GRACE Score Validation in Predicting Hospital Mortality: Analysis of the Role of Sex.

The GRACE (Global Registry of Acute Coronary Events) risk score is recommended for risk stratification in acute coronary syndrome (ACS). It does not include sex, a variable strongly associated with ACS prognosis. The aim of this study was to examine if sex adds prognostic information to the GRACE score in a contemporary population. Analysis of discrimination and calibration of GRACE score in the validation population, derived from the ARIAM-SEMICYUC registry (2012-2015). Outcome was hospital mortality. The uniformity of fit of the score was tested in predefined subpopulations: with and without ST-segment elevation myocardial infarction (STEMI and NSTEMI). A total of 9781 patients were included: 4598 with NSTEMI (28% women) and 5183 with STEMI (23% women). Discriminative capacity of the GRACE score was significantly lower in women with STEMI compared to men (area under the receiver operating characteristic curve [AUC] 0.82, 95% CI 0.78-0.86 vs. AUC 0.90, 95% CI 0.88-0.92,  = 0.0006). In multivariate analysis, female sex predicted hospital mortality independently of GRACE in STEMI ( = 0.019) but not in NSTEMI ( = 0.356) (interaction  = 0.0308). However, neither the AUC nor the net reclassification index (NRI) improved by including female sex in the STEMI subpopulation (NRI 0.0011, 95% CI -0.023 to 0.025;  = 0.928). Although female sex was an independent predictor of hospital mortality in the STEMI subpopulation, it does not substantially improve the discriminative ability of GRACE score.