Key result
Modified GRACE score improves in-hospital mortality discrimination over original GRACE with C-index ~0.87 vs 0.78.
Why the study?
Whether a modified GRACE score incorporating continuous contemporary-sensitive or high-sensitivity troponin I data improves prognostic accuracy over the original GRACE score was uncertain.
Does the modGRACE score incorporating continuous troponin I improve prognostic accuracy compared to the original GRACE score in patients with ACS?
Cohort (n=4,621)
Yes
Does the modGRACE score incorporating continuous troponin I improve prognostic accuracy compared to the original GRACE score in patients with ACS?
Absolute Event Rate: 0.871% vs 0.777%
p-value: p=<0.05
Incorporating continuous troponin I values into the modified GRACE score significantly improves risk discrimination and reclassification for short- and long-term mortality in ACS patients compared to the original GRACE score.
Continuous TnI incorporation into GRACE may refine ACS risk stratification; leaves open prospective validation before practice change.
INTRODUCTION: A modified Global Registry of Acute Coronary Events (modGRACE) model incorporating continuous rather than binary high-sensitivity troponin T data supersedes the performance of the original GRACE score. However, whether a similar prognostic gain can be achieved using contemporary-sensitive (cTnI) or high-sensitivity troponin I (hs-TnI) remains uncertain. METHODS: We analyzed data from 2 independent ACS cohorts of consecutively recruited patients: the Freeman cohort (Newcastle, United Kingdom; n = 2,991) and the Greek Study of ACS (GREECS; Greece; n = 1,630). Risk stratification using the original GRACE score and the modGRACE score incorporating continuous c/hs-TnI values. Model performance was assessed using Harrell's C-index and continuous net reclassification improvement (NRI). RESULTS: In the Freeman cohort, modGRACE showed improvements in discrimination for in-hospital (Harrell's C-index=0.871 vs 0.777) and 30-days mortality (0.848 vs 0.833), with significant improvement at 1-year (0.721 vs. 0.690, all p<0.05). Reclassification improved for in-hospital (NRI=0.67), 30-day (NRI=0.69), and 1-year mortality (NRI=0.49) (all p< .001). In the GREECS cohort, modGRACE showed improvements for discrimination in 30days-mortality (Harrell's C-index 0.778 vs 0.752) and cardiovascular-death at 20 years (0.682 vs. 0.653, p<0.05 for both); and improved risk reclassification for 30-day mortality (NRI, 0.56), 20-year cardiovascular mortality (NRI=0.85), and 20-year MACE (NRI=0.79) (all p<0.001). CONCLUSION: The updated ModGRACE model, incorporating continuous c/hs-TnI alongside re-estimated baseline predictors, demonstrated consistent improvements in risk reclassification and discrimination over original GRACE. Ultimately, these findings support the application of quantitative troponin data across different troponin assays, to improve prognostic accuracy and standardize risk assessment in clinical practice.
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Delialis et al. (2026) conducted a cohort in Acute Coronary Syndrome (n=4,621). Modified GRACE (modGRACE) score incorporating continuous c/hs-TnI values vs. Original GRACE score was evaluated on Discrimination for in-hospital mortality (Harrell's C-index) (p=<0.05). The modGRACE score incorporating continuous troponin data significantly improved discrimination for in-hospital mortality compared to the original GRACE score (C-index 0.871 vs 0.777, p<0.05).
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