GRACE score vs GWTG-HF score: risk stratification in acute heart failure
Authors: Santos M , Paula S , Almeida I , Santos H , Miranda H , Sa C , Chin J , Almeida S , Sousa C , Tavares J , Santos L , Almeida ML 
Published: April 2021

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Patients (P) with acute heart failure (AHF) are a heterogeneous population. Therefore, early risk stratification at admission is essential. The Get With The Guidelines Heart Failure score (GWTG-HF) predicts in-hospital mortality (IHM) of patients admitted with AHF. GRACE score estimates risk of death, including IHM and long-term mortality (M), in non-ST elevation acute coronary syndromes.

Objective
To validate GRACE score in AHF and to compare GRACE and GWTG-HF scores as predictors of IHM, post discharge early and late M [1-month mortality (1mM) and 1-year M (1yM)], 1-month readmission (1mRA) and 1-year readmission (1yRA), in our center population, using real-life data.

Methods
Based on a single-center retrospective study, data collected from P admitted in the Cardiology department with AHF between 2010 and 2017. P without data on previous cardiovascular history or uncompleted clinical data were excluded. Statistical analysis used chi-square, non-parametric tests, logistic regression analysis and ROC curve analysis.

Results
35.3% were admitted in Killip-Kimball class (KKC) 4. Mean GRACE was 147.9 ± 30.2 and mean GWTG-HF was 41.7 ± 9.6. Inotropes’ usage was necessary in 32.7% of the P, 11.3% of the patients needed non-invasive ventilation, 8% needed invasive ventilation. IHM rate was 5%, 1mM was 8% and 1yM 27%. 6.3% of the patients were readmitted 1 month after discharge and 52.7% had at least one more admission in the year following discharge.
Older age (p &lt; 0.001), lower SBP (p = 0,005), higher urea (p = 0,001), lower sodium (p = 0.005), previous history of percutaneous coronary intervention (p = 0,017), lower GFR (p &lt; 0.001) and need of inotropes (0.001) were predictors of 1yM after discharge in our population. As expected, patients presenting in KKC 4 had higher IHM (OR 8.13, p &lt; 0.001), higher 1mM (OR 4.13, p = 0.001) and higher 1yM (OR 1.96, p = 0.011). On the other hand, KKC at admission did not predict readmission (either 1mRA or 1yRA, respectively p = 0.887 and p = 0.695).
Logistic regression confirmed that GWTG-HF was a good predictor of IHM (OR 1.12, p &lt; 0.001, CI 1.05-1.19) but also 1mM (OR 1.1, p = 0.001, CI 1.04-1.16) and 1yM (OR 1.08, p &lt; 0.001, CI 1.04-1.11). GRACE also showed the ability to predict IHM (OR 1.06, p &lt; 0.001, CI 1.03-1.10), 1mM (OR 1.04, p &lt; 0.001, CI 1.02-1.06) and 1yM (OR 1.03, p &lt; 0.001, CI 1.01-1.03). ROC curve analysis revealed that GRACE and GWTG-HF were accurate at predicting IHM (AUC 0.866 and 0.774, respectively), 1mM (AUC 0.779 and 0.727, respectively) and 1yM (AUC 0.676 and 0.672, respectively). Both scores failed at predicting 1mRA (GRACE p = 0.463; GWTG-HF p = 0.841) and 1yRA (GRACE p = 0.244; GWTG-HF p = 0.806).

Conclusion
This study confirms that, in our population, both scores were excellent at predicting IHM, with GRACE performing better. Although both scores were able to predict post-discharge mortality outcomes, their performance was poorer.