European Journal of Cardiovascular Medicine

Acute myocardial infarction (AMI), the most critical manifestation of coronary artery disease (CAD), continues to be a leading cause of illness and death worldwide. According to the World Health Organization, ischemic heart disease is responsible for over 9 million deaths annually, with AMI contributing significantly to this burden. In India, the impact is even greater, with an age-standardized cardiovascular mortality rate of 272 per 100,000 population, higher than the global average of 235. ¹

AMI occurs when a thrombotic blockage, usually triggered by the rupture of an atherosclerotic plaque, abruptly interrupts coronary blood flow. This results in myocardial ischemia and necrosis, which, without prompt reperfusion therapy, can lead to serious complications such as arrhythmias, cardiogenic shock, or death. Based on electrocardiogram findings, AMI is classified into ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), each requiring specific treatment approaches and carrying different prognostic implications.²

Although advances in therapies such as thrombolysis and percutaneous coronary intervention (PCI) have improved outcomes, in-hospital mortality remains a concern for a considerable proportion of patients. Therefore, early and accurate risk assessment at admission is essential to guide management strategies and prioritize critical care resources.

Several prognostic models are available for this purpose, including the TIMI, HEART, CRUSADE, and GRACE scores. Of these, the Global Registry of Acute Coronary Events (GRACE) score is particularly noteworthy, as it was derived from a large multinational dataset and incorporates eight key clinical variables: age, systolic blood pressure, heart rate, serum creatinine, Killip class, cardiac arrest at presentation, ST-segment changes, and elevated cardiac biomarkers. The GRACE score has consistently demonstrated strong predictive value for both in-hospital and six-month mortality across the full spectrum of acute coronary syndromes (ACS).³

Evidence from studies conducted in Pakistan and India has further validated the GRACE score’s utility, particularly in predicting adverse outcomes among STEMI patients. ⁴However, despite its reliability, its routine use in emergency and intensive care settings remains limited, and population-specific validation in Indian cohorts is still scarce.

With this background, the present study is designed to assess the effectiveness of the GRACE score in predicting in-hospital mortality and facilitating risk stratification among STEMI patients admitted to a tertiary care hospital in western India.

Study Design and Setting

This prospective observational analytical study was conducted in the Department of Medicine, Dr. Vithalrao Vikhe Patil Foundation’s Medical College, a tertiary care teaching hospital in Ahmednagar, Maharashtra, India. The study aimed to assess the prognostic utility of the GRACE score in patients diagnosed with acute ST-elevation myocardial infarction (STEMI). The study was carried out over a 6-month period from March 2024 to August 2024, following approval by the Institutional Ethics Committee.

Study Population

A total of 50 consecutive patients who presented to the emergency department with clinical features suggestive of AMI were initially screened. After applying exclusion criteria and accounting for loss to follow-up or incomplete data, 44 patients were included in the final analysis. Importantly, all patients included had ST-elevation myocardial infarction (STEMI) and were managed with thrombolysis using streptokinase.

Inclusion Criteria

1. Adults aged ≥18 years presenting with acute STEMI, diagnosed based on typical chest pain, ECG findings (ST-segment elevation in ≥2 contiguous leads), and elevated cardiac biomarkers (troponin or CK-MB).

Exclusion Criteria

1. Patients with a previous myocardial infarction in the last 6 weeks
2. Incomplete clinical or laboratory data
3. Left bundle branch block (LBBB) or paced rhythm
4. Refusal to participate

Consent and Ethics

Informed written consent was obtained from all participants prior to enrollment. Confidentiality was maintained throughout the study. The study protocol was approved by the institutional ethics committee.

Data Collection and Variables

Upon admission, detailed clinical history and examination findings were recorded, along with vital parameters including systolic blood pressure, heart rate, and Killip classification. Laboratory investigations included serum creatinine, cardiac enzymes, and ECG evaluation.

The GRACE risk score was calculated at admission using the standardized online tool (www.mdcalc.com). The following eight variables were used:

1. Age
2. Heart rate
3. Systolic blood pressure
4. Serum creatinine (mg/dL)
5. Killip class
6. Cardiac arrest at presentation
7. ST-segment deviation
8. Elevated cardiac enzymes

Patients were categorized into low (GRACE ≤108), intermediate (109–140), and high risk (GRACE >140) groups. They were managed as per standard STEMI protocols, including thrombolysis with streptokinase, dual antiplatelet therapy, beta-blockers, ACE inhibitors, and statins. All patients were monitored throughout hospitalization for adverse outcomes, including in-hospital mortality.

Statistical Analysis

Data were entered in Microsoft Excel and analyzed using SPSS software version 22 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as percentages. Comparisons between survivors and non-survivors were made using the Chi-square test or Fisher’s exact test for categorical data and the independent t-test for continuous variables. A p-value < 0.05 was considered statistically significant.

A total of 44 patients diagnosed with ST-elevation myocardial infarction (STEMI) were included in the final analysis. The mean age of the cohort was 64.27 ± 12.73 years, with a male predominance (72.7%). The mean systolic blood pressure on admission was 121.27 ± 18.75 mmHg, and the mean heart rate was 90.4 ± 17.1 bpm. Most patients presented in Killip class I (59.1%), followed by class II (20.5%), class IV (13.6%), and class III (6.8%).

All patients had ST-segment deviation, and 97.7% had elevated cardiac biomarkers. Cardiac arrest at presentation was observed in 4 patients (9.1%).

Table 1: Demographic and clinical profile of the study population:

GRACE- Global Registry of Adverse Cardiac Events

GRACE Score Distribution

The mean GRACE score was 134.86 ± 36.97, placing the majority of patients in the intermediate-to-high risk category. Stratification based on the GRACE score revealed:

1. Low risk (≤108): 12 patients (27.3%)
2. Intermediate risk (109–140): 12 patients (27.3%)
3. High risk (>140): 20 patients (45.5%)

Among patients classified as high risk, 6 patients (30%) experienced in-hospital mortality, whereas no deaths occurred in the low or intermediate groups.

Graph 1 shows the gender distribution of the study population. Males comprised the majority of the study population (72.7%), while females represented 27.3% showing 3:1 male-to-female ratio with the higher prevalence of acute coronary events in men, particularly in the middle-aged and older population.

In-Hospital Outcomes

Out of 44 patients, 38 (86.4%) were successfully discharged, while 6 (13.6%) died during hospitalization. Notably, all the deaths occurred exclusively among patients in the high-risk category with GRACE scores >140, whereas no mortality was reported in the low- or intermediate-risk groups. This finding highlights the strong predictive ability of the GRACE score in identifying patients at highest risk for short-term in-hospital mortality.

Table 2: Percentage of study population with ST Segment deviation:

All patients (100%) in the study showed ST segment deviation on their electrocardiogram. This finding confirms that the entire study population had acute coronary syndrome with significant electrocardiographic changes, likely representing ST-elevation myocardial infarction (STEMI).

Nearly all patients (97.7%) had elevated cardiac enzyme levels, with only one patient (2.3%) showing normal levels. This high percentage of cardiac enzyme elevation confirms myocardial damage in nearly the entire study population, supporting the diagnosis of acute myocardial infarction.

Thrombolysis and Management

All 44 patients included in the study were diagnosed with ST-elevation myocardial infarction (STEMI) and received thrombolytic therapy using streptokinase. This was administered as per standard STEMI protocols after ruling out contraindications. Additionally, all patients were treated with dual antiplatelet therapy (aspirin and clopidogrel), low molecular weight heparin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors or ARBs, and statins, unless contraindicated.

Table 3: Final Outcome of study population

The study showed a favourable overall outcome with 86.4% of patients being discharged alive, while 13.6% died during hospitalization.

The study population was stratified into risk categories based on GRACE scores: 27.3% were low risk, 27.3% were intermediate risk, and 45.5% were high risk. This distribution indicates that nearly half of the patients were at high risk for adverse cardiac events, with the remaining patients were equally divided between low and intermediate risk categories. The high proportion of high-risk patients explains the significant clinical interventions required.

None of the patients underwent primary percutaneous coronary intervention (PCI) during the study period due to institutional limitations. Patients were monitored throughout hospitalization for adverse outcomes, with appropriate adjustments to pharmacologic management based on clinical evolution.

In this study, the Global Registry of Acute Coronary Events (GRACE) score was assessed for its role in predicting in-hospital outcomes among patients with ST-elevation myocardial infarction (STEMI). Of the 44 patients evaluated, the overall in-hospital mortality rate was 13.6%, with all deaths confined to the high-risk category (GRACE score >140). This emphasizes the effectiveness of the GRACE score in early risk stratification and supports existing evidence of its prognostic accuracy. The mean GRACE score in our cohort was 134.9 ± 36.97, which is comparable to previously reported regional data. For instance, Prabhudesai et al., ³in a study of 235 Indian patients with acute coronary syndrome (ACS), found that the mean GRACE score was significantly higher in those who developed adverse outcomes (260.3) compared to survivors (199.3). Their analysis also reported an area under the ROC curve (AUC) of 0.75, reinforcing the score’s good predictive capability for in-hospital events.

Similarly, in a Pakistani cohort studied by Firdous et al.⁴, the mean GRACE score among deceased patients was 208.4 ± 43.1, significantly higher than that of survivors (133.8 ± 36.1), with a reported in-hospital mortality rate of 12.1%. The GRACE score effectively stratified patients, with 90% of expired cases belonging to the high-risk category. Our study mirrors these findings, with all six deaths confined to the high-risk group.

Furthermore, the analysis by Firdous and Malik ⁵emphasized the role of individual GRACE components such as age, systolic blood pressure, heart rate, and Killip class as strong determinants of mortality. We observed a similar pattern: non-survivors in our study had higher heart rates, lower systolic blood pressure, and were more likely to present in Killip class III or IV, further supporting the model’s internal validity

Importantly, all in-hospital deaths in our study occurred among patients with GRACE scores >140, while no mortality was recorded in the low- or intermediate-risk groups. This trend supports the GRACE score’s robust discriminatory power in predicting in-hospital mortality.

The study by Prabhudesai et al. ³also found a correlation between GRACE scores and coronary angiographic severity, with patients having scores ≥217 more likely to exhibit multivessel disease (p = 0.0009). Though angiographic data were not collected in our study, it is plausible that similar anatomical severity contributed to the high GRACE scores and mortality observed. Despite its strengths, GRACE has limitations. As noted by Firdous et al.⁴, it may overestimate mortality in certain high-risk STEMI patients, especially in those who receive timely and effective treatment. In our cohort, some high-score patients survived without complications, suggesting that while GRACE is effective in identifying risk extremes, its predictive accuracy may vary based on intervention timeliness, comorbidities, and institutional resources. The absence of primary percutaneous coronary intervention (PCI) in our study population, due to infrastructural constraints, may have contributed to the relatively high mortality. In centers with PCI availability, mortality may be lower even in high GRACE categories, potentially altering the calibration of the score. Strengths of this study include prospective design, use of real-time GRACE scoring, and complete follow-up during hospitalization. Limitations include the small sample size, single-center design, and absence of follow-up beyond discharge or angiographic correlation. Nonetheless, the findings add to the growing body of evidence supporting the GRACE score’s applicability in resource-limited settings and affirm its role as a valuable decision-support tool in acute cardiac care.

The present study confirms that the GRACE risk score is a reliable and practical tool for in-hospital risk stratification in patients presenting with ST-elevation myocardial infarction (STEMI). A significant association was observed between higher GRACE scores and adverse outcomes, particularly mortality. All in-hospital deaths occurred in the high-risk group, while no mortality was recorded among low- or intermediate-risk patients, highlighting the score’s strong discriminatory and negative predictive value.

Given its ease of calculation, integration of widely available clinical variables, and consistent predictive accuracy across multiple populations, the GRACE score should be routinely employed in emergency and critical care settings. It not only facilitates early identification of high-risk patients who may benefit from intensified monitoring or early intervention but also aids in transparent communication with patients’ families regarding prognosis. Larger multicentric studies with long-term follow-up and angiographic correlation are recommended to further validate these findings and enhance the clinical applicability of the GRACE model in Indian settings.

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