Predictors of Hospital Mortality in the Global Registry of Acute Coronary Events | Acute Coronary Syndromes | JAMA Internal Medicine | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Not Available, American Heart Association 2001 heart and stroke statistical update. Available at: Accessed December 2, 2001.
Murray  CJLopez  AD Mortality by cause for eight regions of the world: Global Burden of Disease Study.  Lancet. 1997;3491269- 1276PubMedGoogle ScholarCrossref
Braunwald  EAntman  EMBeasley  JW  et al.  ACC/AHA guidelines for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina).  J Am Coll Cardiol. 2000;36970- 1062[published erratum appears in J Am Coll Cardiol. 2001;38:294-295].PubMedGoogle ScholarCrossref
Ryan  TJAntman  EMBrooks  NH  et al.  1999 Update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction).  J Am Coll Cardiol. 1999;34890- 911PubMedGoogle ScholarCrossref
Antman  EMCohen  MBernink  PJLM  et al.  The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.  JAMA. 2000;284835- 842PubMedGoogle ScholarCrossref
Bertrand  MESimoons  MLFox  KA  et al.  Management of acute coronary syndromes: acute coronary syndromes without persistent ST segment elevation: recommendations of the Task Force of the European Society of Cardiology.  Eur Heart J. 2000;211406- 1432PubMedGoogle ScholarCrossref
Collinson  JFlather  MDFox  KA  et al.  Clinical outcomes, risk stratification and practice patterns of unstable angina and myocardial infarction without ST elevation: Prospective Registry of Acute Ischaemic Syndromes in the UK (PRAIS-UK).  Eur Heart J. 2000;211450- 1457PubMedGoogle ScholarCrossref
Lee  KLWoodlief  LHTopol  EJ  et al. for the GUSTO-I Investigators, Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction: results from an international trial of 41 021 patients.  Circulation. 1995;911659- 1668PubMedGoogle ScholarCrossref
Morrow  DAAntman  EMCharlesworth  A  et al.  TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial substudy.  Circulation. 2000;1022031- 2037PubMedGoogle ScholarCrossref
Morrow  DAAntman  EMGiugliano  RP  et al.  A simple risk index for rapid initial triage of patients with ST-elevation myocardial infarction: an InTIME II substudy.  Lancet. 2001;3581571- 1575PubMedGoogle ScholarCrossref
Krumholz  HMChen  JWang  YRadford  MJChen  YTMarciniak  TA Comparing AMI mortality among hospitals in patients 65 years of age and older: evaluating methods of risk adjustment.  Circulation. 1999;992986- 2992PubMedGoogle ScholarCrossref
Boersma  EPieper  KSSteyerberg  EW  et al. for the PURSUIT Investigators, Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation: results from an international trial of 9461 patients.  Circulation. 2000;1012557- 2567PubMedGoogle ScholarCrossref
Savonitto  SArdissino  DGranger  CB  et al.  Prognostic value of the admission electrocardiogram in acute coronary syndromes.  JAMA. 1999;281707- 713PubMedGoogle ScholarCrossref
Lindahl  BToss  HSiegbahn  AVenge  PWallentin  Lfor the FRISC Study Group, Markers of myocardial damage and inflammation in relation to long-term mortality in unstable coronary artery disease: Fragmin during Instability in Coronary Artery Disease.  N Engl J Med. 2000;3431139- 1147PubMedGoogle ScholarCrossref
Jollis  JG Measuring the effectiveness of medical care delivery.  J Am Coll Cardiol. 2001;37998- 1000PubMedGoogle ScholarCrossref
The GRACE Investigators, GRACE: a multinational registry of patients hospitalized with acute coronary syndromes.  Am Heart J. 2001;141190- 199PubMedGoogle ScholarCrossref
Tunstall Pedoe  HKuulasmaa  KAmouyel  P  et al.  Myocardial infarction and coronary deaths in the World Health Organization MONICA Project: registration procedures, event rates and case-fatality rates in 38 populations from 21 countries in four continents.  Circulation. 1994;90583- 612Google ScholarCrossref
WHO MONICA project, Objectives and design.  Int J Epidemiol. 1989;18 (suppl 1) S29- S37Google ScholarCrossref
Schafer  JL Analysis of Incomplete Multivariate Data.  New York, NY Chapman & Hall1997;
Harrell  FE  Jr Predicting Outcomes: Applied Survival Analysis and Logistic Regression.  Charlottesville University of Virginia1998;
Efron  BTibshirani  R An Introduction to the Bootstrap.  New York, NY Chapman & Hall1993;
Not Available, SAS STAT User's Guide, Version 8.  Cary, NC SAS Institute1999;1903- 2042
MathSoft, S-Plus User's Manual, Version 3.4.  Seattle, Wash MathSort Inc1996;
Califf  RMWoodlief  LHHarrell  FE  Jr  et al. for the GUSTO-I Investigators, Selection of thrombolytic therapy for individual patients: development of a clinical model.  Am Heart J. 1997;133630- 639PubMedGoogle ScholarCrossref
The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb Investigators, A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes.  N Engl J Med. 1996;335775- 782PubMedGoogle ScholarCrossref
Muller  DWTopol  EJ Selection of patients with acute myocardial infarction for thrombolytic therapy.  Ann Intern Med. 1990;113949- 960PubMedGoogle ScholarCrossref
Morrow  DAAntman  EMParsons  L  et al.  Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3.  JAMA. 2001;2861356- 1359PubMedGoogle ScholarCrossref
Ohman  EMGranger  CBHarrington  RALee  KL Risk stratification and therapeutic decision making in acute coronary syndromes.  JAMA. 2000;284876- 878PubMedGoogle ScholarCrossref
The GUSTO Investigators, An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.  N Engl J Med. 1993;329673- 682PubMedGoogle ScholarCrossref
InTIME-II Investigators, Intravenous NPA for the Treatment of Infarcting Myocardium Early: InTIME-II, a double-blind comparison of single-bolus lanoteplase vs accelerated alteplase for the treatment of patients with acute myocardial infarction.  Eur Heart J. 2000;212005- 2013PubMedGoogle ScholarCrossref
Rao  VWeisel  RDButh  KJ  et al.  Coronary artery bypass grafting in patients with non–dialysis-dependent renal insufficiency.  Circulation. 1997;96 (9 suppl) II-38- II-43Google Scholar
Al Suwaidi  JReddan  DNWilliams  K  et al.  Prognostic implications of abnormalities in renal function in patients with acute coronary syndromes.  Circulation. 2002;106974- 980PubMedGoogle ScholarCrossref
Marchioli  RAvanzini  FBarzi  F  et al. on behalf of GISSI-Prevenzione Investigators F, Assessment of absolute risk of death after myocardial infarction by use of multiple-risk-factor assessment equations: GISSI-prevenzione mortality risk chart.  Eur Heart J. 2001;222085- 2103PubMedGoogle ScholarCrossref
Ohman  EMArmstrong  PWChristenson  RH  et al. for the GUSTO IIA Investigators, Cardiac troponin T levels for risk stratification in acute myocardial ischemia.  N Engl J Med. 1996;3351333- 1341PubMedGoogle ScholarCrossref
Heeschen  CHamm  CWBruemmer  JSimoons  MLfor the CAPTURE Investigators, Predictive value of C-reactive protein and troponin T in patients with unstable angina: a comparative analysis: Chimeric c7E3 Antiplatelet Therapy in Unstable Angina Refractory to Standard Treatment Trial.  J Am Coll Cardiol. 2000;351535- 1542PubMedGoogle ScholarCrossref
Hamm  CWHeeschen  CGoldmann  B  et al. for the c7E3 Fab Antiplatelet Therapy in Unstable Refractory Angina (CAPTURE) Study Investigators, Benefit of abciximab in patients with refractory unstable angina in relation to serum troponin T levels.  N Engl J Med. 1999;3401623- 1629PubMedGoogle ScholarCrossref
Lindmark  EDiderholm  EWallentin  LSiegbahn  A Relationship between interleukin 6 and mortality in patients with unstable coronary artery disease: effects of an early invasive or noninvasive strategy.  JAMA. 2001;2862107- 2113PubMedGoogle ScholarCrossref
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.