Additive value of the CRUSADE score to the GRACE score for mortality risk prediction in patients with acute coronary syndromes Alberto Cordero a,b, ⁎, Moisés Rodriguez-Manero b,c , Jose M. García-Acuña b,c , Ramón López-Palop a , Belen Cid b,c , Pilar Carrillo a , Rosa Agra-Bermejo b,c , Violeta González-Salvado b , Diego Iglesias-Alvarez b , Vicente Bertomeu-Martínez a , Jose R. González-Juanatey b,c a Cardiology Department, Hospital Universitario de San Juan, Alicante, Spain b Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain c Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain abstract article info Article history: Received 4 March 2017 Received in revised form 9 June 2017 Accepted 25 July 2017 Available online xxxx Introduction: Acute coronary syndrome (ACS) treatments increase bleeding complications that also impair prognosis. Bleeding risk scores reclassification of actual mortality risk estimated by the GRACE score might improve overall estimation. Methods: Observational and prospective study of all ACS patients admitted in two hospitals. Mortality risk was assessed by the GRACE score and bleeding risk by the CRUSADE score. We analyzed the net reclassification improvement (NRI) of adding the CRUSADE score to the GRACE score. Results: We included 6997 patients, mean age 67.4 (12.9), 38.0% ST-elevation ACS, mean GRACE score 145.2 (39.9). The percentage of patients with CRUSADE score N 20 or N 50 increased as the GRACE score was higher. Hospital mortality was 5.3% and the addition of the CRUSADE score reclassified a relevant percentage of patients with GRACE score N 109; NRI was 3.80% (1.10–6.10). During follow-up, (median 53.0 months) mortality rate was 22.6% and patients with CRUSADE score N 50 had significantly higher mortality rates in all GRACE score categories; NRI was high (46.6%, 95% CI 41.0–53.1). The multivariate analysis outlined the independent predictive value of CRUSADE score N 20 or N 50 as well as GRACE scores 109–139 and N 140. Conclusions: The addition of the CRUSADE score to the GRACE score improved mortality risk estimation. A CRUSADE score N 50 identified patients with higher post-discharge mortality and higher hospital mortality if GRACE score was N 109. The CRUSADE score improved hospital and long-term mortality prediction in patients with GRACE score N 140. Individual mortality risk estimation should integrate the CRUSADE and GRACE scores. © 2017 Published by Elsevier Ireland Ltd. Keywords: Acute coronary syndrome Bleeding risk Ischemic risk Reclassification Prognosis 1. Introduction Acute coronary syndromes (ACS) are heterogeneous processes trigged by intracoronary thrombosis that lead to myocardial ischemia [1]. Individual estimation of mortality risk has been clearly established for individual classification of hospital [2] and mid-term [3,4] prognosis. Among all the scales, the GRACE score has been widely accepted and endorsed by clinical guidelines [5]. Antiplatelet treatment and revascu- larization are the cornerstone of ACS treatment although they also increase the risk of bleeding complications [6]. The role of bleeding events has gained increased interest since they are also independent predictors of poorer outcomes [6]. Several features have been identified as independent predictors of bleeding, as age, previous bleeding, use dual antiplatelet or renal dysfunction, and most of them are also involved in ischemic risk [2,7–9]. The balance between mortality and bleeding risk can be determinant in many clinical decision-making such as revascularization [10,11], antiplatelet regimens and duration [12,13] or drug-eluting stents (DES) use [14]. Nevertheless, there is scarce evidence or recom- mendations regarding the integration of bleeding risk scales on daily clinical practice and patients' management [15–17].The aim of our study was to assess the role of CRUSADE bleeding score on reclassifica- tion for long-term mortality assessed by the GRACE score in a large cohort of ACS patients. 2. Methods We designed a retrospective study of all consecutive patients admitted for ACS in two different centers. ACS was defined by presence of typical clinical symptoms of chest pain and electrocardiographic changes indicative of myocardial ischemia/lesion and/or elevation of serum markers of myocardial damage [5,13]. A total of 7060 patients were admitted for ACS between November 2003 and March 2013 and 63 were excluding for lacking of any variable need to assess the GRACE and CRUSADE risk scores; therefore, International Journal of Cardiology xxx (2017) xxx–xxx ⁎ Corresponding author at: Cardiology Department, Hospital Universitario de San Juan, Carretera Valencia-Alicante sn, 03550, San Juan de Alicante, Alicante, Spain. E-mail address: acorderofort@gmail.com (A. Cordero). IJCA-25316; No of Pages 5 http://dx.doi.org/10.1016/j.ijcard.2017.07.095 0167-5273/© 2017 Published by Elsevier Ireland Ltd. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard Please cite this article as: A. Cordero, et al., Additive value of the CRUSADE score to the GRACE score for mortality risk prediction in patients with acute coronary syndromes, Int J Cardiol (2017), http://dx.doi.org/10.1016/j.ijcard.2017.07.095