Effectiveness of the GRACE risk score on the management and outcome of patients hospitalised with non-ST elevation acute coronary syndrome (UKGRIS): a parallel-group cluster-randomised registry-based controlled trial.

Chris Gale ; Deborah Stocken ; Suleman Aktaa ; Catherine Reynolds ; Rachael Gilberts ; David Brieger ; Kathryn Carruthers ; Derek Chew ; Shaun Goodman ; Catherine Fernandez ; +3 more... Linda Sharples ; Andrew Yan ; Keith Fox ; (2023) Effectiveness of the GRACE risk score on the management and outcome of patients hospitalised with non-ST elevation acute coronary syndrome (UKGRIS): a parallel-group cluster-randomised registry-based controlled trial. BMJ, 381. e07384. ISSN 1468-5833 DOI: 10.1136/bmj-2022-073843
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Objective: To determine the effectiveness of risk stratification using the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) for patients presenting to hospital with suspected non-ST elevation acute coronary syndrome.

Design: Parallel group cluster randomised controlled trial.

Setting: Patients presenting with suspected non-ST elevation acute coronary syndrome to 42 hospitals in England between 9 March 2017 and 30 December 2019.

Participants: Patients aged ≥18 years with a minimum follow-up of 12 months.

Intervention: Hospitals were randomised (1:1) to patient management by standard care or according to the GRS and associated guidelines.

Main outcome measures: Primary outcome measures were use of guideline recommended management and time to the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospital admission, and readmission for cardiovascular event. Secondary measures included the duration of hospital stay, EQ-5D-5L (five domain, five level version of the EuroQoL index), and the composite endpoint components.

Results: 3050 participants (1440 GRS, 1610 standard care) were recruited in 38 UK clusters (20 GRS, 18 standard care). The mean age was 65.7 years (standard deviation 12), 69% were male, and the mean baseline GRACE scores were 119.5 (standard deviation 31.4) and 125.7 (34.4) for GRS and standard care, respectively. The uptake of guideline recommended processes was 77.3% for GRS and 75.3% for standard care (odds ratio 1.16, 95% confidence interval 0.70 to 1.92, P=0.56). The time to the first composite cardiac event was not significantly improved by the GRS (hazard ratio 0.89, 95% confidence interval 0.68 to 1.16, P=0.37). Baseline adjusted EQ-5D-5L utility at 12 months (difference −0.01, 95% confidence interval −0.06 to 0.04) and the duration of hospital admission within 12 months (mean 11.2 days, standard deviation 18 days v 11.8 days, 19 days) were similar for GRS and standard care.

Conclusions: In adults presenting to hospital with suspected non-ST elevation acute coronary syndrome, the GRS did not improve adherence to guideline recommended management or reduce cardiovascular events at 12 months.


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