Contemporary Risk Stratification After Myocardial Infarction in the Community: Performance of Scores and Incremental Value of Soluble Suppression of Tumorigenicity‐2

BACKGROUND Current American Heart Association/American College of Cardiology guidelines recommend the GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) scores to assess myocardial infarction (MI) prognosis. Changes in the epidemiological characteristics of MI and the availability of new biomarkers warrant an assessment of the performance of these scores in contemporary practice. We assessed the following: (1) the performance of GRACE and TIMI to predict 1-year mortality in a cohort of patients stratified by ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) and (2) the incremental discriminatory power of soluble suppression of tumorigenicity-2, a myocardial fibrosis biomarker. METHODS AND RESULTS Olmsted County, Minnesota, residents with incident MI (N=1401) were recruited prospectively from November 1, 2002 to December 31, 2012 (mean age, 67 years; 61% men; 79% with NSTEMI). Baseline data were used to calculate risk scores; soluble suppression of tumorigenicity-2 was measured in stored plasma samples obtained at index MI. C-statistics adapted to survival data were used to assess the discriminatory power of the risk scores and the improvement gained by adding other markers. During the first year of follow-up, 190 patients (14%) died. The discriminatory performance to predict death was reasonable for GRACE and poor for TIMI, and was generally worse in those with NSTEMI versus those with STEMI. In people with NSTEMI, sequential addition of comorbidities and soluble suppression of tumorigenicity-2 substantially improved the c-statistic over GRACE (from 0.78 to 0.80 to 0.84) and TIMI (from 0.61 to 0.73 to 0.81), respectively (all P≤0.05). CONCLUSIONS Guideline-recommended scores for risk assessment after MI underperform in contemporary community patients, particularly those with NSTEMI, which now represents most infarcts. Incorporating comorbidities and soluble suppression of tumorigenicity-2 substantially improves risk prediction, thereby delineating opportunities to improve clinical care.