Key result
Modified GRACE with continuous hs-TnI significantly improves mortality risk reclassification over GRACE 2.0.
Why the study?
The GRACE 2.0 score incorporates high-sensitivity troponin as a binary variable, which may limit its prognostic precision. Although a modified GRACE model using continuous hs-TnT has shown superior performance, evidence for its efficacy using continuous hs-TnI was limited.
Does the modified GRACE score using continuous high-sensitivity troponin I improve mortality and MACE risk discrimination and reclassification compared to the standard GRACE 2.0 score in patients with acute coronary syndrome?
Cohort
Yes
Does the modified GRACE score using continuous high-sensitivity troponin I improve mortality and MACE risk discrimination and reclassification compared to the standard GRACE 2.0 score in patients with acute coronary syndrome?
Answers are grounded in this paper and cite their sources.
Integrating continuous high-sensitivity troponin I into the modified GRACE score provides consistent and clinically meaningful improvements in short- and long-term risk reclassification for patients with acute coronary syndrome compared to the standard GRACE 2.0 score.
The GRACE 2.0 risk score is a widely used tool for estimating mortality in patients with acute coronary syndrome (ACS). However, it incorporates high-sensitivity troponin (hs-Tn) as a binary variable (elevated vs. non-elevated), which may limit its prognostic precision in contemporary practice. While a modified GRACE (modGRACE) model using continuous hs-troponin T (hs-TnT) has shown superior performance, evidence regarding its efficacy using continuous hs-troponin I (hs-TnI) is limited. This study aimed to validate the modGRACE score using continuous hs-TnI across two independent ACS cohorts. Data were analyzed from two prospective studies: the Freeman cohort (Newcastle, UK) and the GREECS cohort (Athens, Greece). The modGRACE score was calculated by substituting continuous hs-TnT with continuous hs-TnI using previously established regression coefficients. Predictive performance was evaluated by comparing the area under the receiver operating characteristic curve (AUC) and net reclassification improvement (NRI) for short-term (in-hospital, 30-day) and long-term (up to 20-year) outcomes. In the Freeman cohort, modGRACE demonstrated modest improvements in discrimination for in-hospital mortality (AUC 0.884 vs. 0.870) and 30-day mortality (AUC 0.883 vs. 0.868). A significant improvement in discrimination was observed for 1-year mortality (ΔAUC 0.015, p=0.01). Furthermore, risk reclassification was significantly improved for in-hospital (NRI=0.67), 30-day (NRI=0.69), and 1-year mortality (NRI=0.49; all p<0.001). In the GREECS cohort, modGRACE significantly improved risk reclassification for 30-day mortality (NRI=0.56), 20-year cardiovascular mortality (NRI=0.85), and 20-year Major Adverse Cardiovascular Events (MACE; NRI=0.79; all p<0.001). Integrating continuous hs-TnI into the modGRACE score leads to consistent and clinically meaningful improvements in risk reclassification compared to the standard GRACE 2.0 score. These findings support the clinical implementation of modGRACE for long-term risk stratification in ACS patients, regardless of whether hs-TnT or hs-TnI assays are utilized. Improved risk reclassification may help clinicians better tailor follow-up intensity and secondary prevention strategies.
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Delialis et al. (2026) conducted a cohort in Acute coronary syndrome (ACS). Modified GRACE (modGRACE) score using continuous high-sensitivity troponin I (hs-TnI) vs. Standard GRACE 2.0 risk score was evaluated on Short-term (in-hospital, 30-day, 1-year) and long-term (20-year) mortality and Major Adverse Cardiovascular Events (MACE) (NRI 0.69 (30-day, Freeman); NRI 0.85 (20-year CV mortality, GREECS), p=<0.001). Modified GRACE using continuous hs-TnI improved risk reclassification vs GRACE 2.0 for 1-year mortality and 20-year CV mortality.
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