Prognostic impact of admission blood glucose for all-cause mortality in patients with acute coronary syndromes: added value on top of GRACE risk score

Abstract

Background: Abnormal glucose metabolism is a predictor of worse outcome after acute coronary syndrome (ACS). However, this parameter is not included in risk prediction scores, including GRACE risk score. We sought to evaluate whether the inclusion of blood glucose at admission in a model with GRACE risk score improves risk stratification. Methods: Study of consecutive patients included in a single centre registry of ACS. Our primary endpoint was the occurrence of all-cause mortality at one-year follow-up. The ability of the two logistic regression models (GRACE risk score alone and in combination with blood glucose) to predict death was analysed. Continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI), with corresponding 95% confidence intervals (CIs), were also calculated. Results: We included 2099 patients, with a mean age of 64 (SD=13) years, 69% males. In our sample, 55.1% presented with ST-segment elevation ACS and 13.1% in Killip class ≥ 2. Only 25% were known diabetic at admission. In-hospital mortality was 5.8% and 9.7% at one-year follow-up. The best cut-point for blood glucose was 160 mg/dl (sensitivity 62% and specificity 68%), and 35.2% of the patients had increased levels. This group was elderly, had more prevalence of cardiovascular risk factors, worse renal function and GRACE score as well as more frequently Killip class ≥2. Treatment was similar in both groups besides less frequent use of clopidogrel in high glycaemic patients. The hyperglycaemia group had higher one-year mortality (17.2% vs. 5.6%, p<0.001). Moreover, binary blood glucose remained a predictor of death independently of the GRACE risk score and the presence of diabetes (odds ratio (OR) 1.99, 95% CI 1.40–2.84, p<0.001). The inclusion of blood glucose, as a continuous variable, in a logistic regression model with GRACE score, increased the area under the ROC curve from 0.80 to 0.82 (p=0.018) as well as the goodness-of-fit and was associated with an improvement in both the NRI (37%) and the IDI (0.021), suggesting effective reclassification. Conclusions: A blood glucose level on admission ≥ 160 mg/dl is an independent predictor of mortality in medium-term follow-up. It offers an incremental predictive value when added to the GRACE risk score, although with a modest magnitude of improvement, probably due to the high predictive performance of the GRACE risk score alone.

Comparison of the GRACE risk score and the TIMI risk index in predicting the extent and severity of coronary artery disease in patients with acute coronary syndrome

“…Because the parameters in TRI are in GRS and because TRI is not correlated with SS, we think that parameters other than age, heart rate, and SBP predict the extent and severity of CAD. In addition, in our study, significant differences in admission glucose levels and NLR between the GRACE risk groups were confirmed by the results of recently conducted studies (18, 19) in large patient groups.…”

The prevalence of hyperglycaemia and its relationship with mortality, readmissions and length of stay in an older acute surgical population: a multicentre study

“…This association has been studied in the context of myocardial infarction, with significantly higher mortality rates reported among hyperglycaemic patients (8.4% vs 2.4%, p<0.001) 7. Similar findings have also been described, for patients with acute coronary syndrome,8 pneumonia9 and stroke 10. In addition, admission hyperglycaemia is associated with other poor outcomes, including increased length of hospital stay, hospital readmission and increased risk of infection 11 12…”

Clinical profile of patients with acute coronary syndrome with special reference to diabetes mellitus

“…Mean age for male in our study population was 59.9 ± 1.49 (SD years 13.6), whereas in females the same was 64.0 ± 3.63 (SD years 14.5) ( Table 2) and maximum patients (46%) were between 60 and 80 years of age group (Table 1) while mean age in CREATE study was 57.5 years (SD 12.1) 2 and Male/female ratio was 84:16, and the same from the GRACE Study was 69:31 3 and in study done by Lu HT and Nordin RB (2013) the mean age (SD) was 59.1 (12.0) with 70% male population. 4 Most patients (85%) belonged to middle socioeconomic status, and 9% and 6% were from lower and upper socioeconomic status respectively (Table 3).…”