ABC | Volume 113, Nº1, July 2019

Original Article Application of Risks Scores in Acute Coronary Syndromes. How Does ProACS Hold Up Against Other Risks Scores? Júlio Gil, 1 L uís Abreu, 1 Hugo Antunes, 1 M aria Luísa Gonçalves, 1 Maria Inês Pires, 1 Luís Ferreira dos Santos, 1 Carla Henriques, 2,3 Ana Matos, 2 José Costa Cabral, 1 Jorge Oliveira Santos 1 Hospital de São Teotónio, 1 Viseu – Portugal Instituto Politécnico de Viseu e CI&DETS, 2 Viseu – Portugal Centro de Matemática da Universidade de Coimbra (CMUC), 3 Coimbra – Portugal Mailing Address: Júlio Gil • Hospital de São Teotónio - Av. Rei D. Duarte. 3504 509 – Viseu – Portugal Email: juliogilpereira@gmail.com Manuscript received July 26/07/2018, revised manuscript October 02, 2018, accepted October 10, 2018 DOI: 10.5935/abc.20190109 Abstract Background: Multiple risk scores (RS) are approved in the prediction of worse prognosis in acute coronary syndromes (ACS). Recently, the Portuguese Journal of Cardiology has proposed the ProACS RS. Objective: Application of several validated RS, as well as ProACS in patients, admitted for ACS. Evaluation of each RS’s performance in predicting in-hospital mortality and the occurrence of all-cause mortality or non-fatal ACS at one-year follow-up and compare them to the ProACS RS. Methods: A retrospective study of ACS was performed. The following RS were applied: GRACE, ACTION Registry- GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS and ProACS. ROC Curves were created to determine the predictive power for each RS and then were directly compared to ProACS. Results: The ProACS, ACTION Registry-GWTG and GRACE showed a c-statistics of 0.908, 0.904 and 0.890 for predicting in-hospital mortality, respectively, performing better in ST-segment elevation myocardial infarction patients. The other RS performed satisfactorily, with c-statistics over 0.750, apart from the CHA2DS2-VASc-HS and C-ACS which underperformed. All RS underperformed in predicting worse long-term prognosis revealing c-statistics under 0.700. Conclusion: ProACS is an easily obtained risk score for early stratification of in-hospital mortality. When evaluating all RS, the ProACS, ACTION Registry-GWTG and GRACE RS showed the best performance, demonstrating high capability of predicting a worse prognosis. ProACS was able to demonstrate statistically significant superiority when compared to almost all RS. Thus, the ProACS has showed that it is able to combine simplicity in the calculation of the score with good performance in predicting a worse prognosis. (Arq Bras Cardiol. 2019; 113(1):20-30) Keywords: Acute Coronary Syndrome/prognosis; ST Elevation Myocardial Infarction; Hospital Mortality, Risk Assessment/methods; Survival Rate/methods. Introduction Cardiovascular disease is the most common cause of death worldwide. 1,2 In the past three to four decades, studies have shown a significant reduction in acute and long-term mortality by acute coronary syndromes (ACS). 1-3 This is attributed to improvements in medical therapy and invasive strategies. 1-3 However, ACS represent a heterogeneous group, with varying risk of morbimortality. 1-4 Several risk stratification models have been developed to determine which patients carry a higher probability of worst outcome. 3-13 Early risk stratification is crucial to ensure a tailored approach to each individual patient, weighing both the risks and benefits of each treatment option. 1,2 Recently, there has been a systematic approach to risk assessment, with the creation of a myriad of risks scores (RS). 3‑13 Perhaps, the Global Registry of Acute Coronary Events (GRACE) Risk Score 6 is the most widely recognized RS in ACS. According to the most recent European guidelines, the GRACE risk score is recommended when stratifying risk in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction, and/or unstable angina (NSTEMI/UA). 1,2 However, there are several other known RS, such as: the Thrombolysis in Myocardial Infarction (TIMI) for STEMI; 7 the Platelet glycoprotein IIb/IIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT); 5 the Simple Risk Index (SRI); 8 the Evaluation of the Methods and Management of Acute Coronary Events (EMMACE); 9 and more recently, the Canada Acute Coronary Syndrome (C-ACS), 10 the CHA 2 DS 2 -VASc-HS score, 11 and the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry–GWTG. 12 In 2016, the Portuguese Journal of Cardiology published a new risk score, formulated using the Portuguese Registry on Acute Coronary Syndromes. The Portuguese Registry of Acute Coronary Syndromes was established in 2002, 14 20