Global Registry of Acute

Coronary Events
Assessing Today’s Practice Patterns to
Enhance Tomorrow’s Care

Supported by an unrestricted educational grant from

sanofi-aventis to the Center for Outcomes Research
University of Massachusetts Medical School
 What is GRACE?

Global Registry of Acute Coronary Events

 Largest multinational registry covering the full
spectrum of ACS
 Generalizable patient inclusion criteria
 In-hospital and 6-month follow-up
 Representative of the catchment population:
(clusters of hospitals)
 Full spectrum of hospitals and facilities
 Training, audit and quality control
 International Scientific
Advisory Committee

International
International Advisory
AdvisoryCommittee
Committee

‘Americas’
‘Americas’ clusters
clusters ‘European’
‘European’ clusters
clusters
Chair:
Chair:JM
JMGore
Gore Chair:
Chair:KAA
KAAFox
Fox

88advisors
advisors 88advisors
advisors

40
40subsite
subsite 40
40subsite
subsite
cardiologists
cardiologists cardiologists
cardiologists
 Scientific Advisory Committee

Co-Chairs Keith AA Fox, UK Publications Kim A Eagle, USA

Joel M Gore, USA Co-Chairs Ph Gabriel Steg, France

Study Co-ordination Fred Anderson, University of Massachusetts

Argentina Germany United Kingdom

Enrique Gurfinkel Dietrich C Gulba Keith AA Fox
Australia/New Zealand Italy Marcus Flather
David Brieger Giancarlo Agnelli United States
Belgium France Frederick A Anderson
Frans J Van de Werf Gilles Montalescot Kim A Eagle
Brazil Ph Gabriel Steg Robert J Goldberg
Álvaro Avezum Poland Joel M Gore
Canada Andrzej Budaj Christopher B Granger
Shaun Goodman Spain Brian M Kennelly
José López-Sendón
 Objectives of GRACE

 Identify opportunities to improve the quality

of care for patients with ACS
 Describe diagnostic & treatment strategies,
& hospital & post-discharge outcomes
 Develop hypotheses for future clinical
research
 Disseminate findings to a wider audience
 Core GRACE Study Design

 ~100 hospitals in 13 countries

– Europe, North & South America, Australia,
New Zealand

 Population-based clusters with community

hospitals and referral centres

 First 10-20 consecutive cases per centre/month:

qualifying symptoms PLUS evidence of CAD

 Random audit of all centres: 3 year cycle

 Cluster Strategy for Study
Sites: Population-Based Design

1 3

18
18advisory
advisory ~100 hospitals
committee
committee ~10,000 ACS
members
members patients/year

6 4

5
 Multinational Site Network

Argentina 6 sites Germany 5 sites

Australia 6 sites Italy 5 sites

Belgium 6 sites New Zealand 2 sites

Brazil 7 sites Poland 6 sites

Canada 5 sites Spain 3 sites

France 7 sites UK 5 sites

USA 18 sites
81 Active Core Study Sites:
16 Clusters in 13 Countries
 Status of 16 Core Clusters

 60,723 cases enrolled

 85% six-month follow-up

Q3-2006
 The “Big Picture”
Core GRACE & GRACE2

GRACE Core

Substudy 1 Substudy 3
Substudy 2

GRACE Core GRACE2

60,723 patients 24,513 patients
81 hospitals 153 hospitals
13 countries 23 countries
 234 Core GRACE & GRACE2
Study Sites in 29 Countries*

*29 countries = 17 GRACE2 + 6 core GRACE + 6 both

 Status: September 30, 2006
81 Core & 153 Expanded Sites

 29 countries
 234 hospitals
 85,236 cases

Q3-2006
Internet Website
www.outcomes.org/grace
 Hospital Characteristics
Q4-2001 vs. Current Quarter

Q4-2001 Q3-2006
Number of Hospitals 109 81

Coronary care unit 94% 99%

Emergency department 86% 91%
Cardiac catheterization laboratory 65% 74%
Open heart surgery 43% 51%
Hospital beds (mean) 416 555
Coronary care unit beds (mean) 10 11
ACS admissions (mean, per year) 487 640
Q3-2006
 60,723 Cases Enrolled
as of September 30, 2006

70000
Initial CRF 6-Month Follow-up
58866 60723
60000 57406
55454
Cases Received

50000 46945 45106 46521 48045

43117
38444
40000 35301
28699 27618
30000
19453 20303
20000
11543 13245
10000 6689
2411
233
0
1999 2000 2001 2002 2003 2004 2005 Q1-06 Q2-06 Q3-06
Quarter-Year
Q3-2006
 Classification of Cases

40%
34%
29% 30%
30%
Patients (%)

20%

10% 7%

0%
STEMI UA NSTEMI Other
Q3-2006
 Hospital Discharge Status

STEMI NSTEMI UA
Death 8% 4% 3%
Home 77% 78% 87%
Transfer * 9% 11% 9%
Other 6% 6% 2%

*Transfer to another acute care hospital.

Q3-2006
 Admission versus Final
Diagnosis

UA MI ‘Rule-out’ MI Unspecified Other cardiac Non-cardiac

N=4999 N=4100 N=957 chest pain N=381 N=125
(44%) (36%) (9%) N=745 (3%) (1%)
(7%)
*Missing diagnosis in 236 patients

STEMI Non-STEMI Unstable Other cardiac Non-cardiac

N=3419 N=2893 angina N=508 N=326
(30%) (25%) N=4397 (4%) (3%)
(38%)

Admission diagnoses versus final diagnoses (derived from discharge diagnosis,

electrocardiographic changes and cardiac enzymes) in 11,543 patients with acute
coronary syndromes. Figures expressed as percentage of total ACS.

Fox KAA et al.Eur Heart J 2002;23:1177-89.

 Baseline Characteristics
STEMI NSTEMI UA
(n = 13,862) (11,316)
(12,509)
Median age (years) 65 68 66
Male (%) 70 66 64
Prior history (%)
• Angina 43 56 78
• Myocardial infarction 20 32 41
• PCI/CABG 8/5 15/14 25/19
• Smoking 62 57 55
• Diabetes mellitus 21 28 26
• Hypertension 52 62 66
• Hyperlipidemia 38 47 54
Participant in clin trial (%) 117 7
 Hospital Treatment According
to Admission Diagnosis
MI UA ? MI Chest pain
n 16,304 15,266 3,474 3,266

% % % %
ACE inhibitors 69 56 56 55
Aspirin 94 92 92 92
-blockers 83 81 81 79
Ca2+ blockers 15 34 30 29
Gp IIb/IIIa: no PCI 5 4 7 7
Gp IIb/IIIa with PCI 26 11 15 18
LMWH 52 64 40 40
UFH 59 43 51 51
Thrombolytic agents 35 2 3 3
 Diagnostic Procedures

100%
STEMI NSTEMI UA
78%
80% 73%
69%
Procedures (%)

58% 60%
60%
47%

40%
25%
18%17%
20%

0%
LVEF Echo Stress test
 Hospital Cardiac Interventions
According to Final Diagnosis

Intervention STEMI NSTEMI UA

n 13,862 11,316 12,509

% % %

Cardiac catheterization 62 57 49
PCI 45 31 23

CABG 4 7 6
 Treatments at Discharge

STEMI NSTEMI UA
n 13,862 11,316 12,509
% % %

ACE inhibitors 67 56 52
Aspirin 92 89 88
-blockers 78 76 72
Ca2+ blockers 10 20 31
Statins 63 59 57
Warfarin 8 7 7
 Hospital Outcome by
Final Diagnosis
20
STEMI (13,862)
NSTEMI (11,316)
15 UA (12,509)
Patients (%)

10 8

5
5 4
3 3
2
1.3 0.9
0.5
0
Death Major Bleed Stroke
 Hospital Outcomes

<0.0001 Elderly patients (>=75)

12
10.7 Younger patients (65-<75)

8 <0.0001
Patients (%)

5.6 5.6

4.0
4

0
Death Major bleed

Lankes W et al.Eur Heart J 2002;23(Abstr Suppl):502.

What proportion of eligible patients
receive reperfusion therapy?
Practice variation and missed opportunities
for reperfusion in ST-segment-elevation
myocardial infarction: findings from the
Global Registry of Acute Coronary Events
(GRACE)
Kim A. Eagle, Shaun G. Goodman, Álvaro Avezum,
Andrzej Budaj, Cynthia M. Sullivan, José López-Sendón,
for the GRACE Investigators

Lancet 2002;359:373-77
 Missed Opportunities for
Reperfusion
ST ↑ or LBBB, <12 hrs from onset, no contraindications

ANC (%) US (%) AB (%)EUR (%)

n 269 327 339 739

PCI alone 1.1 17.7 13.9 16.2

Lytic alone 66.9 30.6 53.1 49.4
Both 2.2 18.7 5.0 4.9
Neither 29.7 33.0 28.0 29.5

AB, Argentina/Brazil; ANC, Australia/New Zealand/Canada; EUR, Europe; US, United States

Eagle KA et al. Lancet 2002;359:373-7.

 Independent Predictors of
No Reperfusion

Variable OR (95% CI)

Prior CABG 2.28 (1.35 - 3.87)

History of diabetes 1.46 (1.11 -1.94)
History of congestive heart failure 2.92 (1.84 - 4.67)
Presentation without chest pain 2.23 (2.13 - 4.89)
*Age 75 years 2.37 (1.82 - 3.08)

*As compared to the <55 years age group

Eagle KA et al. Lancet 2002;359:373-7.

 Geographical Variation:
Admission to Hospitals
with/without Access to Cath Lab
100 Cath lab No cath lab
80 82
78
80
Patients (%)

61
60

39
40
20 22
18
20

0
USA Europe ANC AB

ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil

Global patterns of use of antithrombotic and
antiplatelet therapies in patients with acute
coronary syndromes: Insights from the Global
Registry of Acute Coronary Events (GRACE)
Andrzej Budaj, David Brieger, Ph Gabriel Steg, Shaun G. Goodman,
Omar H. Dabbous, Keith A. A. Fox, Álvaro Avezum, Christopher P.
Cannon, Tomasz Mazurek, Marcus D. Flather, and
Frans Van De Werf, for the GRACE Investigators

Am Heart J 2003;146:999-1006.
 Geographic Practice Variation
100 United States 92 92 91 95
Australia/New Zealand/Canada
80 Europe
65
Argentina/Brazil
Patients (%)

58
60

37 39
40 33
30
24
17 15
20 13
8 9

0
PCI GP IIb/IIIa LMWH ASA

Budaj A et al. Am Heart J 2003;146:999-1006.

 Antithrombotic Rx Used

None
18%
LMWH + UFH
llb/IIIa 30%
2%
UFH +
llb/IIIa
4%

LMWH
46%
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
 Incidence of Major Bleeding

9 UFH 8.3
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
Patients (%)

3.9
2.9
3 2.4

0
Major bleed
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
 Multivariate Adjusted Odds of
Major Hemorrhage
Major hem
UFH
3.9%
LMWH OR=0.55
P<0.001 2.4%
UFH + OR=2.26
IIb/IIIa 8.3%

LMWH + 2.9%
IIb/IIIa

0 0.5 1 2 3
Lower Higher
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
 Safety Events

3 UFH 2.9
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
Patients (%)

2
1.5
1.2
1 0.7 0.6 0.6 0.7
0.3
0.1 0 0 0
0
ICH Stroke  Plts
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
 Major Cardiac Events

15 UFH 13.8
LMWH 12.4
11.3
UFH + IIb/IIIa 10.6
9.9
LMWH + IIb/IIIa
Patients (%)

10

6.3 6.6
5 4.4 5
5
2.9 2.9

0
Death MI Death/MI

Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.

Predictors of major bleeding in acute
coronary syndromes: the Global Registry
of Acute Coronary Events (GRACE)

M. Moscucci, K.A.A. Fox, Christopher P. Cannon, W. Klein,

José López-Sendón, G. Montalescot, K. White, R.J. Goldberg,
for the GRACE Investigators

European Heart Journal 2003;24:1815-1823

 Incidence of Major Bleeding
6 Overall UA

5 NSTEMI STEMI 4.7 4.8

3.9
% of Patients

3
2.3
2

0
Major Bleed

Moscucci M et al.Eur Heart J 2003;24:1815-23.

 Predictors of Major Bleed
Variables Overall UA STEMI NSTEMI
Age (per 10 year ↑) x x x x
Female gender x x x
History of renal insufficiency x x x
History of bleeding x x x x
Killip Class IV x
MAP (per 20 mmHg ↓) x x
IV Inotropics x x x x
Other vasodilators x x
Thrombolytics x x
Diuretics x x x x
Unfractionated heparin x x
IIb/IIIa receptor blockers x x x
PA catheters x x x x
PCI x x x
Thrombolytics and IIb/IIIa inhib x x x
Moscucci M et al.Eur Heart J 2003;24:1815-23.
 In-Hospital Mortality Rates

50 No Major Bleed
Major Bleed
40
**
Patients (%)

30 ** **
** 22.8
18.6
20 16.1 15.3

10 5.3 7.0
5.1
3.0
0
Overall Unstable Angina NSTEMI STEMI
**P<0.001

Moscucci M et al.Eur Heart J 2003;24:1815-23.

 Outcome of “Low-risk”
Patients with ACS
 Presentation with UA in the absence of dynamic
ECG changes, no troponin elevation, no arrhythmia
nor hypotension
 Abnormal ECG in 38%,
 27% stress test, 37% echo, 52% angio
 6 month outcome:
– 23% readmission
– 12% revascularized
– 3% deaths
 “Low-risk” is not no risk

Devlin et al.Eur Heart J 2001;22(Abstr Suppl):525.

 Evidence Based Medicine
Total Population = 9,980

ST  MI Non- ST  MI UA % of
pts who
are
Therapy (n=2,501) (n=2,504) (n=3,631)
eligible
ASA X X X
B blocker X X
ACE-I X X
Reperfusion X
GP IIb/IIIa/LMWH X X
Granger CB et al. J Am Coll Cardiol 2001;37(2 Suppl A):503A.
 GRACE: Use of EBM in
“Eligible” Patients
100%
93% 89% In-hosp
Discharge
81%
80%
71% 70%
64%
% Ideal Use

60% 57% 14% 58%

PTCA
14%
IIb/IIIa
40%

56%
20% lytics 48%
LMWH

0%
ASA B-blocker ACE-I Reperf LMWH/IIb/IIIa

n=5,373 n=4,480 n=3,254 n=1,963 n=4112

Granger CB et al. J Am Coll Cardiol 2001;37(2 Suppl A):503A.
Management of acute coronary syndromes.
variations in practice and outcome: Findings
from the Global Registry of Acute Coronary
Events (GRACE)

K.A.A. Fox, S.G. Goodman, W. Klein, D. Brieger, P.G. Steg,

O. Dabbous and Á. Avezum for the GRACE Investigators

Eur Heart J 2002;23:1177-1189

 Geographic Practice Variation:
Discharge Medication
100 United States 94 93 94 93
Australia/New Zealand/Canada
80 Europe
Argentina/Brazil
Patients (%)

60 57
54 53 53
47 49 50

40
26
20

0
**P<0.01
ACE Statin AT/AC

AT/AC, antithrombin or anticoagulant

Fox KAA et al. Eur Heart J 2002;23:1177-89.
 Increase in Diagnosis of MI
Utilizing Troponin
30
26 n=3420 of 8213
with CK, CK-MB
25
& troponin
% Increase in Patients

measurements
20
with MI

15
15

10 9

0
Troponin + in addition Troponin + in addition Troponin + in addition
to CK  ULN to CK  2 x ULN to CK-MB  ULN

Goodman SG et al. J Am Coll Cardiol 2001;37(2 Suppl A):358A.

 In-Hospital Mortality
8
OR & 95% CI n=1111
5.8 *
6 (3.3 - 10.1)
Odds Ratio

n=900
4 3* n=124
(1.6 - 5.7) 2.1
(0.6 - 7.4)
2

0
CK  2 x ULN CK  2 x ULN CK > 2 x ULN CK > 2 x ULN
Troponin– Troponin + Troponin– Troponin +

*p<0.05 Goodman SG et al. J Am Coll Cardiol 2001;37(2 Suppl A):358A .

Impact of Aspirin on Presentation and
Hospital Outcomes in Patients with Acute
Coronary Syndromes (The Global Registry
of Acute Coronary Events [GRACE])
Frederick A. Spencer, Jose J. Santopinto, Joel M. Gore, Robert J.
Goldberg, Keith A.A. Fox, Mauro Moscucci, Kami White, and
Enrique P. Gurfinkel

Am J Cardiol 2002;90:1056-1061
 Impact of Prior ASA on ACS:
GRACE
100 Australia/New Zealand/Canada
Europe
77.8 74.5
80 70.3 69.5 South America
USA
Percentage

60

40
25.4
18.1 18.5 18.3
20

0
Hx of CAD (n=4974) No Hx of CAD (n=6414)
Prior long-ASA use according to geographic region
and history
 Type of ACS and Hospital
Mortality in Patients with History
of CAD Stratified By Prior ASA
80
Prior ASA No prior ASA  Impact of
60
58 prior ASA on:
– STEMI 0.52
45
(0.44,0.61)*
40
28 29 – Death 0.69
26
(0.5,0.95)**
20 15
7
3
0
STEMI NSTEMI UA Death
*Controlled for age, sex, medical hx, prior therapies, in hospital therapies
**Controlled for above plus MI type
 Type of ACS and Hospital Mortality
in Patients without History of CAD
Stratified By Prior ASA
60
Prior ASA No prior ASA
51  Impact of prior
44 ASA on:
40 – STEMI 0.35
31 (0.30,0.40)*
27
25
23 – Death 0.77
20 (0.55,1.07)**

5 6

0
STEMI NSTEMI UA Death
*Controlled for age, sex, medical hx, prior therapies, in hospital therapies
** Controlled for above plus MI type
Association of Statin Therapy with Outcomes
of Acute Coronary Syndromes: The GRACE
Study
Frederick A. Spencer, Jeanna Allegrone, Robert J. Goldberg, Joel M.
Gore, Keith A.A. Fox, Christopher B. Granger, Rajendra H. Mehta and
David Brieger for the GRACE Investigators*

Ann Intern Med 2004;140:857-866

 Prior and Early Utilization of Statins
in Patients with ACS: GRACE
18000

16000
Hospital Statins No Hospital Statins
14000
N/N
Patients

12000

10000

8000

6000 N/Y
N/Y
4000

2000
Y/Y
0
Prior Statins No Prior Statins

Ann. Intern Med. 2004;140:856-866.

 Final Diagnosis of ACS Patients
According to Previous Treatment
with Statins
St elevation MI* non-ST elevation MI Unstable angina
100

80
Patients, %

60

40

20

0
Previous Statin Use No Previous Statin Use
*Multivariate analysis: Prior statin users less likely to present with STEMI -OR 0.79 (0.71,0.88)
Ann. Intern Med. 2004;140:856-866.
 Hospital Outcomes of ACS
Patients Stratified by Statin Use
Outcome Prior statins Prior & Hospital Hospital Statins
Only Statin Only

Death 1.39 (0.91,2.14) 0.20 (0.16,0.25) 0.38 (0.30,0.48)

Recurrent MI 0.69 (0.43,1.11) 0.90 (0.75,1.07) 1.22 (1.08,1.37)

Stroke 1.08 (0.43,2.73) 0.68 (0.42, 1.12) 0.80 (0.57, 1.14)

Composite 1.02 (0.74,1.41) 0.66 (0.56,0.77) 0.87 (0.78,0.97)

*Compared to patients never receiving statins

Ann. Intern Med. 2004;140:856-866.

Comparison of Outcomes of Patients With
Acute Coronary Syndromes With and Without

Atrial Fibrillation
Rajendra H. Mehta, Omar H. Dabbous, Christopher B. Granger,
Polina Kuznetsova, Eva M. Kline-Rogers, Frederick A. Anderson, Jr.,

Keith A.A. Fox, Joel M. Gore, Robert J. Goldberg and Kim A. Eagle
for the GRACE Investigators

Ann J Cardiol 2003;92:1031-1036

 Adjusted ORs for Hospital
Events in Patients with ACS and
New-Onset Atrial Fibrillation
AF Better AF Worse

Major bleed

Stroke 

Cardiac arrest 

Pulmonary edema 

Shock 

Death 

0 0.5 1 1.5 2 2.5 3 3.5 4

Odds Ratio
Am J Cardiol 2003;92(9):1031-6
 Adjusted ORs for Hospital Events
in Patients with ACS and Previous
Atrial Fibrillation
AF Better AF Worse

Major bleed

Stroke 

Cardiac arrest 

Pulmonary edema 

Shock 

Death 

0 0.5 1 1.5 2 2.5

Odds Ratio
Am J Cardiol 2003;92(9):1031-6
Determinants and Prognostic Impact of Heart
Failure Complicating Acute Coronary
Syndromes: Observations From the Global
Registry of Acute Coronary Events (GRACE)

Philippe Gabriel Steg, Omar H. Dabbous, Laurent J. Feldman, Alain

Cohen-Solal, Marie-Claude Aumont, José López-Sendón, Andrzej
Budaj, Robert J. Goldberg, Werner Klein, Frederick A. Anderson, Jr,
for the Global Registry of Acute Coronary Events (GRACE)
Investigators

Circulation. 2004;109:494-499
 Impact of Heart Failure on
Admission on Hospital Mortality

>75 years 3.1 (2.4,3.9)

65-74 years 3.3 (2.3,4.8)

55-64 years 5.0 (2.9,8.3)

<55 years 10.1 (5.3,19.2)

1 10 20
Lower odds
ratio for death Higher odds of death
*Relative to patients without HF
Circulation 2004;109:494-499.
 Death Rates from Hospital Admission
to 6-Month Follow-Up for Patients
According to Timing of Heart Failure

Circulation 2004;109:494-499.
 Hospital Case-Fatality Rates
According to Development of
Heart Failure

Group HF (+) HF (-)

All patients 12.0% 2.9%

STEMI 16.5% 4.1%

Non-STEMI 10.3% 3.0%

Unstable angina 6.7% 1.6%

Circulation 2004;109:494-499.
Stenting and Glycoprotein IIb/IIIa Inhibition in
Patients With Acute Myocardial Infarction
Undergoing Percutaneous Coronary Intervention:
Findings From the Global Registry of Acute
Coronary Events (GRACE)

Gilles Montalescot, Frans Van de Werf, Dietrich C. Gulba, Àlvaro

Avezum, David Brieger, Brian M. Kennelly, Tomasz Mazurek,
Frederick Spencer, Kami White, and Joel M. Gore for the GRACE
Investigators

Catheterization & Cardiovascular Interventions. 60:360-367 (2003)

 Probability of Survival at
6 Months (all PCI)

Death rates:
+GP +stent 7.3% +GP –stent 12.8%
-GP +stent 6.7% -GP – stent 14.4%

Montalescot G et al.Catheter Cardiovasc Interv 2003;60:360-7.

 Probability of Survival at
6 Months (Primary PCI)

Death rates:
+GP +stent 7.7% +GP –stent 7.4%
-GP +stent 8.7% -GP –stent 20.1%

Montalescot G et al.Catheter Cardiovasc Interv 2003;60:360-7.

Six-Month Outcomes in a Multinational
Registry of Patients Hospitalized With an
Acute Coronary Syndrome (The Global
Registry of Acute Coronary Events [GRACE])

Robert J. Goldberg, Kristen Currie, Kami White, David Brieger,

Phillippe Gabriel Steg, Shaun G. Goodman, Omar Dabbous, Keith
A.A. Fox and Joel M. Gore for the GRACE Investigators

Am J Cardiol 2004;93:288-293
 Six-Month Follow-Up*

STEMI NSTEMI UA

Death 5% (480/9414) 6% (496/7977) 4% (349/9357)

Stroke 1% (110/9173) 1% (103/7749) 1% (79/9176)

Rehospitalized 18% (1619/9147) 19% (1501/7721) 19% (1761/9150)

*Excluding events that occurred in hospital

Goldberg RJ et al.Am J Cardiol 2004;93:288-93.

 Discharge to 6 Month Outcomes:
Cardiac Interventions
Scheduled and unscheduled procedures
20
STEMI (5,476)
16.2 15.7 NSTEMI (5,209)
14.7 UA (6,149)
15
Patients (%)

10 9.3
8.0 8.3
7.1
6.1
5.0
5

0
Cardiac cath PCI CABG

Goldberg RJ et al.Am J Cardiol 2004;93:288-93.

 6 Month Follow-up

30 UFH 27.6
LMWH
25 23.1
UFH + IIb/IIIa
19.7
Patients (%)

20 LMWH + IIb/IIIa 18.1 18.5 19.0

15 12.2

10 7.8
5.8 6.4 5.7
4.1
5

0
Death MI Rehosp
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
 Total Outcomes:
Admission to 6 Months

30 STEMI (2075)
NSTEMI (1856)
UA (2883) 20 20
Patients (%)

20 17

12 13

10 8

3 3
1.5
0
Death Stroke Urgent
readmission for
cardiac event
 Survival Rate 6 Months Post
Discharge for STEMI, NSTEMI,
and UA Patients
100

90
% Surviving

80
STEMI Non-STEMI UA

70

60

50
0 1 2 3 4 5 6
Months after hospital discharge
Goldberg RJ et al.Am J Cardiol 2004;93:288-93.
 Factors Associated With An
Increased Risk of Post-Discharge
Death
Characteristic STEMI Non-STEMI
Age (yrs) HR 95% CI HR 95% CI
65-74 3.48 2.00-6.06 2.17 1.27-3.72
>75 8.95 5.28-15.20 5.30 3.19-8.80

Medical history
HF 2.21 1.61-3.04 2.20 1.71-2.84
MI 1.69 1.28-2.22
TIA/Stroke 1.37 1.03-1.84

Hospital complications
Cardiogenic shock 1.94 1.20-3.15
HF 2.16 1.65-2.83 1.91 1.49-2.44
Stroke 2.51 1.32-4.78

Goldberg RJ et al.Am J Cardiol 2004;93:288-93.

 Factors Associated with an
Increased Risk of Post-Discharge
Death in Patients with UA

Characteristic
Age (yrs) HR 95% CI
55-64 3.34 1.81-6.19
65-74 5.29 2.88-9.72
Medical history
HF 2.23 1.61-3.08
MI 1.44 1.09-1.91
PCI 0.52 0.35-0.77

Hospital complications
Cardiogenic shock 4.01 1.73-9.28
HF 1.67 1.17-2.37

Goldberg RJ et al.Am J Cardiol 2004;93:288-93.

From guidelines to clinical practice: the
impact of hospital and geographical
characteristics on temporal trends in the
management of acute coronary syndromes:
The Global Registry of Acute Coronary Events
(GRACE)
Keith A.A. Fox, Shaun G. Goodman, Frederick A. Anderson Jr.,
Christopher B.Granger, Mauro Moscucci, Marcus D. Flather ,
Frederick Spencer, Andrzej Budaj, Omar H. Dabbous, Joel M. Gore
on behalf of the GRACE Investigators

European Heart Journal 2003;24:1414-1424

 Temporal Trends in
ACS Diagnostic Categories

STEMI Non-STE MI UA
50%

40%
Patients (%)

30%

20%

10%

0%
1999 2000 2001 2002 2003
(n=5513) (n=8787) (n=8934) (n=8944) (n=5924)
Year of Discharge
 Temporal Trends STEMI:
In-hospital Therapies
60 LMWH Ticl/Clop GPIIb/IIIa*
Patients (%)

40

20

0
Jul-Dec Jan-Jul Jul-Dec Jan-Jul Jul-Dec
1999 2000 2000 2001 2001
Year of Treatment
*without PCI Fox KAA et al. Eur Heart J 2003;24:1414-24.
 Temporal Trends STEMI:
Reperfusion
Lytics Primary PCI* No reperfusion
60
Patients (%)

40

20

0
Jul-Dec Jan-Jul Jul-Dec Jan-Jul Jul-Dec
1999 2000 2000 2001 2001
Year of Treatment
*within 12 h Fox KAA et al. Eur Heart J 2003;24:1414-24.
 Temporal Trends NSTEMI:
In-hospital Therapies
80 LMWH Ticl/Clop GPIIb/IIIa

60
Patients (%)

40

20

0
Jul-Dec Jan-Jul Jul-Dec Jan-Jul Jul-Dec
1999 2000 2000 2001 2001
Year of Treatment
Fox KAA et al. Eur Heart J 2003;24:1414-24.
 GRACE Palm Pilot Software
In-hospital, 6-months
Death, Death/MI Prediction Model
GRACE PDA Software
GRACE PDA Software
At Admission Risk Model
At Discharge Risk Model
GRACE Publications
 Abstract Acceptance Rate
(1999 to 2006)
100% Overall rate = 59%
Number of abstracts accepted = 94
77%
80%
Accepted (%)

57%
60%
43%
40%

20%

0%
ESC ACC AHA
 Manuscript Status

Published/in press 46
Provisionally accepted 1
Submitted 8
Being revised following submission 7
Edit/write assistance 12
Top priority independent 7
Medium priority 7
Low priority 5

0 10 20 30 40 50
GRACE Quarterly Reports to
Investigators
Quarterly Report
Current Quarter vs. Overall
Quarterly Report
Temporal Trends
 Unique Features of GRACE

 Multi-national perspective
 Full spectrum of coronary syndromes
 Increased data on demographics,
presentation, management and outcome
 Regular audits of data quality
 Feedback to participating sites
 6-month follow-up