Optimization of GRACE risk stratification by NT-proBNP combined with D-dimer in patients with non-ST-elevation myocardial infarction

Abstract Background GRACE risk score is the most widely used tool to predict the risk of death and myocardial infarction in patients with Non-ST-elevation myocardial infarction (NSTEMI). Some biomarkers have been shown to have a high predictive value for prognosis. But the models constructed using these studies have some drawbacks, including the using biomarkers that are not routinely monitored. Aims To explore the optimizing role of multiple biomarkers in GRACE risk stratification in NSTEMI and then develop a new scoring system based on GRACE. Methods 1.This multi-center, prospective, cohort study enrolled 1357 patients (mean age 65±12 years; 57% male). Common clinical indicators were collected within the first 12h after admission. 2.The outcome was 1-year all-cause mortality and major adverse cardiac events (MACE: all-cause death,unstable angina, heart failure, recurrent myocardial infarction and stroke). 3.Cox multivariate anlysis was used to quantify the biomarker effect. C-index, NRI and IDI were calculated to verify that the biomarkers improve the predictive accuracy of GRACE. Results 1. During follow-up (mean: 339 days), 57 participants died and 211 participants had 231 MACE. In COX analysis, NT-proBNP (P<0.0001), and d-dimer (P=0.0092) were significant independent biomarkers for death. NT-proBNP (P<0.0001), fibrinogen (P=0.0177) and d-dimer (P<0.0001) were significant independent biomarkers for MACE. 2. For all-cause death, the combination of NT-proBNP and D-dimer improved the predictive accuracy of GRACE the most. For MACE, trigeminal combination of NT-proBNP, fibrinogen, and D-dimer improved GRACE the most 3. NT-proBNP, D-dimer, fibrinogen, and GRACE comprise a new scoring system for assessing 1-year clinical events. Kaplan-Meier analysis revealed a significant rise in 1-year mortality and MACE between different score groups. Conclusions The combination of NT-proBNP, and d-dimer added the prognostic value of GRACE for all-cause death and MACE. Our newly developed scoring system can be easily calculated in clinical practice and strongly correlated with all-cause mortality and MACE. Risk score and survival curve Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Major Science and Technology Projects of Tianjin Science and Technology Commission in 2016; Key Project of Healthcare Industry of Tianjin in 2016