Better Prognostic Risk Scoring Needed for Patients with Type 2 Myocardial Infarction
Key findings
- In a retrospective cohort of 359 patients with type 2 myocardial infarction, the average GRACE, TIMI and TARRACO scores were 140, 3.7 and 4.9, respectively
- The GRACE score modestly predicted in-hospital, 30-day and 90-day all-cause mortality; the other two scores were not predictive
- The TIMI and GRACE scores were modestly predictive of cardiovascular mortality, but the TARRACO score was not predictive
- The TIMI score modestly predicted major adverse cardiovascular events (MACE) within 30 days but not MACE in-hospital or at 90 days; the GRACE and TARRACO scores did not predict MACE
- Better risk stratification tools are needed for patients with type 2 myocardial infarction
In February 2019, researchers from the Joan XXIII University Hospital in Tarragona, Spain described in The American Journal of Medicine a new validated bedside tool, the TARRACO risk score, for predicting which patients with type 2 myocardial infarction (MI) are at the highest risk of adverse events. It considers cardiac troponin concentration, age, hypertension, chest pain, dyspnea and anemia.
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The TARRACO score joins the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk scores, which are validated to predict adverse outcomes in patients with type 1 MI.
Sean Murphy, MB, BCh, BAO, internal medicine resident, Jason H. Wasfy, MD, MPhil, medical director of the Massachusetts General Physicians Organization and director of Quality and Analytics in the Cardiology Division at Massachusetts General Hospital, and colleagues were recently the first to compare the performance of the GRACE, TIMI and TARRACO scores in patients with type 2 MI. In the Journal of the American College of Cardiology, they report that all three risk scores exhibited poor to modest ability to predict mortality or major adverse cardiovascular events (MACE) in type 2 MI.
The team reviewed 359 patients at Mass General who had a diagnosis of type 2 MI between October 2017 and May 2018 and were confirmed by the researchers to meet criteria for type 2 MI according to the 2018 Fourth Universal Definition of MI. The average age was 74. The average GRACE, TIMI and TARRACO scores were 140, 3.7 and 4.9, respectively.
The researchers found the following predictive value of the scores:
- All-cause Mortality: The GRACE score modestly predicted in-hospital, 30-day and 90-day mortality; the other two scores were not predictive
- Cardiovascular Mortality: The TIMI and GRACE scores were modestly predictive; the TARRACO score was not predictive
- MACE (a composite of cardiovascular mortality, stroke and recurrent type 1 or type 2 MI): The TIMI score modestly predicted 30-day MACE but not MACE in-hospital or at 90 days; the GRACE and TARRACO scores did not predict MACE
The Need for Better Risk Stratification
The limited value of the GRACE and TIMI scores in patients with type 2 MI might be attributable to the fact that such patients tend to be older and have a greater comorbidity burden than the type 1 MI cohorts from which the scores were derived.
Another problem might be the less frequent use of traditional type 1 MI therapies by patients with type 2 MI. In this study cohort, only 1.7% of patients underwent revascularization, and the use of secondary prevention medications was relatively low (aspirin, 69%; P2Y12 inhibitors, 11%; statins, 71%; beta blockers, 65%).
New risk stratification tools for patients with type 2 MI could guide risk-based monitoring and post-discharge care and improve patient categorization for clinical trials.
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