ABC | Volume 115, Nº2, August 2020

Short Editorial Short Editorial: Distinct Prognostic Competence between the Clinical and Anatomical Models in Acute Coronary Syndromes: Comparison by Type of Outcome Roberto Coury Pedrosa 1 Departamento de Cardiologia, Hospital Universitário Clementino Fraga Filho / Instituto do Coração Edson Saad - Universidade Federal do Rio de Janeiro, 1 Rio de Janeiro, RJ - Brazil Mailing Address: Roberto Coury Pedrosa • Departamento de Cardiologia, Hospital Universitário Clementino Fraga Filho / Instituto do Coração Edson Saad – UFRJ - Rua Prof. Rodolpho Paulo Rocco, 255. Postal Code 21941-913, Cidade Universitária, Rio de Janeiro, RJ - Brazil E-mail: coury@hucff.ufrj.br, Keywords Cardiovascular Diseases/mortality; Myocardial Infarction; Acute Coronary Syndrome; Public Health; Organizationa and Administration; Diagnostic Equipment; Risk Assessment; Percutaneous Coronary Intervention. Cardiovascular events, especially acute myocardial infarction, are the main causes of death in Brazil. In some European countries (e.g., France, Portugal, Italy), the 30-day mortality rates due to infarction have declined in recent decades to as low as 3% to 5%. This reflects the organization of healthcare logistics, including pre-hospital care, unified protocols, training, central regulation, and commitment to care. 1 In Brazil, the 30-day mortality rates vary from 3% to 5% in advanced centers and 30% in those where care does not apply the recommended guidelines. 2 This disparity usually reflects a still deficient public healthcare system that lacks diagnostic flowcharts, institutional protocols, central regulation, or professionals who are able to interpret the diagnosis for infarction using an electrocardiogram (ECG). Unfortunately, we still find that many centers lack equipment in emergency sectors (defibrillator, intubation materials, ventilators, electrocardiographs, vasoactive drugs, cardiac monitors, temporary pacemakers, and fibrinolytic drugs) and coronary units, as well as the lack of qualified professionals to provide the best treatment. The recognition that acute coronary syndromes (ACS) constitute a heterogeneous disease in relation to prognosis was fundamental for the correct identification of individuals at higher risk, who require more intensive intervention. 3 It has been shown that not all patients with ACS belong to high or very high risk categories; there is a considerable percentage consisting of young patients without classic risk factors that can be adequately classified into intermediate or even low risk categories. Thus, it is important to identify those patients at higher risk who need more intensive treatment. Important clinical studies have contributed to the evolution of the approach to patients with ACS. 4-7 Currently, the emerging focus on the involvement of socioeconomic factors in cardiovascular risk has been constantly reported. 8 In this edition, Viana et al. 9 presented a study that compared the predictive capacity of the SYNTAX 10 and GRACE 11 scores for the prediction of non-fatal ischemic outcomes (infarction or refractory angina) and cardiovascular death during hospitalization of patients with ACS. They draw attention to the fact that recurrent non-fatal ischemic events represent the phenomenon of atherosclerotic plaque instability, while death after an ischemic event results from the severity of the insult and the patient’s resistance. The different pathophysiological nature of these types of events can cause the clinical and anatomical data to have different prognostic capacities, depending on the type of outcome. If this is true, the generalization of the prognostic value in relation to the “cardiovascular outcomes” would be compromised, making it necessary to individualize the prediction of each model for the type of outcome. Considering the justification of the scarcity of studies of this nature reported in the literature aimed at answering this question, the authors performed a serial study of consecutive cases between 2007 and 2014 in a tertiary hospital in Brazil, with objective of evaluating and comparing the prognostic value of clinical and anatomical data in relation to fatal and non-fatal outcomes in patients with ACS. Patients consecutively admitted with ACS submitted to coronary angiography were recruited. The SYNTAX score was used as an anatomical model and the GRACE score as a clinical model. Of the 365 analyzed patients, the mean age was 64 ± 14 years, with 58% male individuals, 19% of whom had ST-segment elevation myocardial infarction. Coronary heart disease with triple vessel or left main coronary artery disease was present in 36% of the sample. The median SYNTAX score was 9 (IQR = 2.5–20) and the median GRACE score was 117 (IQR = 90–144). When analyzing the risk tertiles predicted by the SYNTAX score, 81% of the patients had a low value (0 to 22), 10% showed an intermediate value (23 to 32) and only 8.5% had a high value (≥ 33). Regarding the GRACE score, 44% showed low risk (<109), 28% intermediate risk (110 to 139) and 29% high risk (≥ 140). Among the 365 individuals, there was an incidence of 4.4% of hospital death and 11% of non-fatal ischemic outcomes. For cardiovascular death, both scores - SYNTAX and GRACE - showed discriminatory capacity, with similar C-statistics: 0.80 (95% CI: 0.70–0.92) and 0.89 (95% CI 0.81– 0.96), respectively, with p = 0.19. As for non-fatal ischemic outcomes, the SYNTAX score had a predictive value (C-statistic = 0.64; 95% CI 0.55–0.73); however, the GRACE score did not show an association with this type of outcome (C-statistic) = 0.50; 95% CI: 0.40–0.61), with p = 0.027. In conclusion, the authors propose a further refinement in risk prediction in patients with acute coronary syndrome (ACS). Both the clinical paradigm (GRACE) and the anatomical one DOI: https://doi.org/10.36660/abc.20200758 226