![]() ![]() Notably there was no mortality benefit with an early invasive approach, and this strategy was associated with a 2% absolute increase in protocol-defined bleeding. This benefit was most apparent in patients presenting with ST segment changes, troponin elevation at presentation, and patients with intermediate or high TIMI risk scores (3 or greater). TACTICS-TIMI 18 demonstrated a clear reduction in major adverse cardiovascular events with an early invasive approach, driven primarily by a reduction in nonfatal MI and recurrent ischemia. Overall, 60% of patients in the early invasive arm underwent revascularization versus 36% in the conservative arm. In the conservative strategy, patients underwent coronary angiography only if noninvasive stress testing was positive or there was failure of medical therapy (prolonged angina at rest, hemodynamic instability, recurrent angina or MI). In the early invasive strategy arm, 97% of patients underwent coronary angiography a median of 22 hours (all within 48 hours) after presentation with PCI or CABG to culprit lesions. The 2001 Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy – Thrombolysis in Myocardial Infarction 18 (TACTICS-TIMI 18) trial randomized 2220 patients to either a protocolized early invasive strategy versus a delayed selectively invasive strategy with each arm receiving the IIb/IIIa inhibitor tirofiban. Important prognostic factors like anaemia, C-reactive protein, extent of CAD, left ventricular ejection fraction (LVEF), and so on, are not included in any of the above systems.Unlike patients presenting with STEMI in which there is a clear mortality benefit to emergent coronary angiography and PCI, it is less clear whether patients with non-STEMI ACS (unstable angina or non-ST segment elevation MI) also benefit from routine early angiography and intervention. Each of these scoring systems has avoided some factors. Nonetheless, the authors should be congratulated for an excellent study and this should encourage other hospitals to adopt risk scoring system while dealing with patients of ACS.ĭespite the availability of these above composite risk scores one cannot get away from the fact that there is a need for more inclusive risk scoring systems. ![]() Also, the impact of revascularisation on prognosis and correlation with GRACE score is not clear. There is no information on whether ejection fraction (EF) has any correlation with GRACE score. Is it the financial capacity of the patients? A slightly greater number of patients have undergone coronary angiography among patients with lower GRACE score. The exact basis for choosing patients for coronary angiogram is not clear. They also found a good correlation between GRACE score and extent of coronary artery disease (CAD) at angiography. A GRACE risk score of 217 has emerged as a good cut-off point of risk stratification. All other variables of GRACE risk score have shown excellent correlation. The increase in heart rate tended to show a correlation with risk but it was not statistically significant. Only one patient had cardiac arrest at presentation, hence this factor could not be assessed. Their study has clearly validated most of the risk markers of GRACE score. They have applied GRACE risk score to a cohort of patients which included ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). This group of authors has well established credentials for clinical research. John's Medical College and Hospital is a large tertiary care hospital which caters predominantly to low and middle-class population. John's Medical College and Hospital, Bengaluru have presented the clinical data of 235 patients of ACS and attempted validation of GRACE risk score. In this issue of Indian Heart Journal, Prabhudesai et al. There was a significant interaction between the benefit of myocardial revascularisation during initial hospitalisation and the extent of risk evaluated by GRACE and PURSUIT scores. They have clearly demonstrated that GRACE score was the best in predicting the risk of death or MI at 1 year after admission. 7 They have looked at short-term as well as long-term mortality. from Portugal have applied the three scoring systems TIMI, GRACE, and PURSUIT to the same group of 460 patients admitted to a single centre. In an interesting study published in European Heart Journal, Gonçalves et al. ACS: acute coronary syndrome, BP: blood pressure, CCS: Canadian Cardiovascular Society, ECG: electrocardiogram, GRACE: Global Registry of Acute Coronary Events, TIMI: thrombolysis in myocardial infarction. ![]()
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