane S.; Kiefe, Catarina I.; et al. (2016-10-15)
    The GRACE Risk Score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome (ACS). GRACE Risk Score 2.0 substitutes several variables that may be unavailable to clinicians and, thus, limit use of the GRACE Risk Score. GRACE Risk Score 2.0 performed well in the original GRACE cohort. We sought to validate its performance in a contemporary multiracial ACS cohort, in particular in black patients with ACS. We evaluated the performance of the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality in 2,131 participants in Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE), a multiracial cohort of patients discharged alive after an ACS in 2011 to 2013 from 6 hospitals in Massachusetts and Georgia. The median age of study participants was 61 years, 67% were men, and 16% were black. Half (51%) of the patients experienced a non-ST-segment elevation myocardial infarction (NSTEMI) and 18% STEMI. Eighty patients (3.8%) died within 12 months of discharge. The GRACE Risk Score 2.0 simplified algorithm demonstrated excellent model discrimination for predicting 1-year mortality after hospital discharge in the TRACE-CORE cohort (c-index = 0.77). The c-index was 0.94 in patients with STEMI, 0.78 in those with NSTEMI, and 0.87 in black patients with ACS. In conclusion, the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality exhibited excellent model discrimination across the spectrum of ACS types and racial/ethnic subgroups and, thus, may be a helpful tool to guide routine clinical care for patients with ACS.
  • Prognostic value of dynamic electrocardiographic T wave changes in non-ST elevation acute coronary syndrome

    Sarak, Bradley; Goodman, Shaun G.; Yan, Raymond T.; Tan, Mary K.; Steg, Phillippe Gabriel; Tan, Nigel S.; Fox, Keith A. A.; Udell, Jacob A.; Brieger, David; Welsh, Robert C.; et al. (2016-09-01)
    OBJECTIVE: To assess the relationship between the evolution of T wave inversion (TWI) on the 24-48 h postadmission ECG and the patient characteristics, management and clinical outcomes among those with non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS: We evaluated admission and 24-48 h follow-up ECGs of 7201 patients with NSTE-ACS from the prospective, multicentre Global Registry of Acute Coronary Events (GRACE) and Canadian ACS Registry I. We performed multivariable analyses to determine the association between new TWI (on follow-up ECG only), resolved TWI (on admission ECG only) and persistent TWI (on both admission and follow-up ECG) and inhospital and cumulative 6-month all-cause mortality. RESULTS: Patients with TWI were older, more likely to have cardiovascular risk factors, higher Killip class and GRACE risk scores. After adjustment for known prognostic factors, compared with patients presenting without TWI, new TWI was associated with significantly lower inhospital mortality (OR=0.60, 95% CI 0.38 to 0.95, p=0.029), whereas resolved (OR=1.06, 95% CI 0.65 to 1.75, p=0.81) and persistent (OR=0.73, 95% CI 0.48 to 1.11, p=0.14) TWI did not predict inhospital mortality. No TWI pattern independently predicted inhospital adverse cardiovascular events or cumulative 6-month mortality. In contrast, ST depression on the admission and follow-up ECG were independent predictors of inhospital and 6-month mortality. CONCLUSIONS: Across the spectrum of NSTE-ACS, TWI within 48 h of presentation was associated with high-risk clinical features, but its presence or dynamic change did not provide additional prognostic value beyond other established clinical predictors.
  • Temporal trends in all-cause mortality according to smoking status: Insights from the Global Registry of Acute Coronary Events

    Arbel, Yaron; FitzGerald, Gordon; Yan, Andrew T.; Tan, Mary K.; Fox, Keith A. A.; Gore, Joel M.; Steg, Phillippe Gabriel; Eagle, Kim A.; Brieger, David; Montalescot, Gilles; et al. (2016-09-01)
    Objective Smoking has been shown to be a risk factor for heart disease. However, it was recently reported that despite the evolution in therapy for acute coronary syndrome (ACS), smokers have not demonstrated improved outcomes. The aim of the present study was to evaluate the temporal trends in the treatments and outcomes across a broad spectrum of ACS patients (STEMI and non-ST-elevation ACS [NSTEACS]) according to smoking status on presentation in the Global Registry of Acute Coronary Events (GRACE). Methods Our cohort was stratified into 3 groups: current smokers, former smokers and never smokers. We evaluated trends in demographics, treatment modalities and outcomes in these 3 groups from 1999 to 2007. Results The study population comprised a total of 63,015 patients admitted to hospital with an ACS and with identifiable baseline smoking status. Smokers presented with STEMI more often than non-smokers. There was an unadjusted decline in 30-day mortality in all 3 groups. However, the adjusted decline was not statistically significant among current smokers (HR = 0.98 per study year, 95% CI 0.94–1.01, p = 0.20). A subgroup analysis of 22,894 STEMI patients demonstrated no reduction in annual adjusted 30-day mortality rates among smokers (HR = 1.01, 95% CI 0.96–1.06 (Table 5), whereas former and never smokers' mortality declined. Conclusions Over the years 1999–2007, 30-day mortality declined in patients presenting with acute coronary syndrome. However, smokers presenting with STEMI did not demonstrate a reduction in mortality.
  • Clinical Characteristics, Management, and Outcomes of Acute Coronary Syndrome in Patients With Right Bundle Branch Block on Presentation

    Chan, William K.; Goodman, Shaun G.; Brieger, David; Fox, Keith A. A.; Gale, Chris P.; Chew, Derek P.; Udell, Jacob A.; Lopez-Sendon, Jose; Huynh, Thao; Yan, Raymond T.; et al. (2016-03-01)
    We examined the relations between right bundle branch block (RBBB) and clinical characteristics, management, and outcomes among a broad spectrum of patients with acute coronary syndrome (ACS). Admission electrocardiograms of patients enrolled in the Global Registry of Acute Coronary Events (GRACE) electrocardiogram substudy and the Canadian ACS Registry I were analyzed independently at a blinded core laboratory. We performed multivariable logistic regression analysis to assess the independent prognostic significance of admission RBBB on in-hospital and 6-month mortality. Of 11,830 eligible patients with ACS (mean age 65; 66% non-ST-elevation ACS), 5% had RBBB. RBBB on admission was associated with older age, male sex, more cardiovascular risk factors, worse Killip class, and higher GRACE risk score (all p < 0.01). Patients with RBBB less frequently received in-hospital cardiac catheterization, coronary revascularization, or reperfusion therapy (all p < 0.05). The RBBB group had higher unadjusted in-hospital (8.8% vs 3.8%, p < 0.001) and 6-month mortality rates (15.1% vs 7.6%, p < 0.001). After adjusting for established prognostic factors in the GRACE risk score, RBBB was a significant independent predictor of in-hospital death (odds ratio 1.45, 95% CI 1.02 to 2.07, p = 0.039), but not cumulative 6-month mortality (odds ratio 1.29, 95% CI 0.95 to 1.74, p = 0.098). There was no significant interaction between RBBB and the type of ACS for either in-hospital or 6-month mortality (both p > 0.50). In conclusion, across a spectrum of ACS, RBBB was associated with preexisting cardiovascular disease, high-risk clinical features, fewer cardiac interventions, and worse unadjusted outcomes. After adjusting for components of the GRACE risk score, RBBB was a significant independent predictor of early mortality.
  • Cardiovascular Risk Factors and In-Hospital Mortality in Acute Coronary Syndromes: Insights From the Canadian Global Registry of Acute Coronary Events

    Wang, Jenny Y.; Goodman, Shaun G.; Saltzman, Ilana; Wong, Graham C.; Huynh, Thao; Dery, Jean-Pierre; Leiter, Lawrence A.; Bhatt, Deepak; Welsh, Robert C.; Spencer, Frederick A.; et al. (Pulsus Group, Inc., 2015-04-17)
    BACKGROUND: There are conflicting data regarding the relationship between the number of modifiable traditional risk factors and prognosis in acute coronary syndromes (ACS). This controversy might in part be explained by the differential use of prehospital medications. METHODS: Using data from the Canadian, multicentre Global Registry of Acute Coronary Events (GRACE) (1999-2008), we stratified 13,686 ACS patients into 3 groups (0, 1-2, vs 3-4 risk factors) and compared their baseline characteristics, in-hospital treatments, and outcomes. Multivariable logistic regressions were performed to adjust for the components of the GRACE risk score and preadmission statin and acetylsalicylic acid (ASA) use. RESULTS: Among these patients (ST-elevation myocardial infarction 28.3%), 14.5%, 62.6%, and 22.9% had 0, 1-2, and 3-4 risk factors, respectively. Patients with fewer risk factors were less likely to be on ASA, statin, and other prehospital medications. Unadjusted in-hospital mortality was significantly different across risk factor groups (4.9%, 3.0%, and 3.1% for 0, 1-2, and 3-4 risk factor groups, respectively, P for trend = 0.002). This difference was no longer significant after adjusting for the components of the GRACE risk score (P for trend = 0.088) and further adjusting for preadmission statin and ASA use (P for trend = 0.96). For in-hospital mortality, there was no significant interaction between risk factor categories and ACS type (P = 0.26). CONCLUSIONS: The lower mortality observed in patients with ACS with more risk factors may be partially attributed to the protective effect of prehospital ASA and statin use. The number of risk factors does not provide incremental prognostic value beyond the validated GRACE risk score.
  • In-hospital management and outcomes of acute coronary syndromes in relation to prior history of heart failure

    Zhang, Hanfei; Goodman, Shaun G.; Yan, Raymond T.; Steg, Phillippe Gabriel; Kornder, Jan M.; Gyenes, Gabor; Grondin, Francois R.; Brieger, David; DeYoung, J. Paul; Gallo, Richard; et al. (2015-03-12)
    INTRODUCTION: The prognostic significance of prior heart failure in acute coronary syndromes has not been well studied. Accordingly, we evaluated the baseline characteristics, management patterns and clinical outcomes in patients with acute coronary syndromes who had prior heart failure. METHODS AND RESULTS: The study population consisted of acute coronary syndrome patients in the Global Registry of Acute Coronary Events, expanded Global Registry of Acute Coronary Events and Canadian Registry of Acute Coronary Events between 1999 and 2008. Of the 13,937 eligible patients (mean age 66±13 years, 33% female and 28.3% with ST-elevation myocardial infarction), 1498 (10.7%) patients had a history of heart failure. Those with prior heart failure tended to be older, female and had lower systolic blood pressure, higher Killip class and creatinine on presentation. Prior heart failure was also associated with significantly worse left ventricular systolic function and lower rates of cardiac catheterization and coronary revascularization. The group with previous heart failure had significantly higher rates of acute decompensated heart failure, cardiogenic shock, myocardial (re)infarction and mortality in hospital. In multivariable analysis, prior heart failure remained an independent predictor of in-hospital mortality (odds ratio 1.48, 95% confidence interval 1.08-2.03, p=0.015). CONCLUSIONS: Prior heart failure was associated with high risk features on presentation and adverse outcomes including higher adjusted in-hospital mortality in acute coronary syndrome patients. However, acute coronary syndrome patients with prior heart failure were less likely to receive evidence-based therapies, suggesting potential opportunities to target more intensive treatment to improve their outcome.
  • High-grade atrioventricular block in acute coronary syndromes: insights from the Global Registry of Acute Coronary Events

    Singh, Sheldon M.; FitzGerald, Gordon; Yan, Andrew T.; Brieger, David; Fox, Keith A. A.; Lopez-Sendon, Jose; Yan, Raymond T.; Eagle, Kim A.; Steg, Phillippe Gabriel; Budaj, Andrzej; et al. (2014-09-08)
    BACKGROUND: While prior work has suggested that a high-grade atrioventricular block (HAVB) in the setting of an acute coronary syndrome (ACS) is associated with in-hospital death, limited information is available on the incidence of, and death associated with, HAVB in ACS patients receiving contemporary management. METHODS AND RESULTS: The incidence of HAVB was determined within The Global Registry of Acute Coronary Events (GRACE). The clinical characteristics, in-hospital therapies, and outcomes were compared between patients with and without HAVB. Factors associated with death in patients with HAVB were determined. A total of 59 229 patients with ACS between 1999 and 2007 were identified; 2.9% of patients had HAVB at any point during the index hospitalization; 22.7% of whom died in hospital [adjusted odds ratio (OR) = 4.2, 95% confidence interval (CI), 3.6-4.9, P < 0.001]. The association between HAVB and in-hospital death varied with type of ACS [OR: ST-segment elevation myocardial infarction (STEMI) = 3.0; non-STEMI = 6.4; unstable angina = 8.2, P for interaction < 0.001]. High-grade atrioventricular block present at the time of presentation to hospital (vs. occurring in-hospital) and early (12 h or no intervention) were associated with improved in-hospital survival, whereas temporary pacemaker insertion was not. Patients with HAVB surviving to discharge had similar adjusted survival at 6 months compared with those without HAVB. A reduction in the rate of, but not in-hospital mortality associated with, HAVB was noted over the study period. CONCLUSION: Although the incidence of HAVB is low and decreasing, this complication continues to have a high risk of in-hospital death.
  • GRACE score predicts heart failure admission following acute coronary syndrome

    McAllister, David A.; Halbesma, Nynke; Carruthers, Kathryn F.; Denvir, Martin; Fox, Keith A. (2014-07-01)
    BACKGROUND: Congestive heart failure (CHF) is a common and preventable complication of acute coronary syndrome (ACS). Nevertheless, ACS risk scores have not been shown to predict CHF risk. We investigated whether the at-discharge Global Registry of Acute Coronary Events (GRACE) score predicts heart failure admission following ACS. METHODS AND RESULTS: Five-year mortality and hospitalization data were obtained for patients admitted with ACS from June 1999 to September 2009 to a single centre of the GRACE registry. CHF was defined as any admission assigned WHO International Classification of Diseases 10 diagnostic code I50. The hazard ratio (HR) for CHF according to GRACE score was estimated in Cox models adjusting for age, gender and the presence of CHF on index admission. Among 1,956 patients, CHF was recorded on index admission in 141 patients (7%), and 243 (12%) were admitted with CHF over 3.8 median years of follow-up. Compared to the lowest quintile, patients in the highest GRACE score quintile had more CHF admissions (116 vs 17) and a shorter time to first admission (1.2 vs 2.0 years, HR 9.87, 95% CI 5.93-16.43). Per standard deviation increment in GRACE score, the instantaneous risk was more than two-fold higher (HR 2.28; 95% CI 2.02-2.57), including after adjustment for CHF on index admission, age and gender (HR 2.49; 95% CI 2.06-3.02). The C-statistic for CHF admission at 1-year was 0.74 (95% CI 0.70-0.79). CONCLUSIONS: The GRACE score predicts CHF admission, and may therefore be used to target ACS patients at high risk of CHF with clinical monitoring and therapies.
  • Beta-blocker Use in ST-segment Elevation Myocardial Infarction in the Reperfusion Era (GRACE)

    Lee Park, Kay; Goldberg, Robert J.; Anderson, Frederick A. Jr.; Lopez-Sendon, Jose; Montalescot, Gilles; Brieger, David; Eagle, Kim A.; Wyman, Allison; Gore, Joel M.; GRACE Investigators (Excerpta Medica, 2014-06-01)
    BACKGROUND: Current guidelines recommend early oral beta-blocker administration in the management of acute coronary syndromes for patients who are not at high risk of complications. METHODS: Data from patients enrolled between 2000 and 2007 in the Global Registry of Acute Coronary Events (GRACE) were used to evaluate hospital outcomes in three cohorts of patients admitted with ST-elevation myocardial infarction, based on beta-blocker use (early [first 24 hours] intravenous [± oral], only early oral, or delayed [after first 24 hours]). RESULTS: Among 13,110 patients with a ST-elevation myocardial infarction, 21% received any early intravenous beta-blockers, 65% received only early oral beta-blockers, and 14% received delayed (>24 hours) beta-blockers. Higher systolic blood pressure, higher heart rate, and chronic beta-blocker use were independent predictors of early beta-blocker use. Early beta-blocker use was less likely in older patients, patients with moderate to severe left ventricular dysfunction, and in those presenting with inferior myocardial infarction or Killip class III heart failure. Intravenous beta-blocker use and delayed beta-blocker use were associated with higher rates of cardiogenic shock, sustained ventricular fibrillation/ventricular tachycardia and acute heart failure, compared with oral beta-blocker use. In-hospital mortality was increased with IV beta-blocker use (propensity score adjusted odds ratio [OR] 1.41; 95% confidence interval [CI], 1.03-1.92) but significantly reduced with delayed beta-blocker administration (propensity adjusted OR, 0.44; 95% CI, 0.26-0.74). CONCLUSIONS: Early beta-blocker use is common in patients presenting with ST-elevation myocardial infarction, with oral administration being most prevalent. Oral beta-blockers were associated with a decrease in the risk of cardiogenic shock, ventricular arrhythmias, and acute heart failure. However, the early receipt of any form of beta-blockers was associated with an increase in hospital mortality.
  • Clinical characteristics and outcomes of acute coronary syndrome patients with left anterior hemiblock

    Zhang, Hanfei; Goodman, Shaun G.; Steg, Gabriel P.; Budaj, Andrzej; Lopez-Sendon, Jose; Dorian, Paul; Huynh, Thao; Mangat, Iqwal; Wong, Graham C.; Spencer, Frederick A.; et al. (2014-05-19)
    OBJECTIVE: We aimed to study the relationships between left anterior hemiblock (LAHB) and the patient characteristics, management, and clinical outcomes in the setting of acute coronary syndromes (ACS). METHODS: Admission ECGs of patients enrolled in the Global Registry of Acute Coronary Events (GRACE) ECG substudy, and the Canadian ACS Registry I, were analysed independently at a blinded core laboratory. Multivariable logistic regression analysis was performed to assess the independent associations between LAHB on the admission ECG and in-hospital and 6-month mortality. RESULTS: Of the 11 820 eligible ACS patients, 692 (5.9%) patients had LAHB. The presence of LAHB on admission was associated with older age, male sex, prior myocardial infarction, prior heart failure, worse Killip class, higher creatinine level, and higher GRACE risk score (all p<0.01). Patients with LAHB less frequently underwent cardiac catheterisation, coronary revascularisation or reperfusion therapy (all p<0.05). The LAHB group had higher in-hospital (6.9% vs 3.9%, p<0.001) and 6-month mortality (12.5% vs 7.7%, p<0.001). However, after adjusting for the known predictors of mortality in the GRACE risk models, LAHB was not independently associated with in-hospital death (OR 1.07, 95% CI 0.76 to 1.52, p=0.70), or death at 6 months (OR 1.00, 95% CI 0.75 to 1.34, p=0.99). CONCLUSIONS: Across the broad spectrum of ACS, LAHB was associated with significant comorbidities, high-risk clinical features on presentation, and worse unadjusted outcomes. However, LAHB was not an independent predictor of in-hospital and 6-month mortality and did not carry incremental prognostic value beyond the known prognosticators in the GRACE risk models.
  • Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score

    Fox, Keith A. A.; FitzGerald, Gordon; Puymirat, Etienne; Huang, Wei; Carruthers, Kathryn; Simon, Tabassome; Coste, Pierre; Monsegu, Jacques; Steg, Phillippe Gabriel; Danchin, Nicolas; et al. (2014-02-21)
    OBJECTIVES: Risk scores are recommended in guidelines to facilitate the management of patients who present with acute coronary syndromes (ACS). Internationally, such scores are not systematically used because they are not easy to apply and some risk indicators are not available at first presentation. We aimed to derive and externally validate a more accurate version of the Global Registry of Acute Coronary Events (GRACE) risk score for predicting the risk of death or death/myocardial infarction (MI) both acutely and over the longer term. The risk score was designed to be suitable for acute and emergency clinical settings and usable in electronic devices. DESIGN AND SETTING: The GRACE risk score (2.0) was derived in 32 037 patients from the GRACE registry (14 countries, 94 hospitals) and validated externally in the French registry of Acute ST-elevation and non-ST-elevation MI (FAST-MI) 2005. PARTICIPANTS: Patients presenting with ST-elevation and non-ST elevation ACS and with long-term outcomes. OUTCOME MEASURES: The GRACE Score (2.0) predicts the risk of short-term and long-term mortality, and death/MI, overall and in hospital survivors. RESULTS: For key independent risk predictors of death (1 year), non-linear associations (vs linear) were found for age (p CONCLUSIONS: The updated GRACE risk score has better discrimination and is easier to use than the previous score based on linear associations. GRACE Risk (2.0) performed equally well acutely and over the longer term and can be used in a variety of clinical settings to aid management decisions.
  • Pre-hospital cardiac arrest in acute coronary syndromes: insights from the global registry of acute coronary events and the canadian registry of acute coronary events

    Li, Qin; Goodman, Shaun G.; Yan, Raymond T.; Gore, Joel M.; Polasek, Petr; Lai, Kevin; Baer, Carolyn; Goldberg, Robert J.; Pinter, Arnold; Ahmad, Kamran; et al. (2013-08-01)
    Objectives: Cardiac arrest in acute coronary syndromes (ACS) is associated with high morbidity and mortality. We examined the clinical characteristics, contemporary management patterns and outcomes of ACS patients with pre-hospital cardiac arrest. Methods: The Global Registry of Acute Coronary Events and the Canadian Registry of Acute Coronary Events enrolled 14,010 ACS patients in 1999-2008. We compared the clinical characteristics, in-hospital treatment and outcomes between patients with and without pre-hospital cardiac arrest. Results: Overall, 206 (1.4%) patients had cardiac arrest prior to hospital presentation. ACS patients with pre-hospital cardiac arrest were less frequently treated with aspirin, beta-blocker, angiotensin-converting enzyme inhibitors, and statins within the first 24 h of presentation, but the use of cardiac procedures was similar compared to the group without cardiac arrest. Patients with pre-hospital cardiac arrest had significantly higher rates of in-hospital adverse events. Factors independently associated with pre-hospital cardiac arrest included male gender, current smoker status, tachycardia, higher Killip class and ST-segment deviation. Conclusion: ACS patients with pre-hospital cardiac arrest continue to have more in-hospital complications and higher mortality. Their use of evidence-based medical therapies was lower but the use of cardiac procedures was similar compared to the group without cardiac arrest. Better utilization of evidence-based therapies in these patients may translate into improved outcomes.
  • Do clinical factors explain persistent sex disparities in the use of acute reperfusion therapy in STEMI in Sweden and Canada?

    Johnston, Nina; Bornefalk-Hermansson, Anna; Schenck-Gustafsson, Karin; Held, Claes; Goodman, Shaun G.; Yan, Andrew T.; Bierman, Arlene S. (2013-07-17)
    Aims: This study examined clinical factors associated with sex differences in the use of acute reperfusion therapy (fibrinolysis or primary percutaneous coronary intervention) in ST-elevation myocardial infarction (STEMI) patients, and the interaction between sex and these factors in Sweden and Canada. Methods: Patients with STEMI in Sweden (n=32,676 from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) were compared with similar patients in Canada (n=3375 from the Canadian Global Registry of Acute Coronary Events) for the period 2004–2008. Results: Unadjusted vs. age-adjusted odds ratios (OR) for no reperfusion (women vs. men) were for Sweden 1.57 (95% CI 1.49–1.64) vs. 1.14 (95% CI 1.08–1.20), and for Canada 1.61 (95% CI 1.39–1.87) vs. OR 1.18 (95% CI 1.01–1.39). Sex differences persisted after multivariable adjustments (including prehospital delay, atypical symptoms, diabetes), factors for which no interaction with sex was found. Among women <60 >years, adjusting for atypical symptoms in Canada and angiographic data in Sweden made the greatest contribution to explaining observed sex differences. Conclusions: In both countries, acute reperfusion therapy in STEMI was used less often in women than in men. Factors associated with these sex differences appear to differ between older and younger women. Targeted interventions are needed to optimize care for women with STEMI, as well as sex- and age-stratified reporting of quality indicators to assess their effectiveness.
  • Management and outcomes of non-ST elevation acute coronary syndromes in relation to previous use of antianginal therapies (from the Canadian Global Registry of Acute Coronary Events [GRACE] and Canadian Registry of Acute Coronary Events [CANRACE])

    Kang, Jaskaran S.; Goodman, Shaun G.; Yan, Raymond T.; Lopez-Sendon, Jose; Pesant, Yves; Graham, John J.; Fitchett, David H.; Wong, Graham C.; Rose, Barry F.; Spencer, Frederick A.; et al. (2013-07-01)
    Randomized trials have established the efficacy of antianginal medications in the treatment of chronic stable coronary disease. Using data from the Global Registry of Acute Coronary Events (GRACE) and Canadian Registry of Acute Coronary Events (CANRACE), we examined the temporal trends in antianginal use (beta blockers, calcium antagonists, and nitrates) before non-ST-elevation acute coronary syndrome presentation from 1999 to 2008 in 10,019 patients. The relationships among previous antianginal use, clinical characteristics on presentation, and in-hospital management and outcomes were examined. Beta blockers were the most commonly used agents, and there was a significant decline in the use of nitrates over time. Compared with patients not on any antianginal therapy before presentation, those on treatment were more likely to be older, female, and have a history of hypertension, diabetes, previous angina, and myocardial infarction; they were less likely to present with positive biomarkers (all p <0.001). Patients not on antianginal therapy before presentation were more likely to undergo coronary angiography and percutaneous coronary intervention and less likely to have recurrent ischemia during hospitalization (all p <0.001). In multivariable analysis, previous antianginal use was independently associated with lower use of coronary angiography in hospital (p = 0.034) but not with in-hospital mortality. In conclusion, there has significant temporal decline in nitrate use before non-ST-elevation acute coronary syndrome. Patients receiving antianginal therapy before presentation more frequently had preexisting cardiovascular disease and previous revascularization and were less likely to present with non-ST-segment elevation MI compared with patients on no antianginal therapies. Previous antianginal use was independently associated with a lower use of coronary angiography in hospital.
  • Treatment and outcomes of non-ST elevation acute coronary syndromes in relation to burden of pre-existing vascular disease

    Mohareb, Michael; Goodman, Shaun G.; Yan, Raymond T.; Bhatt, Deepak L.; Elbarouni, Basem; DeYoung, J. Paul; Gallo, Richard; Kornder, Jan M.; Welsh, Robert C.; Saposnik, Gustavo; et al. (Elsevier Scientific Publishers, 2013-04-16)
    BACKGROUND: Patients with atherosclerotic disease in one territory often have disease in other vascular territories. However, the relationships between pre-existing vascular disease and the treatment and outcome of acute coronary syndrome (ACS), have not been well characterized. METHODS: The Canadian ACS2, Global Registry of Acute Coronary Events (GRACE/GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) were used to obtain data on 10,667 non-ST segment elevation acute coronary syndrome (NSTEACS) patients between 2002 and 2008. Multivariable analysis was used to examine the relationships between the number of vascular beds affected and both in-hospital coronary angiography and in-hospital mortality. The ACS2 registry (2002-2003) included physician-reported reasons for non-invasive management, which were stratified by vascular disease burden. RESULTS: Patients with more vascular disease had higher GRACE risk scores at presentation, but less frequently received antiplatelet agents and angiography. The most common reason in the ACS2 registry for patients who did not undergo angiography was "not high enough risk." There was an independent inverse relationship between the extent of vascular disease and in-hospital angiography. Patients with higher vascular disease burden had higher unadjusted in-hospital mortality. In multivariable analysis, patients with 1 vascular territory affected had the lowest and those with 3 vascular beds affected had the highest adjusted in-hospital mortality. In the ACS2 registry, patients with more extensive vascular disease had higher rates of 1-year mortality and death/re-infarction (both p for trend <0.001). CONCLUSIONS: NSTEACS patients with more vascular disease received less intensive treatment, with an associated worse outcome. This undertreatment might be partly mediated by physicians' underestimation of patient risk. More aggressive risk factor modification and intensive ACS therapies may improve the outcome of these high-risk patients. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.
  • Management and outcomes of patients presenting with STEMI by use of chronic oral anticoagulation: results from the GRACE registry

    Alonso, Alvaro; Gore, Joel M.; Awad, Hamza H.; Quill, Ann L.; Montalescot, Gilles; Van de Werf, Frans; Gulba, Dietrich C.; Fox, Keith A. A.; Eagle, Kim A.; Granger, Christopher B.; et al. (2013-03-18)
    Aims: To describe the characteristics, treatment, and mortality in patients with ST-elevation myocardial infarction (STEMI) by use of chronic oral anticoagulant (OAC) therapy. Methods: Using data from the Global Registry of Acute Coronary Syndromes (GRACE), patient characteristics, treatment, and reperfusion strategies of STEMI patients on chronic OAC are described, and relevant variables compared with patients not on chronic OAC. Six-month post-discharge mortality rates were evaluated by Cox proportional hazard models. Results: Of 19,094 patients with STEMI, 574 (3.0%) were on chronic OAC at admission. Compared with OAC non-users, OAC users were older (mean age 73 vs. 65 years), more likely to be female (37 vs. 29%), were more likely to have a history of atrial fibrillation, prosthetic heart valve, venous thromboembolism, or stroke/transient ischaemic attack, had a higher mean GRACE risk score (166 vs. 145), were less likely to be Killip class I (68 vs. 82%), and were less likely to undergo catheterization/percutaneous coronary intervention (52 vs. 66%, respectively). Of the patients who underwent catheterization, fewer OAC users had the procedure done within 24 h of admission (56.5 vs. 64.5% of OAC non-users). In propensity-matched analyses (n=606), rates of in-hospital major bleeding and in-hospital and 6-month post-discharge mortality were similar for OAC users and OAC non-users (2.7 and 3.7%, p=0.64; 15 and 13%, p=0.56; 15 and 12%, p=0.47, respectively), rates of in-hospital recurrent myocardial infarction (8.6 and 2.0%, pp=0.004) were higher in OAC patients, and rates of 6-month stroke were lower (0.6 and 4.3%, p=0.038). Patients in both groups who underwent catheterization had lower mortality than those who did not undergo catheterization. Conclusions: This is the largest study to describe the characteristics and treatment of STEMI patients on chronic OAC. The findings suggest that patients on chronic OAC are less likely to receive guideline-indicated management, but have similar adjusted rates of in-hospital and 6-month mortality.
  • Treatment and outcomes of patients with suspected acute coronary syndromes in relation to initial diagnostic impressions (insights from the Canadian Global Registry of Acute Coronary Events [GRACE] and Canadian Registry of Acute Coronary Events [CANRACE])

    Bajaj, Ravi R.; Goodman, Shaun G.; Yan, Raymond T.; Bagnall, Alan J.; Gyenes, Gabor; Welsh, Robert C.; Eagle, Kim A.; Brieger, David; Ramanathan, Krishnan; Grondin, Francois R.; et al. (2013-01-15)
    The early diagnosis of acute coronary syndrome (ACS) remains challenging, and a considerable proportion of patients are diagnosed with "possible" ACS on admission. The Global Registry of Acute Coronary Events (GRACE/GRACE(2)) and Canadian Registry of Acute Coronary Events (CANRACE) enrolled 16,618 Canadian patients with suspected ACS in 1999 to 2008. We compared the demographic and clinical characteristics, use of cardiac procedures, prognostic accuracy of the GRACE risk score, and in-hospital outcomes between patients given an admission diagnosis of "definite" versus "possible" ACS by the treating physician. Overall, 11,152 and 5,466 patients were given an initial diagnosis of "definite" ACS and "possible" ACS, respectively. Patients with a "possible" ACS had higher GRACE risk score (median 130 vs 125) and less frequently received aspirin, clopidogrel, heparin, or beta blockers within the first 24 hours of presentation and assessment of left ventricular function, stress testing, cardiac catheterization, and percutaneous coronary intervention (all p <0.05). Patients with "possible" ACS had greater rates of in-hospital myocardial infarction (9.0% vs 2.0%, p <0.05) and heart failure (12% vs 8.9%, p <0.05). The GRACE risk score demonstrated excellent discrimination for in-hospital mortality in both groups and for the entire study population. In conclusion, compared to patients with "definite" ACS on presentation, those with "possible" ACS had higher baseline GRACE risk scores but less frequently received evidence-based medical therapies within 24 hours of admission or underwent cardiac procedures during hospitalization. The GRACE risk score provided accurate risk assessment, regardless of the initial diagnostic impression.
  • Young patients hospitalized with an acute coronary syndrome

    Awad, Hamza H.; McManus, David D.; Anderson, Frederick A. Jr.; Gore, Joel M.; Goldberg, Robert J. (2013-01-01)
    OBJECTIVES: Limited data are available describing the magnitude, clinical features, treatment practices, and short-term outcomes of younger adults hospitalized with an acute coronary syndrome (ACS). METHODS: The objectives of this large multinational observational study were to describe recent trends in these and related endpoints among adult men and women younger than 55 years of age who were hospitalized with an ACS between 1999 and 2007 as part of the Global Registry of Acute Coronary Events (GRACE) study. RESULTS: The overall proportion of young adults hospitalized with an ACS in our multinational study population was 23% (n=15 052 of 65 119); this proportion remained relatively constant during the years under study. The proportion of comparatively young patients hospitalized with a previous diagnosis of angina pectoris or heart failure decreased over time, whereas the rates of previously diagnosed hypertension in this patient population increased. The proportion of patients developing atrial fibrillation, heart failure, stroke, or an episode of major bleeding during hospitalization for an ACS decreased significantly over time. Both in-hospital (2.1% in 1999; 1.3% in 2007) and 30-day multivariable-adjusted death rates decreased by more than 30% (odds ratio=0.66, 95% confidence interval=0.60-0.74) during the years under study. The hospital use of effective cardiac therapies (e.g. angiotensin-converting enzyme inhibitors, beta-blockers) increased significantly over time. CONCLUSION: The results of this large observational study provide insights into the magnitude, changing characteristics, and short-term outcomes of comparatively young adults hospitalized with an ACS. Decreasing rates of short-term mortality and important clinical complications likely reflect enhanced treatment efforts that warrant future monitoring.
  • Trends and predictors of rehospitalisation following an acute coronary syndrome: report from the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE)

    Sangu, Prashanthi V.; Ranasinghe, Isuru; Aliprandi-Costa, Bernadette; Devlin, Gerard; Elliot, John; Lefkovits, Jeffrey; Brieger, David (2012-12-01)
    BACKGROUND: Readmission following an acute coronary syndrome (ACS) is frequent in our community. Patient specific factors identifying those at risk of readmission are poorly described. METHODS: Data were analysed from 5219 patients with an ACS enrolled in the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE) between 1999 and 2007. Patients who were readmitted for cardiovascular disease within 6 months of discharge were identified; regression analysis was used to predict independent patient factors associated with readmission 1 month and 1-6 months after discharge. RESULTS: 1048 patients (20.1%) were readmitted within 6 months, with a significant proportion (n=434, 41.4%) of readmissions occurring within 30 days of discharge. Readmission within 6 months was associated with a higher incidence of unscheduled cardiac catheterisation (HR 25.64, 95% CI 18.41 to 35.71), unscheduled percutaneous coronary intervention (PCI) (HR 15.78, 95% CI 10.56 to 23.59), stroke (HR 1.92, 95% CI 1.08 to 3.43), and death (HR 2.40, 95% CI 1.66 to 3.49). Recurrent ischemia in hospital and a diagnosis of S-T elevation myocardial infarction during the index admission were associated with the strongest risk of early rehospitalisation, while revascularisation by PCI or coronary artery bypass surgery (CABG) was associated with lowest risk of early readmission. A history of heart failure, prior myocardial infarction or angina was associated with a greater likelihood of later rehospitalisation, whereas revascularisation by CABG was associated with the lowest risk of later rehospitalisation. CONCLUSIONS: Several patient and clinical factors identify patients at higher risk of readmission. Identifying these factors and escalating in-hospital and post-discharge care for these higher risk patients may prevent readmission and improve outcome.
  • Influence of 23 coronary artery disease variants on recurrent myocardial infarction or cardiac death: the GRACE Genetics Study

    Wauters, Els; Carruthers, Kathryn F.; Buysschaert, Ian; Dunbar, Donald R.; Peuteman, Gilian; Belmans, Ann; Budaj, Andrzej; Van de Werf, Frans; Lambrechts, Diether; Fox, Keith A. A. (2012-11-20)
    Aims: A pooled analysis of 14 genome-wide association studies revealed 23 susceptibility loci for coronary artery disease (CAD), thereby providing the most comprehensive genetic blueprint of CAD susceptibility. Here, we evaluated whether these 23 loci also predispose to recurrent myocardial infarction (MI) or cardiac death following an acute coronary syndrome (ACS). Methods and results: A total of 2099 ACS patients enrolled in the Global Registry of Acute Coronary Events (GRACE) UK-Belgian study were prospectively followed for a median of 5 years (1668 days). C-allele carriers of the rs579459 variant, which is located upstream of the ABO gene and correlates with blood group A, were independently associated with recurrent MI [multivariable-adjusted hazard ratio (HR) 2.25, CI = 1.37-3.71; P = 0.001] and with recurrent MI or cardiac death [multivariable-adjusted (HR) 1.80, CI = 1.09-2.95; P = 0.021] within 5 years after an index ACS. The association of rs579459 was replicated in 1250 Polish patients with 6 months follow-up after an index ACS [multivariable-adjusted (HR) 2.70, CI = 1.26-5.82; P = 0.011 for recurrent MI]. Addition of rs579459 to a prediction model of 17 clinical risk factors improved risk classification for recurrent MI or cardiac death at 6 months as calculated by the integrated discrimination improvement method (P = 0.037), but not by C-statistics (P = 0.096). Conclusion: In this observational study, rs579459 was independently associated with adverse cardiac outcome after ACS. A weak improvement in clinical risk prediction was also observed, suggesting that rs579459 should be further tested as a potentially relevant contributor to risk prediction models for adverse outcome following ACS.

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