Gestalt or Global Registry of Acute Coronary Events (GRACE) Risk Score for Predicting Acute Coronary Syndrome and Associated Complications

Abstract: Introduction: There is a need for risk stratification of emergency department (ED) chest pain patients. The Global Registry of Acute Coronary Events risk score (GRACE RS) predicts adverse events in patients with confirmed acute coronary syndrome (ACS), and has been validated on unselected ED patients with chest pain. Clinical gestalt is the unstructured overall clinical assessment, based on the physicians experience and judgment. This study compared the ability of the gestalt and the GRACE RS to predict ACS and complications within 30 days in ED chest pain patients. Materials and methods: This was a prospective study of ED chest pain patients at the Skåne University Hospital at Lund, Sweden. The GRACE RS was calculated and gestalt noted for each patient. Endpoints at 30 days included: acute myocardial infarction (AMI), unstable angina (UA), revascularization, all cause mortality, major bleeding, stroke and arrhythmia. Gestalt was categorized as no risk of ACS, low risk of ACS, moderate risk of ACS, high risk of UA and high risk of AMI. The predictive ability of the GRACE RS and gestalt was compared using areas under the receiver operator characteristic curves (AUROC). Results: 874 patients were included in the final analysis. Of these, 95 had an ACS and 102 had ACS and/or complications. Gestalt was superior to the GRACE RS in predicting the risk for ACS and/or complications at 30 days (AUROC 0.89 (95 % CI 0.85-0.93) vs. 0.67 (95 % CI 0.62-0.72), p < 0.001)). Conclusions: The clinicians’ overall gestalt assessment was a very good to excellent predictor of ACS and ACS and/or complications within 30 days. Further, gestalt was superior to the GRACE RS in predicting ACS and/or complications. This study indicates that before implementing a risk score in clinical practice, it should be validated against physicians’ gestalt.