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Original Investigation
October 27, 2003

Predictors of Hospital Mortality in the Global Registry of Acute Coronary Events

Author Affiliations

From the Division of Cardiology (Dr Granger), Department of Medicine (Ms Pieper), Duke University Medical Center, Durham, NC; Center for Outcomes Research, University of Massachusetts Medical School, Worcester (Drs Goldberg and Dabbous); Division of Cardiology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor (Dr Eagle); Cardiology Division, Brigham and Women's Hospital, Boston, Mass (Dr Cannon); Department of Cardiology, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium (Dr Van de Werf); Clinical Research Center, Hospital Albert Einstein, São Paulo, Brazil (Dr Avezum); Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario (Dr Goodman); Clinical Trials and Evaluation Unit, the Royal Brompton and Harefield NHS Trust, London, England (Dr Flather); and The University of Edinburgh and Department of Cardiology, The Royal Infirmary of Edinburgh, Edinburgh, Scotland (Dr Fox). Dr Van der Werf is a member of the Speakers' Bureau for Aventis Pharma, who provided financial support for this research. Aventis Pharma had no involvement in the collection, analysis, and interpretation of data, in the writing of the report, or in the decision to submit the article for publication.

Arch Intern Med. 2003;163(19):2345-2353. doi:10.1001/archinte.163.19.2345

Background  Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk.

Objective  To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice.

Methods  A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001. Validation data sets included a subsequent cohort of 3972 patients enrolled in GRACE and 12 142 in the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial.

Results  The following 8 independent risk factors accounted for 89.9% of the prognostic information: age (odds ratio [OR], 1.7 per 10 years), Killip class (OR, 2.0 per class), systolic blood pressure (OR, 1.4 per 20-mm Hg decrease), ST-segment deviation (OR, 2.4), cardiac arrest during presentation (OR, 4.3), serum creatinine level (OR, 1.2 per 1-mg/dL [88.4-µmol/L] increase), positive initial cardiac enzyme findings (OR, 1.6), and heart rate (OR, 1.3 per 30-beat/min increase). The discrimination ability of the simplified model was excellent with c statistics of 0.83 in the derived database, 0.84 in the confirmation GRACE data set, and 0.79 in the GUSTO-IIb database.

Conclusions  Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.