The GRACE score was confirmed to be predictive of adverse outcomes even in older MI patients, and physiology-guided complete revascularization was associated with benefit across the GRACE spectrum, suggesting that the GRACE score alone should not preclude this strategy in older patients with MI.
Key Findings
Results
The GRACE score was significantly associated with increased all-cause mortality in older patients with myocardial infarction.
Hazard ratio 1.027 per unit increase in GRACE score, 95% CI 1.021-1.033, P < 0.001
Analysis was conducted in the FIRE trial cohort of 1445 patients aged 75 years or older with MI and multivessel coronary artery disease
Patients were stratified into three GRACE score tertiles: first (92.6-128.0), second (128.1-146.5), and third (146.6-236.0)
All-cause mortality at 1 year was significantly higher in the third tertile compared to lower tertiles (P < 0.0001)
Results
The GRACE score was significantly associated with cardiovascular death in older MI patients.
Hazard ratio 1.031 per unit increase in GRACE score, 95% CI 1.023-1.039, P < 0.001
Cardiovascular death at 1 year was significantly higher in the third tertile (P < 0.0001)
Patients in the third tertile were more compromised in terms of cardiovascular risk factors and comorbidities
Results
The GRACE score was significantly associated with the composite endpoint of cardiovascular death or MI in older MI patients.
Hazard ratio 1.020 per unit increase in GRACE score, 95% CI 1.013-1.026, P < 0.001
The composite of cardiovascular death or MI at 1 year was significantly higher in the third tertile (P < 0.0001)
This endpoint was assessed at 1-year follow-up across all three GRACE score tertiles
Results
The benefit of physiology-guided complete revascularization did not differ across GRACE score tertiles.
P for interaction > 0.05 for all outcomes of interest when comparing revascularization strategy across GRACE score tertiles
No interaction was found between revascularization strategy and GRACE score in either tertile-based or continuous survival analyses (all P for interaction > 0.05)
The FIRE trial randomized patients to either culprit-only or complete revascularization guided by coronary physiology
This finding applied to all-cause mortality, cardiovascular death, and the composite of cardiovascular death or MI
Results
The best discriminative value of the GRACE score for all-cause mortality at 1 year was 137.
This threshold was identified through analysis of the FIRE trial cohort of 1445 patients aged ≥75 years
The GRACE score tertile cutpoints were 128.0 (first/second tertile boundary) and 146.5 (second/third tertile boundary), placing the discriminative value of 137 within the second tertile range
487 patients (33.7%) were in the first tertile, 477 (33.0%) in the second tertile, and 481 (33.3%) in the third tertile
Results
Patients in the highest GRACE score tertile had greater cardiovascular risk burden and comorbidities.
Patients in the third tertile (GRACE 146.6-236.0) were described as 'more compromised in terms of cardiovascular risk factors and comorbidities'
The study population included 1445 patients aged 75 years or older with MI and multivessel coronary artery disease
The three tertiles included 487, 477, and 481 patients respectively, representing approximately equal distribution
Spadafora L, Bernardi M, Biondi-Zoccai G, Colaiori I, Guiducci V, Escaned J, et al.. (2026). GRACE score for risk stratification and completeness of revascularization in older patients with myocardial infarction.. Journal of cardiovascular medicine (Hagerstown, Md.). https://doi.org/10.2459/JCM.0000000000001853