Clinical Application of CHA(2)DS(2)-VASc versus GRACE Scores for Assessing the Risk of Long-term Ischemic Events in Atrial Fibrillation and Acute Coronary Syndrome or PCI

Background: Early risk stratification of patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) has relevant implication for individualized management strategies. The CHA(2)DS(2)-VASc and GRACE ACS risk model are well-established risk stratification systems. We aimed to assess their prognostic performance in AF patients with ACS or PCI. Methods: Consecutive patients with AF and ACS or referred for PCI were prospectively recruited and followed up for 3 years. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular mortality, myocardial infarction, ischemic stroke, systemic embolism and ischemia-driven revascularization. Results: Higher CHA(2)DS(2)-VASc (HR [hazard ratio] 1.184, 95% CI 1.091-1.284) and GRACE at discharge score (HR 1.009, 95% CI 1.004-1.014) were independently associated with increased risk of MACCEs. The CHA(2)DS(2)-VASc (c-statistics: 0.677) and GRACE at discharge (c-statistics: 0.699) demonstrated comparable discriminative capacity for MACCEs (p = 0.281) while GRACE at admission provided relatively lower discrimination (c-statistics: 0.629, p vs. CHA(2)DS(2)-VASc = 0.041). For predicting all-cause mortality, three models displayed good discriminative capacity (c-statistics: 0.750 for CHA(2)DS(2)-VASc, 0.775 for GRACE at admission, 0.846 for GRACE at discharge). A significant discrimination improvement of GRACE at discharge compared to CHA(2)DS(2)-VASc was detected (NRI = 45.13%). Conclusions: In the setting of coexistence of AF and ACS or PCI, CHA(2)DS(2)-VASc and GRACE at discharge score were independently associated with an increased risk of MACCEs. The GRACE at discharge performed better in predicting all-cause mortality.