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. 2019 Jul 16;8(14):e012433.
doi: 10.1161/JAHA.119.012433. Epub 2019 Jul 4.

Long-Term Risk Stratification of Patients Undergoing Coronary Angiography According to the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention

Barak Zafrir  1   2 , Salim Adawi  1   2 , Marah Khalaily  2 , Ronen Jaffe  1   2 , Amnon Eitan  1 , Ofra Barnett-Griness  3   4 , Walid Saliba  4   2
Affiliations

Long-Term Risk Stratification of Patients Undergoing Coronary Angiography According to the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention

Barak Zafrir et al. J Am Heart Assoc. .

Abstract

Background A risk score for secondary prevention after myocardial infarction (Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention [TRS2P]), based on 9 established clinical factors, was recently developed from the TRA 2°P- TIMI 50 (Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events) trial. We aimed to evaluate the performance of TRS 2P for predicting long-term outcomes in real-world patients presenting for coronary angiography. Methods and Results A retrospective analysis of 13 593 patients referred to angiography for the assessment or treatment of coronary disease was performed. Risk stratification for 10-year major adverse cardiovascular events was performed using the TRS 2P, divided into 6 categories (0 to ≥5 points), and in relation to the presenting coronary syndrome. All clinical variables, except prior coronary artery bypass grafting, were independent risk predictors. The annualized incidence rate of major adverse cardiovascular events increased in a graded manner with increasing TRS 2P, ranging from 1.65 to 16.6 per 100 person-years ( Ptrend<0.001). Compared with the lowest-risk group (risk indicators=0), the hazard ratios (95% CIs) for 10-year major adverse cardiovascular events were 1.60 (95% CI, 1.36-1.89), 2.58 (95% CI, 2.21-3.02), 4.31 (95% CI, 3.69-5.05), 6.43 (95% CI, 5.47-7.56), and 10.03 (95% CI, 8.52-11.81), in those with 1, 2, 3, 4 and ≥5 risk indicators, respectively. Risk gradation was consistent among individual clinical end points. TRS 2P showed reasonable discrimination with C-statistics of 0.693 for major adverse cardiovascular events and 0.758 for mortality. The graded relationship between the risk score and event rates was observed in both patients presenting with acute and nonacute coronary syndromes. Conclusions The use of TRS 2P, a simple risk score based on routinely collected variables, enables risk stratification in patients undergoing coronary angiography. Its predictive value was demonstrated in a real-world setting with long-term follow-up and regardless of the acuity of coronary presentation.

Keywords: acute coronary syndrome; cardiovascular outcomes; coronary angiography; risk score; risk stratification.

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Figures

Figure 1
Figure 1
Cumulative 10‐year incidence of major adverse cardiovascular events (MACEs; first occurrence of myocardial infarction, ischemic stroke, or all‐cause death) according to the number of risk indicators.
Figure 2
Figure 2
Hazard ratios for major adverse cardiovascular events (MACEs) according to presentation to coronary angiography. P for trend <0.0001 for each presentation. ACS indicates acute coronary syndrome; NSTEMI, non–ST‐segment–elevation myocardial infarction; STEMI, ST‐segment–elevation myocardial infarction; UAP, unstable angina pectoris.
Figure 3
Figure 3
A, Observed vs predicted 3‐year probability of major adverse cardiovascular events (MACEs) among risk categories. In A, the dashed line is the identity line. The solid line represents the regression line. For each dot, the bar represents 95% CI for the observed risk. B, Three‐year estimated MACE (myocardial infarction, ischemic stroke, or death, which was defined as all‐cause death in the current study [observed cohort] compared with cardiovascular death in the TRA2°P‐TIMI 50 [Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events] trial [predicted cohort]) rates among TRS2P categories in the study cohort compared with the TRA2°P‐TIMI 50 trial.
Figure 4
Figure 4
Three‐year estimated major adverse cardiovascular events (MACEs; myocardial infarction, ischemic stroke, or all‐cause death) cumulative incidence among Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2P) categories according to the 3 coronary presentations. ACS indicates acute coronary syndrome; NSTEMI, non–ST‐segment–elevation myocardial infarction; STEMI, ST‐segment–elevation myocardial infarction; UAP, unstable angina pectoris.
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