Acute Coronary Syndrome: Prognostic Factors

Key points

• GRACE regression models predict in-hospital and post-discharge death in acute coronary syndrome.
• Poor prognostic factors: age · heart failure (history or development) · peripheral vascular disease · reduced systolic BP · Killip class · initial serum creatinine · elevated cardiac markers · cardiac arrest on admission · ST-segment deviation.
• Killip class 30-day mortality: I (no heart failure signs) 6% · II (crackles, S3) 17% · III (frank pulmonary oedema) 38% · IV (cardiogenic shock) 81%.
• GRACE 6-month mortality bands: below 1.5% lowest · 1.5-3% low · 3-6% intermediate · 6-9% high · above 9% highest risk.
• Predicted 6-month mortality above 3.0% = intermediate or higher risk → coronary angiography with follow-on PCI if indicated WITHIN 72 HOURS (NICE NG185) · immediate angiography if clinically unstable. Routine glycoprotein IIb/IIIa inhibitors are no longer part of this pathway.
• LVEF of 40% or less is a strong poor-prognosis marker after MI and triggers heart failure therapy — see NG106 for the four pillars.

Decision points in this pathway

• Predicted 6-month mortality above 3.0% (intermediate or higher risk)?

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