ABC | Volume 110, Nº1, January 2018

Original Article Prognostic Accuracy of the GRACE Score in Octogenarians and Nonagenarians with Acute Coronary Syndromes Antonio Mauricio dos Santos Cerqueira Junior, 1 Luisa Gondim dos Santos Pereira, 1 Thiago Menezes Barbosa de Souza, 1 Vitor Calixto de Almeida Correia, 1 Felipe Kalil Beirão Alexandre, 2 Gabriella Sant’Ana Sodré, 1 Jessica Gonzalez Suerdieck, 1 Felipe Ferreira, 1 Marcia Maria Noya Rabelo, 2 Luis Cláudio Lemos Correia 1,2 Escola Bahiana de Medicina e Saúde Pública; 1 Hospital São Rafael, Fundação Monte Tabor, 2 Salvador, BA – Brazil Mailing Address: Luís Cláudio Lemos Correia • Av. Princesa Leopoldina, 19/402. Postal Code 40150-080, Graça, Salvador, BA – Brazil E-mail: lccorreia@cardiol.br , lccorreia@terra.com.br Manuscript received March 06, 2017; revised manuscript July 07, 2017; accepted July 07, 2017. DOI: 10.5935/abc.20170175 Abstract Background: The GRACE Score was derived and validated from a cohort in which octogenarians and nonagenarians were poorly represented. Objective: To test the accuracy of the GRACE score in predicting in-hospital mortality of very elderly individuals with acute coronary syndromes (ACS). Methods: Prospective observational study conducted in the intensive coronary care unit of a tertiary center from September 2011 to August 2016. Patients consecutively admitted due to ACS were selected, and the very elderly group was defined by age ≥ 80 years. The GRACE Score was based on admission data and its accuracy was tested regarding prediction of in-hospital death. Statistical significance was defined by p value < 0,05. Results: A total of 994 individualswas studied, 57%male, 77%with non-ST elevationmyocardial infarction and 173 (17%) very elderly patients. The mean age of the sample was 65 ± 13 years, and the mean age of very elderly patients subgroup was 85 ± 3.7 years. The C-statistics of the GRACE Score in very elderly patients was 0.86 (95% CI = 0.78 – 0.93), with no difference when compared to the value for younger individuals 0.83 (95% CI = 0.75 – 0.91), with p = 0.69. The calibration of the score in very elderly patients was described by χ 2 test of Hosmer-Lemeshow = 2.2 (p = 0.98), while the remaining patients presented χ 2 = 9.0 (p = 0.35). Logistic regression analysis for death prediction did not show interaction between GRACE Score and variable of very elderly patients (p = 0.25). Conclusion: The GRACE Score in very elderly patients is accurate in predicting in-hospital ACS mortality, similarly to younger patients. (Arq Bras Cardiol. 2018; 110(1):24-29) Keywords: Acute Coronary Syndrome / mortality; Aged 80 years and over; Prognosis; Risk Assessment; Data Reliability. Introduction Acute coronary syndromes (ACS) are an important cause of in-hospital death in the Western world. 1,2 Due to the great heterogeneity of clinical and prognostic presentation of ACS, risk stratification is essential so that more aggressive actions can be adopted toward patients at higher risk. In this context, theGRACE Score is the most accurate predictor of hospital death in ACS. 3-6 However, the derivation and validation of the GRACE Score were conducted in a low representative cohort of octogenarians or nonagenarians. 3,4 Provided that old age is an important risk indicator, which accumulates aspects of constitutional fragility and higher prevalence of comorbidities, there are reasons to question whether the GRACE Score has modified accuracy in very elderly people. The present study aimed to test the hypothesis that the GRACE Score has a satisfactory accuracy in predicting in-hospital death when applied to octogenarian and nonagenarian individuals with ACS. The cohort of Prospective Registry of Acute Coronary Syndromes was used in order to answer this question, comparing the discriminatory capacity and calibration of GRACE among individuals aged ≥ 80 years old versus < 80 years old. Methods Sample selection Patients consecutively admitted to the coronary unit of the tertiary hospital between September 2011 and August 2016, due to suspected ACS (unstable angina and myocardial infarction) were screened for the study. The inclusion criteria were precordial discomfort within 48 hours prior to admission associated with at least one of the following criteria: 1. Positive myocardial necrosis marker, defined by troponin T ≥ 0.01 ug/L or troponin I > 0.034 g/L, which corresponds to values above 99 percent; 7 24