Predicting mortality after acute coronary syndromes in people with chronic obstructive pulmonary disease

Abstract

Objective: To assess the accuracy of Global Registry of Acute Coronary Events (GRACE) scores in predicting mortality at 6 months for people with chronic obstructive pulmonary disease (COPD) and to investigate how it might be improved.

Methods: Data were obtained on 481 849 patients with acute coronary syndrome admitted to UK hospitals between January 2003 and June 2013 from the Myocardial Ischaemia National Audit Project (MINAP) database. We compared risk of death between patients with COPD and those without COPD at 6 months, adjusting for predicted risk of death. We then assessed whether several modifications improved the accuracy of the GRACE score for people with COPD.

Results: The risk of death after adjusting for GRACE score predicted that risk of death was higher for patients with COPD than that for other patients (RR 1.29, 95% CI 1.28 to 1.33). Adding smoking into the GRACE score model did not improve accuracy for patients with COPD. Either adding COPD into the model (relative risk (RR) 1.00, 0.94 to 1.02) or multiplying the GRACE score by 1.3 resulted in better performance (RR 0.99, 0.96 to 1.01).

Conclusions: GRACE scores underestimate risk of death for people with COPD. A more accurate prediction of risk of death can be obtained by adding COPD into the GRACE score equation, or by multiplying the GRACE score predicted risk of death by 1.3 for people with COPD. This means that one third of patients with COPD currently classified as low risk should be classified as moderate risk, and could be considered for more aggressive early treatment after non-ST-segment elevation myocardial infarction or unstable angina.

Figure 1

Flow of participants through the study. ACS, acute coronary syndromes; COPD, chronic obstructive pulmonary disease; MINAP, Myocardial Ischaemia National Audit Project; non-STEMI, non-ST-elevation myocardial infarction; OAD, obstructive airway disease; ONS, Office of National Statistics.

Figure 2

Proportion of deaths occurring in patients with COPD in each decile of predicted risk for the normal GRACE model, the GRACE model multiplied by 1.3 for patients with COPD, and the MINAP-derived model including COPD. COPD, chronic obstructive pulmonary disease; GRACE, Global Registry of Acute Coronary Events; MINAP, Myocardial Ischaemia National Audit Project.