Comparison of Mortality Prediction by the GRACE Score, Multiple Biomarkers, and Their Combination in All-comer Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Abstract

Objective This study examined the ability of a combination of biomarkers, including N-terminal pro-B-type natriuretic peptide (N-BNP) and high-sensitivity C-reactive protein (hs-CRP), to better predict mortality than the Global Registry of Acute Coronary Events (GRACE) score in acute myocardial infarction (AMI) patients who received primary percutaneous coronary intervention (PPCI). Methods The in-hospital mortality in 754 all-comer patients with AMI who underwent successful PPCI over 8 years was examined. A receiver operating characteristic (ROC) analysis was performed to determine the in-hospital mortality in a single center. A logistic regression analysis was used to compare the predictive accuracy of the GRACE score and biomarkers. The incremental predictive value of those biomarkers beyond the GRACE score was also examined. Results The mean age was 66±13 years old, and 609 patients with ST-elevated AMI (80.8%) were included. The in-hospital mortality was 6.8%. The GRACE score (in-hospital survivor/non-survivor: 106±33/161±32; p<0.05,) and N-BNP (in-hospital survivor/non-survivor: 2,458±7,058/8,880±1,1331 pg/mL; p<0.05) were significantly lower in survivors than in non-survivors. The area under the ROC curve (AUC) of in-hospital mortality of the GRACE score was significantly higher than that of the dual-biomarker combination (0.868/0.720; p<0.05). The AUC of the combination of the GRACE score and dual-biomarkers was not significantly higher than that of the GRACE score alone (0.870/0.868; p=0.747). Conclusion The measurement of representative cardiovascular biomarkers did not provide any additional benefit for mortality prediction beyond the GRACE score in AMI patients who received PPCI.

Keywords: acute myocardial infarction; cardiovascular biomarker; the GRACE score.

Figure 1.

ROC curves for the prediction of in-hospital mortality in patients with AMI. (a) ROC curve comparing the GRACE score with each biomarker for the in-hospital mortality. (b) ROC curve comparing the GRACE score with the multi-biomarker combination of N-BNP, TnT, and hs-CRP. (c) ROC curve comparing the GRACE score with the combination of N-BNP plus the GRACE score. (d) ROC curve comparing the GRACE score with the combination of the dual-biomarker parameter (N-BNP, TnT, hs-CRP) plus the GRACE score. AMI: acute myocardial infarction, GRACE: Global Registry of Acute Coronary Events, hs-CRP: high-sensitivity C-reactive protein, N-BNP: N-terminal pro-B-type natriuretic peptide, ROC: receiver operating characteristic, TnT: troponin-T, Dual BM: combination of N-BNP, TnT, and hs-CRP, GRACE+N-BNP: combination of GRACE and N-BNP, GRACE+Dual BM: combination of GRACE and Dual BM

Figure 2.

AUC comparing the prediction of in-hospital mortality in patients with AMI between the GRACE score and each biomarker, the dual-biomarker parameter, the combination of N-BNP plus GRACE score, and the combination of the multi-biomarker parameter plus the GRACE score. AMI: acute myocardial infarction, AUC: area under the receiver operating characteristic curve, GRACE: Global Registry of Acute Coronary Events, hs-CRP: high-sensitivity C-reactive protein, dual-biomarker: combination of N-BNP, and hs-CRP, N-BNP: N-terminal pro-B-type natriuretic peptide, Statistically significant difference (p<0.05), Statistically non-significant difference