Diagnostic accuracy of TIMI versus GRACE score for ...

The mean TIMI score of the patients was 4.19±1.86. The mean GRACE score of the patients was 132.77±52.73. The study results showed that the ... SubmitaManuscript Articles Journals Editors Reviewers Indexing&Abstracting ScienceOpen TechnicalUniversityofDenmark BIUSante LUBSearch FloaridaInstituteofTechnology UWLibrarySearch SJSU OAJI Publons KB VU SearchIT NSULibrary McGillLibrary JCUDiscovery WorldCat UniversidadDeLima ResearchGate OpenArchives AcademicMicrosoft BaseSearch TDNet JournalTOCs Ithenticate CrossRefSimilarityCheck HarvardLibrary ICMJE CNKI AcademicKeys CrossRef Scilit GoogleScholar SemanticScholar ISSN:2575-0143 ResearchArticle DiagnosticaccuracyofTIMIversusGRACEscoreforpredictionofdeathinpatientspresentingwithAcuteNon-STElevationMyocardialInfarction(NSTEMI) SyedHaseebRazaNaqvi1,TariqAbbas1,HanNaungTun2*,AliAhmadNaqvi1,ZubairZaffar1,BadarulAhadGill1andNisarAhmad1 1CPEInstituteofCardiology,Multan,Punjab,Pakistan 2ClinicalandResearchWorkingGroups,EuropeanSocietyofCardiology,SophiaAntipolis,France *AddressforCorrespondence:HanNaungTun,ClinicalandResearchWorkingGroups,EuropeanSocietyofCardiology,SophiaAntipolis,France,Email:[email protected] Dates:Submitted:14February2019;Approved:21February2019;Published:22February2019 Howtocitethisarticle:NaqviSHR,AbbasT,TunHN,NaqviAA,ZaffarZ,etal.DiagnosticaccuracyofTIMIversusGRACEscoreforpredictionofdeathinpatientspresentingwithAcuteNon-STElevationMyocardialInfarction(NSTEMI).JCardiolCardiovascMed.2019;4:001-005.DOI:10.29328/journal.jccm.1001032 CopyrightLicense:©2019NaqviSHR,etal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited. Keywords:TIMI;GRACE;Cardiac;Infarction;Acute;Risk;Elevation. Abstract Background:AcuteCoronarySyndromedescribesaspectrumofdiseaserangingfromunstableanginathroughnon-ST-ElevationMyocardialInfarction(NSTEMI)toST-ElevationMyocardialInfarction(STEMI).EarlydeathinNSTEMIisusuallyduetoanarrhythmia.Patientsshouldbeadmittedimmediatelytohospital,preferablytoacardiaccareunitbecausethereisasignificantriskofdeath. Objective:TocomparethediagnosticaccuracyofTIMIversusGRACEforpredictionofdeathinpatientspresentingwithAcuteNon-STelevationMyocardialInfarction. Material&Methods:ThispresentcrosssectionalstudywasconductedatDepartmentofCardiology,CPEIC,Multan.Allpatientsassessedaccordingtogivenscoresinthetwoscoringsystemi.e.TIMIriskscoreandGRACEscore.Thenpatientswerelabeledashighorlowriskfordeath.Datawascollectedbyusingpre-designedproforma.2x2tablesweregeneratedtomeasurethesensitivity,specificity,positivepredictivevalue,negativePredictivevalueanddiagnosticaccuracyofTMIRiskscoreandGRACEScoreforpredictionofdeathinNSTEMIpatients. Results:Inourstudythemeanageofthepatientswas55.73±9.78years.Themaletofemaleratioofthepatientswas1.6:1.Thediabetesasriskfactorwasfoundin145(39%)patients,smokingasriskfactorwasfoundin53(14.2%)patientsandhypertensionasriskfactorwasfoundin174(46.8%)patients.thesensitivityofTIMIriskwas97.7%withspecificityof92.93%andthediagnosticaccuracywas95.16%,similarlythesensitivityofGRACEriskwas100%withspecificityof95.96%andthediagnosticaccuracywas97.85%. Conclusion:OurstudyresultsconcludedthatboththeTIMIriskandGRACEriskaregoodpredictorofdeathinpatientspresentingwithAcuteNon-STelevationMyocardialInfarctionwithhighersensitivityanddiagnosticaccuracy.HowevertheGRACEriskshowedmoreaccurateresultsascomparedtoTIMIrisk. Introduction AcuteCoronarySyndromedescribesaspectrumofdiseaserangingfromunstableanginathroughnon-ST-ElevationMyocardialInfarction(NSTEMI)toST-ElevationMyocardialInfarction(STEMI).The6monthsmortalityratesinglobalregistryofAcuteCoronaryEvents(GRACE)were13%forpatientswithNSTEMIand8%forthosewithunstableanginaand30daymortalitywas9.1%despitethebestconventionaltherapy[1,2]. AllpatientswithUnstableAnginaandNSTEMIshouldundergoriskstratificationsoonafterpresentation.TheThrombolysisinMyocardialInfarction(TIMI)riskscore,GlobalRegistryofAcuteCoronaryEvents(GRACE)riskindexandPlateletglycoproteinIIb/IIIainUnstableangina[3].TIMIandGRACEaretheriskscoresthatupuntilnowhavebeenmostextensivelyinvestigated,withGRACEperformingbetter.ThereareotherpotentiallyusefulACSriskscoresavailablehoweverthesehavenotundergonerigorousvalidation.Thisstudysuggeststhattheseotherscoresmaybepotentiallyusefulandshouldbefurtherresearched[4]. LiteratureisevidentthatGRACEScorecanpredictbetterforhighriskofmortalityamongNSTEMIcases.ButstillTIMIriskassessmentismoreinpractice.SoweaimedtoconductthisstudytoimplementtheuseofmoreappropriateandaccuratemethodinfuturetobeusedasfirstlinediagnostictoolinemergencycasestopredicttheoutcomeofNSTEMIcases.Thiswillalsohelpustogetlocalmagnitudesaswellaswillhelpustoimproveourclinicalpracticeandknowledge. Objective TheobjectiveofthisstudyistocomparethediagnosticaccuracyofTIMIversusGRACEforpredictionofdeathinpatientspresentingwithAcuteNon-STelevationMyocardialInfarction. MaterialsandMethods ThisCasecontrolstudywasconductedatDepartmentofCardiology,CPEIC,Multanfor6months.Samplesizeof372patientsiscalculatedwith95%confidenceinterval,9%marginoferrorandtakingexpectedpercentageofNSTEMIi.e.64.5%andsensitivityandspecificityofTIMIi.e.75%and86%respectively,forpredictionofdeathinpatientspresentingwithNSTEMI.Non-probabilityconsecutivesamplingwasusedtoincludethepatients.Patientsofage40-80yearsofeithergenderpresentingwithAcuteNSTEMI.AcuteNSTEMIwasinfarctionwithoutST-segmentelevationprecordialdiscomfortinthelast48hours,associatedwithatleastoneofthefollowingcharacteristics:1)positivemyocardialnecrosismarker,definedasTroponinT≥0.01ug/l,whichcorrespondstovalues>99thpercentileofthenormalreferencepopulation;2)ischemicelectrocardiographicalterations,consistingofT-waveinversion(³0.1mV)ortransientST-segmentdepression(³0.05mV);3)previouslydocumentedcoronaryarterydisease,definedbyahistoryofmyocardialinfarctionorpreviousangiographydemonstratingcoronaryobstruction≥50%.RiskofDeathonTIMI:IfTIMIRiskscorewas>5,thencaseswerelabeledashighriskfordeath.RiskofDeathonGRACE:IfGRACEscorewas>172,thencaseswerelabeledashighriskfordeath.PatientswithmedicalrecordofinterventionforpreviousMIi.e.PCIorCABG,valvularheartdiseases.Allpatientsassessedaccordingtogivenscoresinthetwoscoringsystemi.e.TIMIriskscoreandGRACEscore.Thenpatientswerelabeledashighorlowriskfordeath.Patientsfollowedupduringhospitalstayfor7days.Duringhospitalstay,ifpatientwoulddie,deathwaslabeled.Datawascollectedbyusingpre-designedproforma.DatawasenteredandanalyzedbySPSSversion20.AllquantitativevariableslikeageweredescribedbyusingmeanandSD.Allqualitativevariablesgenderanddeathwasdescribedbyusingfrequencyandpercentage.2x2tablesweregeneratedtomeasurethesensitivity,specificity,PPV,NPVanddiagnosticaccuracyofTMIRiskscoreandGRACEScoreforpredictionofdeathinNSTEMIpatients. Results Themeanageofthepatientswas55.73±9.78years.Inourstudy61.83%patientsweremalesand38.17%patientswerefemales.Themaletofemaleratioofthepatientswas1.6:1.Diabeteswasfoundin145(39%)patients,smokingin53(14.2%)patientsandhypertensionin174(46.8%)patients(Table1).ThemeanTIMIscoreofthepatientswas4.19±1.86.ThemeanGRACEscoreofthepatientswas132.77±52.73.Thestudyresultsshowedthatthedeathoccurredin46.77%patientsandrecoveredpatientswere53.23%patients(Table2). Table1:Baselinecharacteristicsofpatients. Age 55.73±9.78 Gender(m/f) 38.2%/61.8% Diabetes 145(39%) Smoking 53(14.2%) Hypertension 174(46.8%) Table2:DescriptivestatisticsofTIMIscore. TIMIscore 4.19±1.86 GRACEscore 132.77±52.73 Deathoccurred 46.77% ThesensitivityofTIMIriskwas97.7%withspecificityof92.93%.ThePPVvalueofTIMIriskscorewas92.39%andNPVvaluewas97.87%.ThediagnosticaccuracyofTIMIriskwas95.16%(Table3).ThesensitivityofGRACEriskwas100%withspecificityof95.96%.ThePPVvalueofGRACEriskscorewas95.6%andNPVvaluewas100%.ThediagnosticaccuracyofGRACEriskwas97.85%(Table4). Table3:ComparisonofTIMIriskwithdeathofthepatients.   Death Total Yes No TIMIrisk Highrisk 170 14 184 Lowrisk 4 184 188 Total 174 198 372 Sensitivity:97.7%,Specificity:92.93%,PPV:92.39%,NPV:97.87%andDiagnosticAccuracy:95.16% Table4:ComparisonofGRACEriskwithdeathofthepatients.   Death Total Yes No GRACErisk Highrisk 174 8 182 Lowrisk 0 190 190 Total 174 198 372 Sensitivity:100%,Specificity:95.96%,PPV:95.6%,NPV:100%andDiagnosticAccuracy:97.85%. Discussion GlobalRegistryofAcuteCoronaryEvents(GRACE)andThrombolysisinMyocardialInfarction(TIMI)riskscoreshavebeenwidelyusedforprognosispredictinginpatientswithACS[4-6].Inourstudythedeathoccurredin46.77%patients.InthisstudythesensitivityofTIMIriskwas97.7%withspecificityof92.93%andthediagnosticaccuracywas95.16%,similarlythesensitivityofGRACEriskwas100%withspecificityof95.96%andthediagnosticaccuracywas97.85%.Someofthestudiesarediscussedbelowshowingtheresultsonfavorofourstudyas,thePortuguesestudybyGoncalvesetal.[14],demonstratedthesuperiorityoftheGRACEscorewhencomparedtotheTIMIscorewithadifferenceof0.12inC-statisticsforthecombinationofdeathandin-hospitalinfarction[7].ThereareotherpotentiallyusefulACSriskscoresavailablehoweverthesehavenotundergonerigorousvalidation.Thisstudysuggeststhattheseotherscoresmaybepotentiallyusefulandshouldbefurtherresearched[4].AstudybyKozieradzkaetal.[8],comparedthesescoresinST-segmentelevationmyocardialinfarctionandobservedsimilardiscriminatoryability.However,theseauthorsdidnotanalyzescorecalibration.Inaddition,thatstudyanalyzedlong-termoutcomes(five-yearevolution). TheresultsofErikPHessetal.[9],meta-regressionanalysisindicatedastronglinearrelationbetweenTIMIriskscoreandtheshort-termincidenceofcardiacevents.Theincidenceofcardiaceventsinthelowestriskstratum(TIMIscoreofzero)was1.8%;thesensitivitywas97.2%andspecificitywas25.0%atthisdecisionthreshold.OnemorestudybyHangZhuetal.[10],presentedthatbothGRACEandTIMIwereadoptableinclinicalriskstratificationandprognosisoffemalepatientswithNSTE-ACSatdifferentagegroups.astudyconductedinBrazil,hasfoundthatGRACEscorehas50%sensitivityand98%specificityforpredictionofhighriskfordeathinNSTEMIpatientsascomparedtoTIMIRiskscore(sensitivity=75%,specificity=86%).Theauthorsconcludedthatalthoughthescoresshowsimilardiscriminatorycapacityforhospitaldeath,theGRACEscorehadbettercalibrationthanTIMI.Thesefindingsneedtobevalidatedpopulationsofdifferentriskprofiles[11]. OnemorestudybyEnderÖneretal.[12],resultedthatGRACEscoreshowedgooddiscriminatorycapacitybetweenthepatientswithandwithoutahigh-risk(>33)SYNTAXscore,withanareaundertheROCcurveof0.804(CI0.6600.948,p=0.002);however,theTIMIscoreshowednopredictivecapacityandhadanareaundertheROCcurveof0.532(CI0.358-0.749,p=0.749).AstudybyG.Ramsayetal.[13],describedthattheBothGRACE(p  EmadAbu-Assetal.[14],revealedintheirstudythattheGRACEriskscoreforpredictingdeathwithin6monthsofhospitaldischargewasvalidatedandcanbeusedinpatientswithACS.ItwouldbewisetoincludetheGRACEriskscoreinthemedicalrecordsofthesepatients.TwomorestudiespresentedthatTheGRACEscorehasshownagreaterprognosticvalueascomparedwiththatoftheTIMIscore[15,16]. Conclusion OurstudyresultsconcludedthatboththeTIMIriskandGRACEriskaregoodpredictorofdeathinpatientspresentingwithAcuteNon-STelevationMyocardialInfarctionwithhighersensitivityanddiagnosticaccuracy.HowevertheGRACEriskshowedmoreaccurateresultsascomparedtoTIMIrisk. 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