ABC | Volume 110, Nº1, January 2018

Original Article Cerqueira Junior et al GRACE Score in Octogenarians Arq Bras Cardiol. 2018; 110(1):24-29 Figure 1 – ROC curves of the GRACE Score for the prediction of in-hospital mortality in patients aged ≥ 80 years old versus < 80 years old with acute coronary syndromes. Area below the curve in very elderly was 0.86 (95% CI = 0.78 – 0.93), with no difference in relation to the value found in patients aged < 80 years old (statistic-C = 0.83; 95% CI = 0.75 – 0.91), with p = 0.69 in the comparison between both curves. 1.0 1.0 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0.0 1.0 0.8 0.6 0.4 0.2 0.0 0.0 1.0 0.8 0.6 0.4 0.2 0.0 1 – Specificity 1 – Specificity Sensitivity Age < 80 years old Age ≥ 80 years old Figure 2 – Calibration of the GRACE Score in the prediction of in-hospital mortality in patients aged ≥ 80 years old versus < 80 years old with acute coronary syndromes. The graphics represent the comparison between predicted and observed mortality, in quartiles of probability predicted by the GRACE Score. 14% 12% 10% 8% 6% 4% 2% 0% Quartile I Quartile II Quartile III Quartile IV Quartile I Quartile II Quartile III Quartile IV Mortality terciles predicted by GRACE Mortality terciles predicted by GRACE Age < 80 years old Age < 80 years old In-hospital mortality In-hospital mortality Predicted Observed Predicted Observed 50% 40% 30% 10% 0% 20% 0.4% 0.5% 0.8% 1.0% 1.0% 1.7% 7.1% 11.9% 1.7% 2.4% 3.5% 5.0% 7.0% 10.2% 22.8% 47.0% uncertainty of this age range, “very elderly” was defined in our method as people from 80 years of age on, when the occurrence of fragility and comorbidities become more prevalent. Our findings are in agreement with preliminary studies which evaluated the GRACE Score in very elderly, respectively, two European works (Portugal and Spain), and two Chinese ones. 12-15 Therefore, our results support the literature, being the first to compare the sample of very elderly with individuals aged less than 80 years old. That is, not only do we present an accurate score, but also the suggestion that there is no loss of accuracy. A risk-treatment paradox depending on age has been described in ACS, 11,12,16-19 that is, individuals with higher risk being treated in a more conservative way due to the fear of complications, while lower-risk and young individuals receive more aggressive treatment. The use of risk scores in elderly will potentially prevent this paradox, once it allows estimating greater magnitude of the benefit when more aggressive strategies are applied in patients with higher absolute risk derived from GRACE. On the other hand, it should be recognized that provided the mortality is an outcome resulting from cardiovascular 27