ABC | Volume 113, Nº1, July 2019

Original Article Gil et al Risks scores in acute coronary syndromes Arq Bras Cardiol. 2019; 113(1):20-30 However, the ProACS and ACTION Registry–GWTG presented with a HL test p-value of 0.001 and < 0.001, respectively, indicating model lack of fit. Regarding all-cause mortality and non-fatal ACS at one-year follow-up, all RS underperformed, with c-statistics consistently under 0.700. ProACS was only statistically superior to the C-ACS RS, which showed particularly poor discriminatory accuracy (c-statistic 0.550). Most RS revealed model lack of fit. Discussion Development of risks scores in acute coronary syndromes Advances in medical therapy and the development of invasive strategies has had a significant impact on prognosis in ACS. 1-3 Risk stratification has become an essential part of the establishment of a personalized treatment strategy in patients with ACS, weighing the risks and benefits of an early invasive approach. 1,2 In STEMI patients, primary percutaneous coronary intervention is the standard approach, thus early risk stratification is less important. 1,3 However, risk stratification in STEMI still plays an important role in predicting which patients are at higher risk for mortality or recurrent ACS, thus warranting a more aggressive medical therapy. 1 Patients with NSTEMI/UA represent a much more heterogeneous group, Continuation Medication and therapeutic strategy during hospitalization iRAAS 59.5% 83.7% < 0.001 78.8% 84.3% 0.090 Beta-blocker 34.2% 61.6% < 0.001 48.7% 63.3% 0.002 Nitrates 39.2% 31.9% 0.392 28.3% 23.3% 0.082 Antiarrhythmics 21.8% 13.0% 0.038 19.5% 12.2% 0.025 Inotropes 53.2% 9.0% < 0.001 10.6% 8.8% 0.316 Invasive strategy 54.0% 80.6% < 0.001 56.2% 83.4% 0.001 Left Ventricular Ejection Fraction, % 40.7 ± 15.2 54.1 ± 12.0 < 0.001 50.1 ± 12.6 54.7 ± 11.8 0.001 Hospitalization days 5.6 ± 6 7.42 ± 4.8 < 0.001 9.2 ± 5.0 7.2 ± 4.8 < 0.001 Risk Scores TIMI for STEMI 7 (5-9) 4 (2-6) < 0.001 7 (4-8) 4 (2-6) < 0.001 PURSUIT 15 (14-16) 12 (10-14) < 0.001 14 (12-16) 12 (10-14) < 0.001 SRI 38.9 (28.7-54.8) 25.2 (17.5 – 35.8) < 0 .001 36.2 (23.3-48.5 ) 24.2 (17.0-33.8) < 0.001 GRACE 217 (195-249) 140 (109-171) < 0.001 170 (142-194) 137 (107-167) < 0.001 EMMACE 0.36 (0.23-0.55) 0.14 (0.06 – 0.31) < 0 .001 0.29 (0.13-0.48 ) 0.13 (0.05-0.28) < 0.001 CHA 2 DS 2 -VASc-HS 4 (3-5) 4.28 ± 1.6 4 (3-5) 3.73 ± 1.6 0.001 4 (3-5) 4.36 ± 1.8 4 (3-5) 3.7 ± 1.6 < 0.001 ACTION Registry–GWTG 58.5 (51-66) 33 (27 -42) < 0.001 42 (33-50) 32 (26-41) < 0.001 C-ACS 1 (1-2) 1 (1-1) < 0.001 1 (1-2) 1 (1-1) 0.029 ProACS 5 (4-6) 2 (1- 3) < 0.001 3 (2-4) 2 (1-3) < 0.001 ACS: acute coronary syndrome; STEMI: ST-segment elevation myocardial infarction; NSTEMI/UA: non-ST-segment elevation myocardial infarction/ unstable angina; iRAAS: Renin angiotensin aldosterone system inhibitors; TIMI: Thrombolysis in Myocardial Infarction; PURSUIT: Platelet glycoprotein IIb/IIa in Unstable angina: Receptor Suppression Using Integrilin Therapy; Simple Risk Index; GRACE: Global Registry of Acute Coronary Events; EMMACE: Evaluation of the Methods and Management of Acute Coronary Events; C-ACS: Canada Acute Coronary Syndrome. P-values obtained by the Mann-Whitney test for numerical variables and by chi-square or Fisher’s exact test for categorical variables. with early risk stratification playing a more central role in deciding which patients benefit more from an early invasive strategy. 2-5,13 Several risk score have been formulated in the last 20 years, attempting to best predict which patients are at a higher risk for a worse outcome. 3-13 The simple TIMI risk score for STEMI 7 and for NSTEMI/UA 13 was developed from large clinical trials, with controlled and selected populations. The TIMI RS for STEMI 7 was formulated from the InTIME II trial which enrolled a total of 15,078 patients, all were candidates for fibrinolytic therapy. This risk score performed well at identifying high risk patients (c-statistics for predicting in-hospital mortality and in the first 24 hours after admission was 0.784 and 0.813, respectively). 7 The TIMI for NSTEMI/UA was developed using the database of the TIMI 11B trial, with a total of 3910 patients, satisfactorily predicting all-cause mortality, myocardial infarction or urgent revascularization at 14 days. 13 However, since it underperformed in our population, the authors decided not to use the RS. The SRI risk score was also calculated from the InTIME trial, using a cohort of 13,253 STEMI patients. This risk score satisfactorily predicted in-hospital death (c-statistic 0.79). The PURSUIT risk score was developed through the Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy trial using a NSTEMI population of 9,461 patients, with a 24