Abstract
Background
Risk score is widely used in non-ST segment elevation myocardial infarction (NSTEMI) patients to predict the in-hospital outcome for immediate coronary angiography decision and care of unit selection.
Objectives
This study compared the performances of the thrombolysis in myocardial infarction (TIMI), Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), and Revised Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (Revised CADILLAC) risk scores in predicting in-hospital and long-term outcomes in diabetic NSTEMI patients.
Methods
A total of 750 diabetic NSTEMI patients from 27 hospitals were enrolled between January 2013 and December 2015 in the nationwide registry initiated by the Taiwan Society of Cardiology. Four score systems were calculated with receiver operator characteristic analysis used to compare outcome discrimination performance.
Results
No studied risk scores reached acceptable discrimination per area under curve (AUC) in the prediction of in-hospital outcome except for the revised CADILLAC score which reached acceptable discrimination in new-onset cardiogenic shock (AUC = 0.7191) and acute renal failure (AUC = 0.7283). In long-term outcomes, only the revised CADILLAC score reached acceptable discrimination of mortality prediction at 6, 12 and 24 months (AUC = 0.7261 at 6 months, 0.7319 at 12 months, and 0.7256 at 24 months). Subgroup analysis based on the revised CADILLAC score risk class showed a significant difference in adjusted mortality rate between low-risk group/intermediate-risk group and high-risk group.
Conclusions
Only the revised CADILLAC score showed acceptable accuracy to predict the long-term mortality outcome among the scores studied.
Keywords: CADILLAC score, Diabetes mellitus, GRACE score, NSTEMI, PAMI score, TIMI score
INTRODUCTION
Diabetes is one of the major risk factors for cardiovascular disease. Furthermore, diabetes is also an independent predictor of mortality in non-ST-segment elevation myocardial infarction (NSTEMI).1 Patients with diabetes have demonstrated poorer cardiovascular outcomes after NSTEMI when compared to non-diabetic patients.2
Several risk scores have been developed to identify the high-risk patients who may benefit more from aggressive treatment and also predict short-term outcomes.3-6 Among the developed risk scores, some were suggested by practical guidelines for acute risk assessment.7,8 The thrombolysis in myocardial infarction (TIMI) and primary angioplasty in myocardial infarction (PAMI) scores are the most commonly used in clinical practice. The GRACE score has shown reliable predictive power for short-term outcomes,9 and the same also applies to diabetic patients.10 However, the ability to predict long-term outcome in acute myocardial infarction (AMI) population remains controversial and only a limited number of studies have investigated the predictive value in ST-segment elevation myocardial infarction (STEMI) populations.11,12 The controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC)5,13 and primary angioplasty in myocardial infarction (PAMI) scores14 are mostly used for STEMI patients post primary percutaneous coronary intervention (PCI) prognosis prediction and few applications in NSTEMI population but little discussion has focused on NSTEMI in this regard. Furthermore, most of the developed risk scores were only validated in Western countries so there is limited data to support the effectiveness in predicting short-term and long-term outcomes in an Asian population. There is one retrospective, single center study conducted in Taiwan which validated the predictive value of the GRACE score in an AMI population and supported the predictive value in short-term and long-term outcomes.15 However, there is still the need to conduct further investigation for the diabetes population.
The aim of the research was to compare the prognostic predictive value of the GRACE, TIMI, revised CADILLAC, and PAMI scores in NSTEMI with diabetes by using the Acute Coronary Syndrome-Diabetes Mellitus Registry of the Taiwan Society of Cardiology (TSOC ACS-DM Registry) database. Comparison of the risk scores and its components are shown in Table 1.
Table 1. Risk scoring models and their components.
| Model components | GRACE | TIMI for NSTEMI | Revised CADILLAC | PAMI |
| Age | X | X | X | X |
| Low blood pressure | X | X | ||
| Heart rate | X | X | X | |
| Killip Class | X | X | X | X |
| Diabetes mellitus | X | X | ||
| Hypertension | X | |||
| Angina pectoris | X | |||
| Anterior MI or LBBB | X | X | ||
| Weight | X | |||
| Ischemia time | X | |||
| TIMI flow | ||||
| Ejection fraction | X | |||
| Anemia | X | |||
| Three-vessel disease | X | |||
| ST-segment deviation | X | |||
| Creatinine/renal insufficiency | X | X | ||
| Cardiac arrest | X | |||
| Increased cardiac markers | X |
CADILLAC, Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications; GRACE, Global Registry of Acute Coronary Events; LBBB, left bundle branch block; MI, myocardial infarction; NSTEMI, non ST-segment elevation myocardial infarction; PAMI, primary angioplasty in myocardial infarction; TIMI, thrombolysis in myocardial infarction.
METHODS
Study population
This prospective, nationwide, multi-center, non-interventional, observational study, the TSOC ACS-DM Registry, was launched by the Scientific Committee of the TSOC.16 Patients diagnosed of acute coronary syndrome (ACS) with type 2 diabetes were enrolled. Type 2 diabetes could be newly or previously diagnosed and the diagnosis of type 2 diabetes is defined by the criteria of the World Health Organization and American Diabetes Association. Informed consent was provided to the potential patients to be included in this study. ACS accompanied or precipitated by significant co-morbidities were excluded by this registry such as trauma, motor vehicle accidents, severe gastrointestinal bleeding, peri-operative or peri-procedural related myocardial infarction, or participating in an investigational drug study. All patients could only be enrolled one time in the registry and any further ACS events were recorded as adverse events.
Data collection
The demographic data, clinical characteristics, biochemistry data, inpatient therapy, and in-hospital outcomes including mortality, recurrent non-fatal myocardial infarction (MI), and nonfatal stroke were collected by the study coordinators at the study sites. Medications at admission, during the in-hospital stay, and at discharge were also collected, retrospectively and prospectively. The revised CARDILLAC score was used in the current study to exclude final TIMI flow because post-procedural TIMI flow was not included in the registry data collection. Missing TIMI flow data is also possible in NSTEMI patients as PCI treatment might not be performed. All data was then submitted electronically to a central laboratory for verification.
Endpoints
The primary endpoint of interest was all-cause mortality at 6 months, 12 months, and 24 months. The secondary endpoints included recurrent non-fatal MI, bleeding, new-onset cardiogenic shock, and acute renal failure. All records were collected from medical records by well-trained study nurses.
Statistical analysis
Continuous variables were expressed as the mean with standard deviation and categorical variables were shown as the frequency with percentage. Receiver operator characteristic curve analysis was used to determine the performance of each score to discriminate outcomes in NSTEMI patients. All statistical analyses were performed using SAS (version 9.4, SAS, Inc). A p-value < 0.05 was considered statistically significant.
RESULTS
A total of 750 NSTEMI patients with diabetes were enrolled from 27 hospitals between January 2013 and December 2015.
Demographics and baseline characteristics
The average age of the enrolled patients was 66.8 ± 12 years with a male preponderance (66.5%). 92.7% of the patients had a history of type 2 diabetes, and 7.3% of them had newly diagnosed diabetes during this ACS episode. 39.1% had known coronary artery disease (CAD), 18.1% had a history of myocardial infarction and 27.6% of patients already had received PCI. Nearly half of the patients had Killip class I at presentation. Nearly 50% of the patients had Killip class II and III at presentation. 59.1% of them had renal insufficiency in admission. Around one fourth (28%) of patients were under insulin treatment and the average glycated hemoglobin (HbA1C) level was 8.1%. During the hospitalization, guideline-directed medical therapy (GDMT), dual anti-platelet (DAPT) was used in 82.7% of patients, renin-angiotensin blockers, beta-blocker and statin prescription rate were all higher than 60%. Most of the patients (81.3%) received reperfusion therapy, and 74% of them received PCI. 18.3% of the patients did not receive coronary artery angiography and this resulted in missing data for the number of diseased vessels. Other baseline characteristics, laboratory tests and invasive procedure characteristics are shown in Table 2 and Table 3.
Table 2. Baseline characteristics of patients and medical therapy upon hospital admission.
| Non-ST elevation MI (N = 750) | |
| Mean (SD) or N (%) | |
| Age (years) | 66.8 (12.0) |
| Gender (female) | 251 (33.5%) |
| Height (cm) | 162.2 (8.1) |
| Weight (kg) | 68.4 (13.8) |
| Body mass index (kg/m2) | 26.0 (4.4) |
| Systolic blood pressure (mmHg) | 147.1 (31.7) |
| Diastolic blood pressure (mmHg) | 82.2 (18.9) |
| Heart rate (min-1) | 90.3 (22.2) |
| Smoker | 201 (27.8%) |
| History of dyslipidemia | 359 (47.9%) |
| History of hypertension | 609 (81.2%) |
| History of diabetes | 695 (92.7%) |
| Known CAD | 293 (39.1%) |
| Previous myocardial infarction | 136 (18.1%) |
| Previous PCI | 207 (27.6%) |
| Previous CABG | 50 (6.7%) |
| History of atrial fibrillation | 38 (5.1%) |
| Previous heart failure | 89 (11.9%) |
| COPD | 24 (3.2%) |
| Obstructive sleep apnea | 15 (2.0%) |
| Peripheral arterial disease | 39 (5.2%) |
| Cerebrovascular disease | 89 (11.9%) |
| Killip Class 1 | 333 (46.6%) |
| Killip Class 2 | 243 (34.0%) |
| Killip Class 3 | 107 (15.0%) |
| Killip Class 4 | 31 (4.3%) |
| Reperfusion therapy | 610 (81.3%) |
| PCI | 556 (74.1%) |
| Thrombolysis | 2 (0.3%) |
| CABG | 52 (8.5%) |
| Ejection fraction < 40% | 231 (30.8%) |
| In-hospital medication | |
| Acetylsalicylic acid | 664 (88.5%) |
| P2Y12 | 686 (91.5%) |
| Clopidogrel | 491 (65.5%) |
| Licodin | 3 (0.4%) |
| Ticargrelor | 216 (28.8%) |
| DAPT | 620 (82.7%) |
| Renin-angiotensin blockers | 469 (62.5%) |
| Beta blocker | 478 (63.7%) |
| Statin | 561 (74.8%) |
| Insulin | 230 (30.7%) |
| Sulfonylurea agent | 250 (33.3%) |
| Mitiglinde | 58 (7.8%) |
| Metformin | 302 (40.3%) |
| DPP4-inhibitor | 267 (35.6%) |
| TZD | 14 (1.9%) |
CABG, coronary artery bypass surgery; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; DAPT, dual antiplatelet therapy; DDP4, dipeptidyl peptidase-4; EF, ejection fraction; MI, myocardial infarction; PCI, percutaneous coronary intervention; SD, standard deviation; TZD, thiazolidinedione.
Table 3. Characteristics of laboratory tests and invasive procedures.
| Non-ST elevation MI (N = 750) | |
| Mean (SD) or N (%) | |
| Initial CK (U/L) | 321.5 (461.9) |
| Initial CKMB (μg/L) | 26.4 (38.1) |
| Initial troponin (μg/L) | 32.0 (217.5) |
| Peak CK (U/L) | 634.2 (924.0) |
| Peak CKMB (μg/L) | 48.8 (69.6) |
| Peak troponin (μg/L) | 132.2 (651.7) |
| Creatinine (mg/dl) | 2.3 (2.6) |
| Hemoglobin (mg/dl) | 12.6 (2.6) |
| HbA1c (%) | 8.1 (1.9) |
| Total cholesterol (mg/dl) | 168.4 (48.9) |
| HDL (mg/dl) | 40.9 (12.3) |
| LDL (mg/dl) | 101.3 (43.7) |
| Triglyceride (mg/dl) | 172.3 (228.3) |
| Culprit lesion (%) | 88.3 (14.1) |
| Number of diseased vessels | |
| 0 | 13 (1.7) |
| 1 | 185 (24.7) |
| 2 | 167 (22.3) |
| ≥ 3 | 248 (33.1) |
| Missing | 137 (18.3) |
CK, creatine kinase; CKMB, creatine kinase-MB; HbA1C, glycated hemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein, MI, myocardial infarction; SD, standard deviation; TIMI, thrombolysis in myocardial infarction.
Accuracy of predictive in-hospital outcome
In-hospital outcome includes recurrent myocardial infarction (Re-MI), bleeding episode, new onset cardiogenetic shock and acute renal failure. Among the 4 risk scores studied, the prediction of the majority of the in-hospital outcome did not reach acceptable discrimination per area under curve (AUC) except for the revised CADILLAC score which reached acceptable discrimination in new onset cardiogenic shock (AUC = 0.7191) and acute renal failure (AUC = 0.7283). Details of the results are in Table 4.
Table 4. AUC of the risk scores at different time points in patient with NSTEMI.
| TIMI | PAMI | Revised CADILLAC | GRACE | |
| In hospital outcomes | ||||
| Re MI | 0.6405 (0.3616-0.9193) | 0.5722 (0.3088-0.8356) | 0.6357 (0.4718-0.7996) | 0.6756 (0.4530-0.8981) |
| Bleed | 0.5496 (0.4674-0.6319) | 0.6307 (0.5491-0.7122) | 0.6606 (0.5880-0.7332) | 0.6728 (0.5956-0.7500) |
| New onset cardiogenic shock | 0.5258 (0.4264-0.6251) | 0.6348 (0.5245-0.7451) | 0.7191 (0.6182-0.8199)* | 0.6628 (0.5193-0.8062) |
| Acute renal failure | 0.4997 (0.4003-0.5992) | 0.6719 (0.5684-0.7755) | 0.7283 (0.6399-0.8167)* | 0.6935 (0.5949-0.7921) |
| Death | ||||
| 6 months | 0.5171 (0.4336-0.6005) | 0.6444 (0.5644-0.7244) | 0.7261 (0.6598-0.7923)* | 0.6675 (0.5829-0.7521) |
| 1 years | 0.4994 (0.4298-0.5691) | 0.6484 (0.5849-0.7118) | 0.7319 (0.6827-0.7811)* | 0.6851 (0.6230-0.7472) |
| 2 years | 0.5172 (0.4570-0.5774) | 0.6754 (0.6215-0.7292) | 0.7256 (0.6801-0.7711)* | 0.6952 (0.6416-0.7488) |
AUC, area under curve; CADILLAC, Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications; GRACE, Global Registry of Acute Coronary Events; MI, myocardial infarction; NSTEMI, non ST-segment elevation myocardial infarction; PAMI, primary angioplasty in myocardial infarction; TIMI, thrombolysis in myocardial infarction.
* Reach acceptable discrimination.
Accuracy of predictive mortality
Among the 4 risk scores studied, the prediction of mortality did not reach acceptable discrimination per AUC except for the revised CADILLAC score which reached acceptable discrimination at 6, 12 and 24 months (AUC = 0.7261 at 6 months, 0.7319 at 12 months, and 0.7256 at 24 months). Details of the results are listed in Table 4. Further subgroup analysis based on the revised CADILLAC score risk class showed a significant difference in adjusted mortality rate at 6 months, 1 year and 2 years between the low-risk group (0-2 points)/intermediate-risk group (3-5 points) and high-risk group (≥ 6 points). Details of the results are shown in Table 5. The basic characteristics of the CADILLAC low/intermediate-risk group and high-risk group are listed in Supplemental Table 1.
Table 5. Adjusted rate and HRs of mortality by revised CADILLAC risk class.
| Alive | Death | HR (95% CI) | p-value | HR* (95% CI) | p-value | |
| 6 months | ||||||
| Low risk (0-2)/intermediate risk (3-5) | 285 (40.20) | 4 (9.8) | 1.0 | 1.0 | ||
| High risk (≥ 6) | 424 (59.8) | 37 (90.2) | 6.1 (2.2-17.0) | 0.0006 | 5.5 (2.0-15.5) | 0.0012 |
| 1 year | ||||||
| Low risk (0-2)/intermediate risk (3-5) | 284 (41.5) | 5 (7.6) | 1.0 | 1.0 | ||
| High risk (≥ 6) | 400 (58.5) | 61 (92.4) | 8.3 (3.3-20.6) | < 0.0001 | 7.5 (3.0-18.8) | < 0.0001 |
| 2 year | ||||||
| Low risk (0-2)/intermediate risk (3-5) | 281 (42.5) | 8 (9.0) | 1.0 | 1.0 | ||
| High risk (≥ 6) | 380 (57.5) | 81 (91.0) | 7.4 (3.6-15.2) | < 0.0001 | 6.7 (3.2-14.0) | < 0.0001 |
CADILLAC, Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications; CI, confidence intervals; HR, Hazard ratios.
* Adjustment for gender, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation.
Supplement Table 1. Basic characteristic of low/intermediate and high-risk group by CADILLAC risk class.
| Low risk (0-2)/Intermediate risk (3-5) | High risk (6+) | p-value | |
| AGE (years) | 60.2 (10.9) | 69.8 (11.3) | < 0.0001 |
| Gender (female) | 58 (24.9) | 193 (37.3) | 0.0008 |
| Height (cm) | 163.9 (8.6) | 161.5 (7.7) | 0.0003 |
| Weight (kg) | 72.2 (14.1) | 66.5 (13.3) | < 0.0001 |
| Body mass index (kg/m2) | 26.9 (4.5) | 25.5 (4.3) | 0.0003 |
| Systolic blood pressure (mmHg) | 147.3 (28.8) | 146.9 (32.9) | 0.8708 |
| Diastolic blood pressure (mmHg) | 85.8 (17.5) | 80.6 (19.3) | 0.0003 |
| Heart rate (min-1) | 86.8 (21.3) | 91.9 (22.4) | 0.0038 |
| Smoker | 83 (36.9) | 118 (23.7) | 0.0002 |
| History of dyslipidemia | 106 (45.5) | 253 (48.9) | 0.3825 |
| History of hypertension | 173 (74.3) | 436 (84.3) | 0.0011 |
| History of diabetes | 205 (88.0) | 490 (94.8) | 0.0010 |
| Known CAD | 65 (27.9) | 228 (44.1) | < 0.0001 |
| Previous myocardial infarction | 33 (14.2) | 103 (19.9) | 0.0582 |
| Previous PCI | 44 (18.9) | 163 (31.5) | 0.0003 |
| Previous CABG | 6 (2.6) | 44 (8.5) | 0.0025 |
| History of atrial fibrillation | 9 (3.9) | 29 (5.6) | 0.3128 |
| Previous heart failure | 10 (4.3) | 79 (15.3) | < 0.0001 |
| COPD | 5 (2.2) | 19 (3.7) | 0.2709 |
| Obstructive sleep apnea | 3 (1.3) | 12 (2.3) | 0.3495 |
| Peripheral arterial disease | 6 (2.6) | 33 (6.4) | 0.0297 |
| Cerebrovascular disease | 20 (8.6) | 69 (13.4) | 0.0620 |
| EF < 40% | 1 (0.4) | 109 (21.1) | < 0.0001 |
CABG, coronary artery bypass surgery; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; EF, ejection fraction; PCI, percutaneous coronary intervention.
DISCUSSION
It is observed in the current study that the revised CADILLAC score is the only scoring system that showed acceptable accuracy to predict the long-term mortality outcome compared with the other scores. The components of the revised CADILLAC score and the niche of the diabetic population of the current study may be a possible explanation. As shown in several prior studies, multiple vessel disease had the worst long-term prognosis in coronary artery disease patients,17 and some of the studies showed that the GRACE score was not a good predictor in identifying triple-vessel disease (TVD) and left main disease (LM).18 On the other hand, the diabetes population had a higher prevalence to TVD/LM in ACS19 and 33% of our patients have triple-vessel disease. Among the 4 prediction scores evaluated, the revised CADILLAC score is the only scoring systemic with parameters to evaluate TVD and it may explain why it is the only scoring system noted with acceptable statistical discrimination.
The other ACS risk scores (including TIMI, PAMI, GRACE) in this study showed little prediction in either the short-term (in-hospital outcome) or long-term outcomes (6 months to 24 months mortality) in the studied NSTEMI patients with diabetes. There are several possible reasons which may explain the distinctive finding from prior studies. For instance, there is the difference in the researched niche of the current study compared to previous GRACE and CADILLAC score studies. All of our patients were diabetic with 92.7% of patients diagnosed before the NSTEMI episode and 7.3% of the patients diagnosed during this NSTEMI episode. More than one fourth of diabetes patients were treated with insulin which suggested a long history of diabetes. In addition, the average creatinine level was 2.2 mg/dl and nearly 60% of patients had renal insufficiency in admission, which presented a population with diabetes nephropathy. And that is distinct to the original GRACE score study which consisted of only 23.3% of diabetic and 7.2% of renal dysfunction among the enrolled patient pool.4,5 Since renal insufficiency is one of the known factors of the GRACE score, the percentage of chronic kidney disease (CKD) may decrease the statistical discrimination ability to predict an outcome. When using Killip classification, it was noted that 50% of enrolled patients were classified as Killip class II/III at presentation while only 16% and 10.9% of patients were classified the same in prior GRACE and CADILLAC score studies at presentation.4,5 This should indicate that the condition of our patients was worse than those of other prior studies due to the comorbidity resulting from diabetic nature. The remaining comparison of baseline characteristic in our study, the GRACE and CADILLAC study patients, are shown in Table 6.
Table 6. Comparison of TSOC-ACS DM (NSTEMI), GRACE and CADILLAC study patient baseline characteristic.
| Variable | TSOC-ACS DM (NSTEMI) (N = 750) | GRACE 20034 (N = 11389) | CADILLAC 20055 (N = 2082) |
| Age (years) | 66.8 | 66.3 | 59.0 |
| Female | 33.5% | 33.5% | 27.0% |
| Risk factor | |||
| DM | 92.7% | 23.3% | 16.6% |
| Dyslipidemia | 52.2% | 52.2% | 37.9% |
| HTN | 81.2% | 57.8% | 48.1% |
| Smoking | 27.8% | 56.7% | 43.1% |
| Renal dysfunction | 59.1% | 7.2% | - |
| Dialysis dependent | 11.2% | - | - |
| CAD known | 39.1% | 22.0% | - |
| MI history | 18.1% | 32.0% | 13.7% |
| Killip | |||
| I | 46.6% | 82.7% | - |
| II | 34.0% | 13.2% | 10.9% (II and III) |
| III | 15.0% | 3.1% | |
| IV | 4.3% | 1.0% | - |
| TVD | 37.0% | - | 15.6% |
| Reperfusion strategy | |||
| PCI | 74.1% | - | - |
| Thrombolysis | 0.3% | - | - |
| CABG | 8.5% | - | - |
| Outcome | |||
| In hospital death | 1.5% | 3.5% | 1.6% |
| 6 month | 5.5% | - | - |
| 1 year | 8.8% | - | 4.3% |
| 2 year | 11.9% | - | - |
ACS, acute coronary syndrome; CABG, coronary artery bypass surgery; CAD, coronary artery disease; CADILLAC, Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications; DM, diabetes mellitus; GRACE, Global Registry of Acute Coronary Events; HTN, hypertension; MI, myocardial infarction; NSTEMI, non ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; TSOC, Taiwan Society of Cardiology; TVD, triple vessel diseas.
It was unexpected that the GRACE score failed to show predicted value for in-hospital outcome which it was initially designed for and is widely used in clinical practice. It may be that the progress in patient care over time by using troponin testing has aided early detection of NSTEMI and further contributes to the improvement of short-term outcome. In the current used registry, NSTEMI patients in-hospital mortality rate was only 1.5%, which is relatively low compared to studies conducted 20 years ago.4,5,20 The difference in mortality rate could be the result of increasing use of GDMT in the early stages, including DAPT and beta-blockers, which may also help to lower the in-hospital outcome and long-term mortality.21,22 Increased early reperfusion strategy may also play an important role in lowering the outcomes as 74.1% of NSTEMI patients received PCI for reperfusion in the current registry which is much different from scoring systems in the developed era.20 Comparisons of patient basic characteristics, management and outcome with the prior GRACE and CADILLAC scores are shown in Table 4. To sum up, as patient care strategies evolve over time, the GRACE score was developed in a time when troponin, early reperfusion and ACS-GDMT had not been widely applied and it may not continue to be superior in predictive value in in-hospital outcome and long-term outcome in current clinical settings and in diabetes patients with NSTEMI.
There are several limitations to this study. First, selection bias may exist as this study was a post-hoc data analysis based on the TSOC ACS-DM Registry. Second, several parameters were not including in this study, such as how long the patients had diabetes, and the scoring system, like syntax score which applies angiography findings. Third, some patients may have transit hyperglycemia during acute coronary syndrome which could be an over-diagnosis of a diabetes patient. Fourth, there were few studies regarding the application of the CADILLAC score in NSTEMI patients as the original study design of the CADILLAC score was for prognosis evaluation post primary PCI for AMI patients and it only enrolled few NSTEMI patients and excluded NSTEMI patients who required multivessel PCI.5 Furthermore, the original registry data used in the current study did not include final TIMI flow data so the revised CADILLAC score which excluded TIMI flow from the calculation was used for prognosis evaluation. This might be different from the original population and design of the CADILLAC score but the current study result has demonstrated that the revised CARDILLAC score is reliable in prognostic evaluation. Last, the calculated CADILLAC score may be underestimated in some patients in the current study since only 81.3% of the patients from the current registry study received reperfusion therapy.
CONCLUSIONS
The revised CADILLAC score is the only scoring system that showed acceptable accuracy to predict long-term mortality outcome compared with other scores. The GRACE score and other scoring systems cannot show good predictive value either in in-hospital outcome or long-term survival outcome. Based on our findings, we may consider that in the era of high prevalence of troponin use and early reperfusion strategy, a new scoring system, especially in NSTEMI and diabetes patients, may be needed.
Acknowledgments
None.
CONFLICT OF INTEREST
All the authors declare no conflict of interest.
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