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Identification of patients with suspected NSTE-ACS in the observe zone: Evaluating GRACE 1.0 score and a biomarker panel for risk stratification and management optimization

https://doi.org/10.1007/s00392-025-02625-4

Mustafa Yildirim (Heidelberg)1, C. Reich (Heidelberg)1, C. Salbach (Heidelberg)1, M. Biener (Heidelberg)1, M. Müller-Hennessen (Heidelberg)2, N. A. Sörensen (Hamburg)3, P. Haller (Hamburg)4, S. Blankenberg (Hamburg)4, J. T. Neumann (Hamburg)5, R. Twerenbold (Hamburg)4, N. Frey (Heidelberg)1, E. Giannitsis (Heidelberg)1

1Universitätsklinikum Heidelberg Klinik für Innere Med. III, Kardiologie, Angiologie u. Pneumologie Heidelberg, Deutschland; 2Atos Praxisklinik Zentrum für Gefäßerkrankungen und Präventivmedizin Heidelberg, Deutschland; 3Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Kardiologie Hamburg, Deutschland; 4Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 5Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland

 

Background. Current guidelines recommend additional diagnostic work-up for patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) triaged in the observe zone using accelerated diagnostic protocols. This study assessed the effectiveness of combining the Global Registry of Acute Coronary Events (GRACE) 1.0 score with additional non-cardiospecific biomarkers for risk stratification in the observe zone.

Methods. A total of 6,789 patients with suspected NSTE-ACS were enrolled over 24 months, with 961 (21.8%) assigned to the observe zone. A classification and regression tree (CART) analysis dichotomized risk using the GRACE score and additional biomarkers beyond high-sensitivity cardiac troponin including C-reactive protein <10mg/dL, N-terminal pro-B-type natriuretic peptide <300ng/L, D-dimers <5mg/L, estimated glomerular filtration rate >30ml/min/1.73m², Copeptin <10pmol/L, and haemoglobin >10g/dL. The primary endpoint was 1-year all-cause mortality, validated using the Biomarkers in Acute Cardiac Care (BACC) cohort.

Results. A low GRACE 1.0 score <109 points was found in 37.6% of observe zone patients, showing a negative predictive value of 98.6% and sensitivity of 89.8% for death. Adding biomarker information reduced predicted 1-year-mortality from 1.38% with the GRACE score alone to 0.46% when none of the biomarkers were above cutoff (prevalent in 22.7%). The proportion of protocol-eligible patients increased from 22.7% to 37.6%, with no events within 30 days. Findings were confirmed in the BACC cohort.

Conclusions. A low GRACE 1.0 score combined with ≤1 elevated biomarker significantly improves mortality prediction in the observe zone, helping identify low-risk patients for further out-of-hospital diagnostic work-up, potentially decongesting crowded emergency departments.

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