BackgroundAcute coronary syndrome (ACS) is common in patients approaching the end-of-life (EoL), but these patients rarely receive palliative care. We compared the utility of a palliative care prognostic tool (Gold Standards Framework (GSF)) and the Global Registry of Acute Coronary Events (GRACE) score, to help identify patients approaching EoL.Methods and Findings172 unselected consecutive patients with confirmed ACS admitted over an eight-week period were assessed using prognostic tools and followed up for 12 months. GSF criteria identified 40 (23%) patients suitable for EoL care while GRACE identified 32 (19%) patients with ≥10% risk of death within 6 months. Patients meeting GSF criteria were older (p = 0.006), had more comorbidities (1.6±0.7 vs. 1.2±0.9, p = 0.007), more frequent hospitalisations before (p = 0.001) and after (0.0001) their index admission, and were more likely to die during follow-up (GSF+ 20% vs GSF- 7%, p = 0.03). GRACE score was predictive of 12-month mortality (C-statistic 0.75) and this was improved by the addition of previous hospital admissions and previous history of stroke (C-statistic 0.88).ConclusionsThis study has highlighted a potentially large number of ACS patients eligible for EoL care. GSF or GRACE could be used in the hospital setting to help identify these patients. GSF identifies ACS patients with more comorbidity and at increased risk of hospital readmission.
Introduction and aimsIdentifying patients with non-malignant disease in the hospital setting who might benefit from palliative and supportive care is challenging. There is little research in this area. A screening tool, the Scottish Palliative Care Indicator Tool (SPICT) was developed to help identify acute cardiac patients who might benefit from supportive/palliative care. We aimed to compare this new tool with the Gold Standards Framework Prognostic Indicator Guide (GSF-PIG)and two clinical prognostic scores currently used in hospital practice (GRACE and Seattle).MethodsConsecutive patients admitted to a cardiology ward with acute coronary syndrome (ACS) and acute heart failure (AHF) over a 4 week period were identified. Data for SPICT, GSF-PIG, GRACE (estimated 6 month% mortality) and Seattle scores (estimated 12 month% mortality) were obtained from patient records and by interviews with hospital staff.ResultsACS (78)AHF (16)% meeting criteriaMean GRACE score(% (SD))% meeting criteriaMean Seattle score (% (SD))SPICT negative92.310.0 (9.9)75.013.2 (8.2)SPICT positive7.720.0 (12.4)25.013.3 (7.3)p value(t test)p=0.022p=0.985GSF negative84.49.5 (9.8)37.512.3 (11.6)GSF positive15.617.0 (11.3)62.513.7 (4.9)p value(t test)p=0.019p=0.745ConclusionsSPICT and GSF identified ACS patients with significantly higher risk of death within 6 months of discharge. Neither prognostic tool appeared to predict Seattle score mortality in patients with AHF. SPICT and GSF have equivalent predictive utility in identifying acute cardiac patients nearing end-of life.
Introduction and aimsDue to the variable illness trajectory and uncertain prognosis, most patients with advanced heart disease fail to receive adequate end-of-life care. The Gold Standards Framework (GSF) has been used in primary care to identify such patients. We assessed its utility in patients presenting in the acute hospital setting with acute coronary syndrome (ACS).MethodsConsecutive patients with ACS admitted to an acute cardiology unit, over two separate 4 week periods, were included. Data were collected from patient notes and interviews with doctors. Patients were assessed using GSF and a clinical prognostic score (Global Registry of Acute Coronary Events, GRACE). All patients were followed-up for 1 year.Results168 patients were included. 40 (24%) patients were identified under the GSF as being in the last year of life due to their heart disease. Compared with GSF negative patients, GSF positive patients had a significantly higher GRACE score (13.9 vs 8.3, p=0.002). The GRACE score of patients who died within 6 months was significantly higher than those who survived (20.2 vs 9.27, p=0.008). GSF poorly predicted 6 month mortality (sensitivity 17%) but was strongly predictive of all-cause readmission during follow-up (p=0.000001).ConclusionGSF may be useful in predicting readmissions in ACS patients but is poor at predicting mortality. Combining GSF criteria with GRACE may guide secondary care clinicians in identifying ACS patients who may benefit from end of life care.
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