Background: We hypothesize that the discriminative performance of GRACE, ACHTUNG-Rule,
CHADS2 or CHA2DS2-VASc may be lower in
patients with a Myocardial Infarction (MI) and concurrent atrial fibrillation
(AF), as none of these scores seem able to fully capture both atherothrombotic/thromboembolic
risks. This study aims to evaluate the mid-term prognostic performance of these
algorithms in patients with these two conditions and to analyze the utility of a
score combining GRACE and CHA2DS2-VASc.
retrospective single-centre cohort study including 1852 patients admitted with a MI. We tested the prognostic
performance of the aforementioned risk stratification schemes in patients with
vs. without AF at admission or during hospitalization. Primary endpoints: a) total all-cause
mortality, comprising intrahospital and post-discharge all-cause
mortality; b) intrahospital all-cause mortality and c) all-cause mortality
during follow-up. Furthermore, all three versions of the ACHTUNG-Rule were
directly compared to their equivalent GRACE score versions, and a new score,
entitled GRACE-CHA2DS2-VASc, was developed and compared
Results: The mid-term prognostic performance of all scores was considerably lower in
patients with AF, corroborating our hypothesis. The ACHTUNG-Rule seemed
superior to GRACE in the prediction of post-discharge (AUC 0.790±0.032 vs.
0.685±0.038, p=0.079; integrated discrimination improvement index [IDI] of
0.166 and relative IDI of 83.7%) and total mortality (0.762±0.031 vs.
0.712±0.033, p=0.144; IDI of 0.042, relative IDI of 11.7%), but its performance
decreased in those with AF as well. GRACE-CHA2DS2-VASc
was only marginally superior to GRACE in discriminative performance, but
detected truly low- (CHA2DS2-VASc <2; total mortality
0%) and high-risk patients (GRACE high-risk stratum, and CHA2DS2-VASc
>4; total mortality 44.3%) with considerable efficacy.
Conclusions: In patients with MI and concurrent AF, the GRACE, CHADS2 and CHA2DS2-VASc
scores seemed less accurate in the prediction of all-cause mortality. A
hypothetic GRACE-CHA2DS2-VASc score or the recently
developed ACHTUNG-Rule may eventually provide a more rigorous approach to risk
stratification in this high-risk setting.
Credits: Sérgio Barra; Rui Providência; Luís Paiva; Inês Almeida; Francisca Caetano; Paulo Dinis; António Leitão Marques