NSTEMI, What Can We Learn from GRACE

Risk and TIMI Risk

SURYONO, MD
 Acute Coronary Syndrome

• An ischemic myocardial event that is a direct consequence of

atherosclerotic plaque activation and/or local thrombus formation

• May be divided into that association with ST segment elevation and

that associated with ST segment depression

• Spectrum: UANSTEMISTEMI
 Hospital Admissions for ACS:
Unstable Angina/NSTEMI vs STEMI

Acute Coronary Syndrome

2.3 Million Hospital Admissions ACS

UA/NSTEMI STEMI

1.43 million 829,000

Admissions per Year Admissions per Year
Sodnick EJ, et al. National Center for Health Statistics. 2001.
 Unstable Angina:
Guideline Definition

Three principal presentations:

• Rest angina >20 minutes in last week

• New onset angina in last 2 months
• Increasing angina - increased frequency, duration, or severity
 Risk Stratification
• Based on validated risk prediction models
that include the most important predictors
of outcomes
• Certain patients that are such high risk
that they need not be risk stratified:
– cardiogenic shock
– overt CHF or LV dysfunction
– Rest angina despite max medical therapy
– Hemodynamic instability, mechanical
complications
– Unstable ventricular arrythmias
Clinical Indicators of Increased Risk in UA/NSTEMI
 Prognosis: Early Risk Stratification
Recommendations COR LOE
Additional troponin levels should be obtained beyond 6 hours
after symptom onset (see Section 3.4, Class I, #3
recommendation if time of symptom onset is unclear) in
patients with normal troponin levels on serial examination I A
when changes on ECG and/or clinical presentation confer an
intermediate or high index of suspicion for ACS.
Risk scores should be used to assess prognosis in patients
I A
with NSTE-ACS.
Risk-stratification models can be useful in management. IIa B
 1. TIMI Risk Score for UA/NSTEMI
• Age >65 years
• 3 or more CAD risk factors
– HTN, DM, Hyperlipidemia, smoking, +
family hx
• Prior CAD (cath stenosis>50%)
• ASA in last 7 days
• 2 or more anginal events in last 24
hours
• ST deviation on admission ECG
• Elevated cardiac markers
(troponin/CK-MB) Antman EM, et al. JAMA.. 2000;284:835-842.
 The TIMI Risk Score and
Incidence of Adverse Ischemic
Events in Patients with NSTEMI

Urgent Revascularization
50

14 day Death, MI, or

40.9
40

30 26.2
19.9

(%)
20 13.2
10
8.3
4.7
0
0/1 2 3 4 5 6/7
# of Risk Factors
Antman EM, et al. JAMA.. 2000;284:835-842.
Download at: http://www.timi.org/
 2. GRACE Risk Calculator
• Estimates the risk of in-hospital and six-month mortality
among all patients with an ACS

• This end point is different from the composite end point in

the TIMI risk score of all-cause mortality, new or recurrent
MI, or severe recurrent ischemia requiring
revascularization

• While the GRACE prediction model is well validated and its

use is recommended by multiple guideline organizations,
its complexity makes it somewhat difficult to use in some
clinical settings
GRACE Risk Calculator – 6 month mortality after ACS

Eagle et al. JAMA 2004;291:2727–33.

GRACE Risk Calculator – 6 month mortality after ACS

55

32%
14
14
11
3

15
112
4%

Eagle et al. JAMA 2004;291:2727–33.

Download at: http://www.outcomes-umassmed.org/grace
GRACE Score Provide a Mortality Risk Stratification for NSTEMI

Setting Score Risk Mortality

In hospital < 109 Low < 1%
In hospital 109 – 140 Intermediate 1 – 3%
In hospital > 140 High > 3%
6 months < 89 Low < 3%
6 months 89 – 118 Intermediate 3 – 8%
6 months > 118 High > 8%
 Comparison of GRACE Risk and TIMI Risk
GRACE TIMI
Complexity of variables Complex Simple
Ability to predict : inhospital ++ +
mortality, need of
revascularization/interventional
procedure
Prognostic value ++ +
Variables included : heart rate, + -
plasma creatinine, Killip
classification
Age Variable in ‘Several Strata’ form + -
Clinical use Seldom often
Correlation with SS Correlated-Significant not correlated
Ability to predict : short/long term ++ -
mortality, severity&extent of CAD
Factors Associated With Appropriate Selection of Early Invasive
Strategy or Ischemia-Guided Strategy in Patients With NSTEMI
Refractory angina
Immediate Signs or symptoms of HF or new or worsening mitral
invasive regurgitation
(within 2 h) Hemodynamic instability
Recurrent angina or ischemia at rest or with low-level
activities despite intensive medical therapy
Sustained VT or VF

Ischemia- Low-risk score (e.g., TIMI [0 or 1], GRACE [<109])

guided Low-risk Tn-negative female patients
strategy Patient or clinician preference in the absence of high-risk
features
Factors Associated With Appropriate Selection of Early Invasive
Strategy or Ischemia-Guided Strategy in Patients With NSTEMI
Early None of the above, but GRACE risk score >140
invasive Temporal change in Tn
(within New or presumably new ST depression
24 h)

Delayed None of the above but diabetes mellitus

invasive Renal insufficiency (GFR <60 mL/min/1.73 m²)
(within Reduced LV systolic function (EF <0.40)
2572 h) Early postinfarction angina
PCI within 6 mo
Prior CABG
GRACE risk score 109–140; TIMI score ≥2
Algorithm for management of NSTEMI
 Summary
All patients with NSTEMI should be early stratified

TIMI risk score can be widely applied

GRACE risk score is superior at long term follow up in high risk score

Generally, the higher the risk is (according to TIMI/GRACE), the higher the mortality

Use of the TIMI risk score/GRACE Score helps identify strategy of theraphy whether
invasive or non invasive

Improved adherence to clinical adjustmend results and guidelines in improved

outcomes
THANK YOU