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ACUTE CORONARY SYNDROMES

Use of risk scores in acute coronarysyndromesHector Bueno, Francisco Fernandez-Aviles

Risk is dened as the probability and severity ofloss from exposure to a hazard, and can be assessedin different ways. The application of quantitativeor qualitative measures to determine the level ofrisk associated with a specic hazard denes theprocess of risk assessment. Qualitative risk assess-ments (ie, high, intermediate or low risk) are basedon the presence or absence of certain characteristics(risk markers or factors). These are easy to use butnot accurate as there may be wide variations inindividual risk within risk subgroups. Quantitativerisk assessments, based on algorithms or mathe-matical formulae, are more precise but morecomplicated to use. Risk scores are formula gener-ated numbers used for quantitative risk assessmentthat rank-order individuals according to the likeli-hood of developing a specic outcome (or combi-nation of outcomes) during a dened time interval.

Acute coronary syndromes (ACS) are clinicalentities characterised by acute symptomaticmyocardial ischaemia that has not been triggeredby stimuli causing a signicant increase of thedemand for oxygen by the heart. ACS are usuallycaused by acute thrombosis of a coronary artery,

most frequently associated with lesions caused bychronic coronary atherosclerosis. According to theinitial ECG, ACS are classied as presentingwith ST segment elevation or non-ST segmentelevation. This article will focus on non-STsegmentelevation ACS.

The clinical consequences of ACS range fromnone or minimal sequelae to early death. Patientswith ACS have a relatively high incidence of cardiacevents in the short term, particularly myocardialischaemic recurrencesdrecurrent angina ormyocardial infarction (MI)dbut also heart failure,arrhythmias and other events, which may also leadto future further complications. For this reason,

ACS require an early pharmacological treatmentd

based on antithrombotic therapies, anti-ischaemicdrugs, and a number of preventive therapiesdand,frequently, the revascularisation of one or morediseased coronary arteries, either percutaneously orsurgically. There are many therapeutic options thatcan be used to treat patients with ACS, includingpharmacologic treatmentsdparticularly severalantithrombotic therapies, such as antiplateletagents (aspirin, clopidogrel, prasugrel, ticagrelor)and anticoagulant agents (unfractionated heparin,low molecular weight heparins, fondaparinux,bivalirudin)dand strategies for invasive assessment

and treatment of coronary lesions (emergent,

urgent, or elective coronary angiography andrevascularisation). The different combinations ofpharmacologic treatments and invasive strategiesare associated with different benets and risks,which frequently differ according to the patientsbaseline clinical prole and risk.

RISKS OF PATIENTS WITH ACSRisk in ACS refers to the probability of sufferinga major negative clinical outcome, most frequentlyassociated with ischaemic recurrences and its clin-ical correlates, which is known as ischaemic risk.Thus, recurrent ischaemia, need for urgent coro-nary revascularisation, myocardial infarction,death, and their combinations are the mostfrequently measured outcomes in ACS risk analysis.However, while some of these outcomes areobjective (death) or potentially objective throughstrict denitions (myocardial infarction), othershave a substantial amount of subjectivity in theirassessment (recurrent ischaemia requires a clinicaljudgement to be made of new symptoms or signs,and the need for urgent revascularisation requiresa clinical decision making process which is medi-

ated by availability and local policies). For thisreason, the former, objective outcomes are calledhard endpointsand the latter, subjective outcomesare called soft endpoints.

The spontaneous risk of ACS to patients dependsessentially on local factors, such as the severity ofischaemia, the burden of coronary artery disease,the myocardial mass at risk, the baseline functionof the left ventricle, and the patient clinical prole(age, comorbidities, etc). However, this risk changesover time depending on the evolution of the causalfactors (progression of coronary thrombosis andobstruction, embolisation, etc), the development ofcomplications, and the response to treatment.Therefore, risk assessment is a dynamic processthat starts at the time ofrst medical contact andchanges with clinical evolution and response totreatment, so it needs to be updated over time inorder to be accurate.

Risk assessment is important for the ne calcu-lation of the prognosis of individual patients, whichis an important issue not only for communicatingwith patients and relatives but also for therapeuticdecision making. There is strong evidence demon-strating that an aggressive treatment approach hasthe potential to change the prognosis of patientswith ACS, although this effect is frequently risk

dependent. Today, it is accepted that high risk

< Additional references arepublished online only. To viewthese references please visit thejournal online (http://heart.bmj.com/content/98/2.toc).

Department of Cardiology,Hospital General UniversitarioGregorio Maranon, Madrid,Spain

Correspondence toDr Hector Bueno, Department of

Cardiology, Hospital GeneralUniversitario Gregorio Maranon,Dr Esquerdo, 46, Madrid 28007,Spain; [email protected]

162 Heart2012;98:162e168. doi:10.1136/heartjnl-2011-300129

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ischaemic patients with ACS deserve more aggres-sive management, including more potent anti-thrombotic treatment and a rapid invasive strategy,while lower risk patients may do well with lesspotent antithrombotic treatment and a moreselective invasive strategy.w1 w2 Therefore, there isa need to assess ischaemic risk on an individualbasis to guide these treatment strategies, tailoring

care for each individual patient.Several trials have shown that antithrombotic

drugs and coronary invasive procedures can reducethe number of ischaemic events in ACS patients,but these treatments usually increase the risk ofbleeding. Given that antithrombotic therapies andinvasive strategies are key steps in the managementof ACS, and that haemorrhages are associated withhigher mortality when they are not mild,1e4 theassessment of bleeding risk has become necessary in

ACS risk assessment for the calculation of trade-offs between ischaemic risk reduction and sponta-neous and treatment related bleeding hazards.

RISK ASSESSMENT IN ACS PATIENTSDifferent ways have been used to stratify risk in

ACS patients. Simple risk stratications have beenproposed according to the presence or absence ofsome key prognostic factors. These include olderage, markers of severe ischaemia (positive tropo-nins, dynamic ST segment changes, ischaemicrecurrences on adequate treatment), signs ofhaemodynamic (admission heart rate or systolicblood pressure, shock) or electrical (ventriculararrhythmias) instability, signs of myocardialdysfunction (heart failure, left ventricular dysfunc-

tion), comorbidities (diabetes, renal dysfunction,anaemia), and other factors. These simple riskassessment methods were initially recommendedby scientic societies to assess risk and selecta therapeutic strategy, as they allow an easy quali-tative risk classication of high or non-high riskpatient groups. However, although risk stratica-tion through single variables is easy when used ina dichotomous fashion (yes/no), and may help inselecting patients with an elevated risk of futureadverse cardiovascular events who may benetfrom certain therapeutic interventions, such asantiplatelet therapies or early invasive therapies, itdoes not provide a reliable assessment of risk

because it does not allow the absolute risk of indi-vidual patients to be estimated. For example, it isnot possible to dene what is the increase in riskassociated with one versus several high riskmarkers, with the level of troponin elevation introponin positive patients, with age in olderpatients, or with diabetes according to its type orduration.

This lack of accuracy limits the capacity ofqualitative risk stratication systems to weigh theindividual patients risk against the potentialbenets and risks associated with the use of avail-able interventions, particularly when risks are not

placed on the extreme sides of the spectrum (veryhigh, very low).

Interestingly, many conditions associated withan increased ischaemic risk (eg, advanced age, dia-betes, renal failure, anaemia) are also associatedwith higher bleeding risk. In these cases, theintensity of antithrombotic therapy should betailored to the individual patients ischaemic andbleeding risk. However, it is very difcult to makeindividual decisions on the intensity of anti-

thrombotic therapy when both risks are qualita-tively high. Therefore, quantitative risk estimationsare more helpful than qualitative risk straticationsin guiding therapy for ACS patients.

USE OF RISK SCORES FOR ACSRisk scores for ischaemic risk assessment

A number of risk scores have been developed topredict short and mid term outcomes in patientswith ACS (table 1).5e15 These scores were createdby giving an appropriate number of points for thepresence of each risk factor identied by multi-variable statistical techniques as an independentpredictor of the adverse outcome/s (and with anadditive contribution to overall risk), based on theobservation of events in specic populations. Thenumber of points given to each component may beproportional to the coefcients obtained inthe prognostic modeldthat is, to their prognosticweight (weighed models)dor they may not relateto their individual prognostic impact (ie, one pointfor each predictor present). The former use complexformulae to provide continuous risk estimates,while the latter provide stepwise risk estimationsaccording to the number of present predictors(gure 1).

One potentially relevant factor for the externalvalidity of risk scores is the population from whichthey are derived. Models derived from clinicalregistries enrolling consecutive patients are theo-retically more applicable to real life patients thanthose developed from patients enrolled in clinicaltrials, which tend to exclude higher risk patients(very old, with important comorbidities).

Several variables have been associated withhigher ischaemic risk in the different scoringsystems. These include patient characteristics suchas age, gender and body weight, risk factors, ante-cedents related to a previous history of cardiac ornon-cardiac disease, data related to the clinical and

haemodynamic presentation, and ECG and labora-tory abnormalities. However, there is a limitedconcordance between models in the selectedpredictors (table 1). Only age, heart failure, STsegment deviation and elevated cardiac markerswere selected as independent risk factors by mostpredictive models, while a variety of other factorsare used in individual models. The most popularrisk scoring systems in clinical practice have beenthe TIMI risk score,8 the GRACE risk scores,5 11

and, to a lesser extent, the PURSUIT risk score.10

The TIMI (Thrombolysis in Myocardial Infarc-tion) risk score for unstable angina/non-ST eleva-

tion myocardial infarction (UA/NSTEMI)

8

(not tobe confused with the TIMI ST segment elevation

Heart2012;98:162e168. doi:10.1136/heartjnl-2011-300129 163

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Tab

le1

Pre

dictorsof

ischaem

icor

bleed

ing

even

tsinriskscores

forpat

ientsw

ithacu

tecoronarysyndromes

Ischaemic

risk

Bleedingrisk

GRACE

AMIs

Piombo

TIM

I

PREDICT

PURSUIT

GR

ACE

SYNERGY

FRISCII

CRUSADE

Mehran

Refe

rences

5

6

7

8

9

10

11

12

13

14

15

Outc

ome

Dea

thor

deat

h/MI

Dea

th

Dea

th/MI/re

frac

tory

ischaem

ia

Dea

th/MI/

urgen

trevasc

Dea

thor

dea

th/MI

Dea

thor

dea

th/MI

De

athor

deat

h/MI

Dea

th

Dea

thor

deat

h/MI

Major

blee

d

Non-

CABG

major

blee

d

Time

In-h

osp

ital

In-h

ospi

tal

In-h

ospi

tal

14days

28days

30days

6m

onths

12mon

ths

12mon

ths

In-h

osp

ital

In-h

osp

ital

Populat

ion

Reg

istry

(GRACE)

Reg

istry

(AMIsPlus)

Reg

istry

(?)

RCT

(TIM

I11B)

Reg

istry

(?)

RCT

(PURSUIT)

Re

gistry

(GRACE)

RCT

(SYNERGY)

RCT

(FRISCII)

Reg

istry

(CRUSADE)

RCT

(ACUITY

-HORIZONS)

Pred

ictors

A

ge

[

[

[

[

[

[

[

[

[

[

Femalegen

der

Y

Y

[

[

Bodyweigh

t

[

Riskfactors

Diabetes

[

[

Hyper

tens

ion

[

$3risk

factors

(inc

luding

fam

ilyhistory

)

[

Previous

history

Worst

CCSclass

inprevious

6mont

hs

[

[

Signi

fican

tCAD

[

Previous

MI

[

Previous

CVD

[

[

[

Previous

HF

[

Previous

CABG

[

Charlson

index

[

Clinicalpresen

tation

Killipclass/

hear

tfailure

[

[

[

[

[

[

Car

diacarrest

[

[

[

[

Severeangina

lsymp

toms

[

Haemodynam

icpresen

tation

HRonadm

ission

[

[

[

[

[

SBPonadm

ission

[

[

[

[

[

ECG S

Tsegmen

tdeviat

ion

[

[

[

[

[

Laboratory

tests

Eleva

tedcard

iacmar

kers

/troponin

[

[

[

[

[

[

Renal

dysfunct

ion

[

[

[

[

[

[

Lower

haemoglo

bin

[

[

[

WBCcoun

t

[

Plateletcoun

t

[

Inflammat

ionmar

kers

(CRP

,IL6)

[

A

ntithrom

botic

therapy

Useof

ASAw

ithin

7days

[

Useof

GPIIb/IIIainhibitors

[

[

AS

A,

asp

irin;

CABG

,coronaryar

tery

bypassgra

ftsurgery;

CAD

,coronaryar

tery

disease;

CCS

,Canad

ian

Car

diovasc

ular

Society;

CRP

,Creac

tiveprotein;

CVD

,card

iovascular

disease;

GP

,g

lycopro

tein;

HF,heart

failure;

HR

,heartra

te;

IL,

interleu

kin;

MI,myocard

ial

infarct

ion;

RCT;random

isedcontro

lledtrial;revasc

,revascu

larisa

tion;

SBP

,systo

licbloo

dpressure;

WBC

,w

hite

bloo

dce

ll.Forexplanat

iono

ftrialab

brev

iations

,seete

xt.


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AMI risk score) was developed in a derivation cohortconsisting of 1957 patients with ACS who wererandomised to the unfractionated heparin arm of theTIMI 11B trial; this compared unfractionatedheparin with enoxaparin, and initially validated threeseparate cohorts of patients: the enoxaparin group ofthe TIMI 11B trial; the group allocated to unfrac-tionated heparin in the ESSENCE (Efcacy andSafety of Subcutaneous Enoxaparin in NoneQ-waveCoronary Events) trial; and the enoxaparin groupfrom ESSENCE. The TIMI risk score is a simplesemiquantitative score that includes seven variablesto predict the 14 day risk of the composite end pointof death, MI or urgent revascularisation. These sevenvariables are classied into historical factors: (1) age(65 years); (2) $3 risk factors for coronaryartery disease; (3) known coronary artery disease

(stenosis $50%); (4) aspirin use in the past 7 days;and presentational factors: (5) recent (#24 h) severeangina; (6) ST segment deviation $0.5 mm; and (7)positive cardiac markers. One point is given for thepresence of each predictor so the score ranges from0 (lowest risk) to 7 (highest risk), which correlatewell (c-statistic 0.65) with the selected outcome(14 day incidence of all cause mortality, MI, andsevere recurrent ischaemia prompting urgent revas-cularisation), and mortality (table 2). The TIMI riskscore has been validated in populations with ACSfrom randomised trials,w3 and observational studiesfor the prediction of in-hospital death,w4 or the

composite outcome of death or MI at 28 days.9 TheTIMI risk score has also been shown to be useful forclinical decision making as it showed increasedbenets with enoxaparinw5 or glycoprotein IIb/IIIainhibitors in high risk patients,w6 or proved the ef-cacy of clopidogrel in high risk patients with non-STelevation ACSw7 after the original publicationfailed to show such efcacy using the OASIS risk

stratication method.w8

The GRACE (Global Registry of Acute CoronaryEvents) risk score was developed to predict death,and death/MI, in a cohort of 21 688 patients withNSTEMI enrolled into a multinational observa-tional registry. Nine factors based on the presentingclinical and biomarker characteristics of thepatients were identied as independent predictorsof death or a combined outcome of death andMI both in-hospital5 and at 6 months11: (1) age,(2) heart failure, (3) peripheral vascular disease,(4) admission systolic blood pressure, (5) Killipclass, (6) initial serum creatinine concentration,(7) elevated cardiac markers, (8) cardiac arrest onadmission, and (9) ST segment deviation. Thesewere incorporated into a continuous model becauseboth age and creatinine value are analysed ascontinuous variables. The GRACE risk scores havegood predictive accuracy both for death (c0.82)and death/MI (c0.70) at 6 months and providequantitative risk estimations through a complexformula. However, due to the complexity of thecalculation, this risk score requires specic tools forits use to estimate risk at the bedside. The speciccalculator is available at http://www.outcomes-massmed.org/grace/acs_risk/acs_risk_content.html.Interestingly, although precise estimates can be

obtained, three risk categories have been developedaccording to the GRACE risk score results for low,intermediate, and high risk patients (table 2).

The ability of the GRACE risk score to predictdeath at different time points has been assessed inseveral ACS patient cohort registries in the UK,Canada, Portugal, Spain, and New Zealand.w9ew16

Moreover, its clinical utility in selecting patientsfor a specic therapy has also been validated, bothretrospectively in clinical trials (such as fordetermining the difference in efcacy and safetybetween fondaparinux and enoxaparin accordingto patient riskw17) and in observational studies(showing the benet of an early invasive strategy

restricted to higher risk patientsw18), andprospectively, such as in the TIMACS (Timing ofIntervention in Acute Coronary Syndromes) trial.The TIMACS trial compared a routine earlyintervention (coronary angiography #24 h afterrandomisation) with more delayed intervention(coronary angiography $36 h after random-isation) in patients with non-ST elevation ACS;it showed that those patients at the highest risktertile (GRACE risk score >140) improved theirprimary outcome with an early intervention(hazard ratio (HR) 0.65, 95% CI 0.48 to 0.89),while those patients at low-to-intermediate risk

obtained no bene

t (HR 1.12, 95% CI 0.81 to1.56).w19

Table 2 Mortality risk estimations in patients with non-ST-segment elevation acute coronary syndromesaccording to the GRACE and TIMI risk scores

GRACEin-hospital

TIMI14 days

GRACE6 months

Low risk

Score #108 0e2 #88

Mortality 8%

For explanation of trial abbreviations, see text.

Figure 1 Risk estimation according to the type of risk score. Quantitative risk scores,such as GRACE, PURSUIT, and CRUSADE, use formulae that produce continuous resultsfor the estimation of risk. Semiquantitative risk scores, such as TIMI and FRISC-II, definea number of independent risk predictors. The number of present predictors is associatedwith a stepwise increase in event risk. For explanation of trial abbreviations, see text.

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The PURSUIT risk score10 was developed fromthe 9461 patients enrolled in the PURSUIT (PlateletGlycoprotein IIb/IIIa in Unstable Angina: ReceptorSuppression Using Integrilin Therapy) trial, whichtested the efcacy of eptibatide versus placebo inpatients with ACS. This quantitative risk scoreestimates the absolute risk of 30 day death ordeath/MI based on age, heart rate, systolic blood

pressure on admission, ST segment depression,signs of heart failure, and positive cardiac enzymes.It showed a better accuracy to predict death(c0.81) than to predict death/MI (c0.67). ThePURSUITscore has been validated in populations inthe USA,w20 Portugal,w15 and Canada,w11 where itshowed high discriminative power, but poor cali-bration. It allows separate risk stratication ofpatients with unstable angina and NSTEMI.However, it is a complex model that needs a specictool for calculations and it is not frequently used.

The FRISC II risk score13 was developed for 2457patients with unstable coronary artery disease fromthe FRISC (Fast Revascularisation During Insta-bility in Coronary Artery Disease) II trial (rando-mised trial comparing an early invasive vs a non-invasive strategy). Seven factorsdage >70 years,male sex, diabetes, previous MI, ST depression, andincreased concentrations of troponins and markersof inammation (interleukin 6 or C reactiveprotein)dwere associated with an independentincreased risk for death or death/MI at 1 year. TheFRISC II risk score has the merit of being the rstone to show the clinical benet of a therapeuticintervention in a specic subset of patientsaccording to risk. Thus, the FRISC II trial demon-strated a reduction in mortality with an invasive

strategy in patients with $5 of the score riskfactors (5.2% vs 15.4%; relative risk (RR) 0.34, 95%CI 0.15 to 0.78), and a reduction of death/MI inthose patients with 3e4 factors (10.8% vs 15.7%;RR 0.69, 95% CI 0.50 to 0.94), while no benet wasobserved with the invasive strategy in patientswith 0e2 risk factors.w21

Some other risk scores have been developed buttheir use is not as common as the previous ones. Acomprehensive review of the characteristics andmerits of each of these risk scores for ACS has beenpublished by the National Institute for Health andClinical Excellence (NICE) in the UK.16

Risk scores for bleeding risk assessmentThe clinical relevance of bleeding in patients with

ACS has been identied in the last 10 years.1e4

There has been growing interest in identifying thepredictors of bleeding, particularly major bleeding.1

Some attempts have been performed recently toquantitatively assess the risk of major bleeding. Forthis purpose, two risk scores have been produced.

The rst bleeding risk score was developed in71277 patients with NSTEMI enrolled in theCRUSADE (Can Rapid risk stratication ofUnstable angina patients Suppress ADverseoutcomes with Early implementation of the

ACC/AHA guidelines) US Quality ImprovementInitiative. The CRUSADE bleeding score14 assigned

weighted integers that corresponded to the coef-cient of each variable to the outcome of in-hospitalmajor bleeding. The model identied eight inde-pendent baseline predictors (baseline haematocrit


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omission of key risk factors by the TIMI riskscore.w24

The 2007 American College of Cardiology/American Heart Association guidelines for themanagement of ACS recommended the use of onevalidated risk score, mentioning the TIMI, GRACE,

and PURSUIT risk scores, but showing no prefer-ence.w2 The 2007 European Society of Cardiologyguidelines for the management of ACS favoured theuse of the GRACE risk score over others,acknowledging that the FRISC II score was theonly one showing a benet associated with selec-tion of strategy.w1 The review by NICE comparedthe discriminative capacity of some of the risk

scores to predict short and longer term outcomes inpopulations with ACS in a cohort of 75627patients admitted to hospitals in England and

Wales and enrolled in the large MINAP (MyocardialInfarction National Audit Project) dataset. Theirconclusion was that none of the risk scores isclearly superior in terms of prognostic value,although PURSUIT, GRACE, and PREDICTseem tohave better discrimination than TIMI formortality.16 Thus, the GRACE score is probably thebest predictor of ischaemic risk in patients with

ACS, but whether this score should be systemati-cally recommended for all patients is not welldened. In contrast, bleeding risk scores have notbeen compared so far and no recommendations fortheir use have been formally established yet.

Guidelines recommend the use of risk scores forrisk assessment and clinical decision making inpatients with ACS. The 2007 ESC guidelines for thediagnosis and treatment of non-ST elevation ACSrecommended an early invasive strategy in inter-mediate to high risk patients according to a riskscore, or a conservative strategy in low risk patientsas assessed by a risk score.w1 The 2011 ACCF-AHAFocused Update of the Guidelines for the Manage-ment of NSTEACSw25 recommend an invasivestrategy as being preferable in patients with a high

risk score (eg, TIMI, GRACE), or not recom-mending upstream glycoprotein IIb/IIIa inhibitorsin UA/NSTEMI patients who are at low risk forischaemic events (eg, TIMI risk score #2).w25 Therecently released ESC Guidelines for the manage-ment of NSTEACS17 recommend the use of riskscores for stratication of both ischemic andbleeding risk, with a preference for the GRACE andCRUSADE risk scores, respectively. Moreover, anearly invasive strategy within 24 h is recommendedfor patients with a GRACE risk score >140 or withat least one major high risk criterion while for thosewith a GRACE risk score of


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CONCLUSIONSRisk scores are helpful tools for the assessment ofrisk in ACS patients. Risk scores allow accurateestimations of ischaemic and bleeding risk forindividual patients. In addition to its utility inprognosis assessment, this information may behelpful for weighing the patients risks with theexpected benets and risks associated with avail-

able therapies, hence facilitating individual tailoringof treatments. Despite these theoretical advantages,there is a need for stronger evidence showinga benet associated with the systematic use of riskscores on optimising therapies, reducing costs orimproving patient outcomes. More research isneeded to address the impact of the use of riskstratication systems, and particularly of riskscores, on practice patterns and patient outcomesas well as the most effective ways to increase theiruse in routine clinical practice.w29

Competing interestsIn compliance with EBAC/EACCME guidelines,all authors participating in Education inHearthave disclosed potential

conflicts of interest that might cause a bias in the article. Theauthors have no competing interests.

ContributorsHector Bueno designed and drafted the manuscript;Francisco Fernandez-Aviles reviewed the manuscript addingsignificant intellectual content.

Provenance and peer reviewCommissioned; internally peerreviewed.

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bleeding in acute coronary syndromes: the Global Registry ofAcute Coronary Events (GRACE). Eur Heart J 2003;24:1815e23.

< First major study on predictors of major bleeding in patientswith ACS.

2. Rao SV,OGrady K, Pieper KS, et al. Impact of bleeding severity

on clinical outcomes among patients with acute coronarysyndromes. Am J Cardiol2005;96:1200e6.

3. Eikelboom JW, Mehta SR, Anand SS, et al. Adverse impact ofbleeding on prognosis in patients with acute coronary syndromes.Circulation2006;114:774e82.

4. Mehran R, Pocock SJ, Stone GW, et al. Associations of majorbleeding and myocardial infarction with the incidence and timing ofmortality in patients presenting with non-ST-elevation acutecoronary syndromes: a risk model from the ACUITY trial.Eur Heart

J 2009;30:1457e66.< A study showing how major bleeding in patients with ACS

carries a prognosis as poor as a new MI in terms ofmortality.

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Intern Med2003;163:2345e53.< First study of the GRACE risk scores for ACS patients, this

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stratification in acute coronary syndromes: the AMIS model. Heart2009;95:662e8.

7. Piombo AC,Gagliardi JA, Guetta J, et al. A new scoring systemto stratify risk in unstable angina.BMC Cardiovas Disord2003;3:8.

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< Presentation of the TIMI risk score for ACS, one of themost popular systems used internationally to estimateischaemic risk.

9. Singh M, Reeder GS, Jacobsen SJ, et al. Scores for post-myocardial infarction risk stratification in the community.Circulation2002;106:2309e14.

10. Boersma E, Pieper KS, Steyerberg EW, et al. Predictors ofoutcome in patients with acute coronary syndromes withoutpersistent ST-segment elevation. Results from an international trialof 9461 patients. The PURSUIT Investigators.Circulation2000;101:2557e67.

< Presentation of the PURSUIT score, the first quantitativerisk score for ACS.

11. Fox KAA, Dabbous OH, Goldberg RJ, et al. Prediction of risk ofdeath and myocardial infarction in the six months afterpresentation with acute coronary syndrome: prospectivemultinational observational study (GRACE). BMJ 2006;333:1091.

< GRACE risk score for death or death/MI at 6 months.12. Mahaffey KW, Yang Q, Pieper KS, et al. Prediction of one-year

survival in high-risk patients with acute coronary syndromes:results from the SYNERGY trial. J Gen Intern Med2008;23:310e16.

13. Lagerqvist B, Diderholm E, Lindahl B, et al. FRISC score for

selection of patients for an early invasive treatment strategy inunstable coronary artery disease.Heart2005;91:1047e52.

< The FRISC II risk score showed not only that it couldaccurately estimate mortality risk in ACS patients but thatit could define the group of patients who benefit most froman early invasive strategy.

14. Subherwal S, Bach RG, Chen AY, et al. Baseline risk of majorbleeding in non-ST-segment-elevation myocardial infarction: theCRUSADE (Can Rapid risk stratification of Unstable angina patientsSuppress ADverse outcomes with Early implementation of theACC/AHA Guidelines) Bleeding Score. Circulation2009;119:1873e82.

< First risk score for major bleeding in ACS patients, derivedfrom the large US CRUSADE registry.

15. Mehran R, Pocock SJ, Nikolsky E, et al. A risk score to predictbleeding in patients with acute coronary syndromes.J A CollCardiol2010;55:2556e66.

16. National Institute for Health and Clinical Excellence.Unstable angina and NSTEMI: the early management of unstable

angina and non-ST-segment-elevation myocardial infarction.London: NICE, 2010. http://www.nice.org.uk/nicemedia/live/12949/47921/47921.pdf

< The chapter Risk assessment of this document is a must-read for anyone interested in risk assessment andparticularly in risk scores for ACS patients. There isa comprehensive comparison of the performances of themost important risk scores developed for ACS patients.

17. Hamm CW,Bassand JP, Agewall S, et al. ESC Guidelines for themanagement of acute coronary syndromes in patients presentingwithout persistent ST-segment elevation: The Task Force for themanagement of acute coronary syndromes (ACS) in patientspresenting without persistent ST-segment elevation of theEuropean Society of Cardiology (ESC). Eur Heart J. 2011 Sep 21.

< First guidelines recommending the assessment of ischemicand bleeding risk through risk scores (GRACE and

CRUSADE), and changing management recommendationsaccording to risk scores results (invasive strategy within24 hours for patients with GRACE risk score > 140) inpatients with NSTEACS.

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Education in Heart



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doi: 10.1136/heartjnl-2011-3001292012 98: 162-168Heart

Hctor Bueno and Francisco Fernndez-AvilssyndromesUse of risk scores in acute coronary

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