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GRACE Score in Patients with COAD

Rothnie et al report on the performance of the GRACE score for acute coronary syndromes in patients with concomitant chronic obstructive airways disease (COAD or COPD). The data source was the Myocardial Ischemia National Audit Project (MINAP) registry. The authors found that the GRACE score underestimates the risk of acute coronary syndrome. Alternative models are explored (1.3 x GRACE estimate or MINAP registry derived GRACE). The authors also quantify the reclassification and discuss its implications.



To assess the accuracy of Global Registry of Acute Coronary Events (GRACE) scores in predicting mortality at 6 months for people with chronic obstructive
pulmonary disease (COPD) and to investigate how it might be improved.


Data were obtained on 481 849 patients with acute coronary syndrome admitted to UK hospitals between January 2003 and June 2013 from the Myocardial Ischaemia National Audit Project (MINAP) database. We compared risk of death between patients with COPD and those without COPD at 6 months,
adjusting for predicted risk of death. We then assessed whether several modifications improved the accuracy of the GRACE score for people with COPD.
Results The risk of death after adjusting for GRACE score predicted that risk of death was higher for patients with COPD than that for other patients (RR 1.29, 95% CI 1.28 to 1.33). Adding smoking into the GRACE score model did not improve accuracy for patients with COPD. Either adding COPD into the model (relative risk (RR) 1.00, 0.94 to 1.02) or multiplying the GRACE score by 1.3
resulted in better performance (RR 0.99, 0.96 to 1.01).


GRACE scores underestimate risk of death for people with COPD. A more accurate prediction of risk of death can be obtained by adding COPD into the GRACE score equation, or by multiplying the GRACE score predicted risk of death by 1.3 for people with COPD. This means that one third of patients with COPD currentlyclassified as low risk should be classified as moderate risk,
and could be considered for more aggressive early treatment after non-ST-segment elevation myocardial infarction or unstable angina.


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