320 Rev Assoc Med Bras 2023;69(2):320-324 ORIGINAL ARTICLE https://doi.org/10.1590/1806-9282.20221125 Investigation of the effectiveness of the Quick Sequential Organ Failure Assessment-Troponin scores in non- ST-elevation myocardial infarction Başar Cander1 , Bahadır Taşlıdere1* , Ertan Sönmez1 INTRODUCTION Chest pain constitutes a significant portion of all emergency department (ED) admissions1. Approximately 5–20% of patients who enter the ED with chest pain (typical or atypi- cal) are diagnosed with acute coronary syndrome (ACS)2. This syndrome is one of the leading causes of death3. Even in ACS patients with timely medical intervention, 1-year mortality is 5%, and in-hospital mortality is 7.5%4. Approximately 70% of all ACS present as non-STEMI (ST-elevation myocardial infarction)5. The international cardiac guidelines recommend that patients presenting to the ED with chest pain should be evaluated using a risk score6. A frequently used and high-per- forming tool for this purpose is the Global Registry of Acute Coronary Events (GRACE)7. The GRACE identifies risk factors that help independently predict in-hospital and 6-month mor- tality rates. The score is calculated based on clinical parameters such as creatinine, troponin value, Killip class, and vital signs. The Quick Sequential Organ Failure Assessment (qSOFA) tool was developed to predict the prognosis and need for intensive care in sepsis patients. The qSOFA measurement is a sim- ple score composed of three parameters, i.e., respiratory rate, Glasgow Coma Scale, and blood pressure8. Many studies have shown that the qSOFA score can be used to predict the need for intensive care and the probability of mortality9. Serum cardiac troponins are used to verify a diagnosis of ACS and predict its prognosis10. But a more reliable predictor is needed for ACS patients with high mortality risk. Therefore, we investigated the prognostic accuracy of the qSOFA score by adding cTnI concentration (as a fourth parameter). The aim of this study was to assess the effectiveness of the GRACE and qSOFA-T scores on in-hospital mortality rate in non-STEMI patients. METHODS This study was conducted retrospectively between January 1, 2016, and December 31, 2018, on patients over the age of 18 years who were admitted to the ED. All patients who presented to the ED with ACS were evaluated consecutively (symptoms 1Bezmiâlem Vakıf Üniversitesi, Faculty of Medicine, Department of Emergency Medicine – İstanbul, Turkey. *Corresponding author: drbahadir@yahoo.com Conflicts of interest: the authors declare there is no conflicts of interest. Funding: none. Received on August 24, 2022. Accepted on October 26, 2022. SUMMARY OBJECTIVE: A reliable predictor is needed for non-ST-elevation myocardial infarction patients with high mortality risk. The aim of this study was to assess the effectiveness of the Global Registry of Acute Coronary Events and Quick Sequential Organ Failure Assessment-Troponin (qSOFA-T) scores on in-hospital mortality rate in non-ST-elevation myocardial infarction patients. METHODS: This is an observational and retrospective study. Patients admitted to the emergency department with acute coronary syndrome were evaluated consecutively. A total of 914 patients with non-ST-elevation myocardial infarction who met inclusion criteria were included in the study. The Global Registry of Acute Coronary Events and qSOFA scores were calculated and investigated its contribution to prognostic accuracy by adding cardiac troponin I (cTnI) concentration to the qSOFA score. The threshold value of the investigated prognostic markers was calculated by receiver operating characteristic curve analysis. RESULTS: We found the in-hospital mortality rate to be 3.4%. The area under the receiver operating characteristic curve for Global Registry of Acute Coronary Events and qSOFA-T is 0.840 and 0.826, respectively. CONCLUSION: The qSOFA-T score, which can be calculated easily, quickly, and inexpensively and obtained by adding the cTnI level, had excellent discriminatory power for predicting in-hospital mortality. Difficulty in calculating the Global Registry of Acute Coronary Events score, which requires a computer, can be considered a limitation of this method. Thus, patients with a high qSOFA-T score are at an increased risk of short-term mortality. KEYWORDS: Acute coronary syndrome. Troponin I. Mortality. Non-ST elevated myocardial infarction. https://doi.org/10.1590/1806-9282.20221125 http://orcid.org/0000-0003-1035-1907 http://orcid.org/0000-0002-5920-8127 http://orcid.org/0000-0003-1774-3276 mailto:drbahadir@yahoo.com Cander, B. et al. 321 Rev Assoc Med Bras 2023;69(2):320-324 determined by the American Heart Association). Patients diag- nosed with non-STEMI were included in the study. Informed consent was waived (a retrospective study). This is an observa- tional study, in accordance with the Declaration of Helsinki. The Ethics Committee’s approval was obtained. Patient infor- mation was obtained using the International Classification of Diseases (ICD)-10. The study excluded patients with trauma, pregnant women, patients with missing data, patients whose scores could not be calculated, patients with STEMI, patients with unstable angina pectoris (USAP), and patients with a Charlson Comorbidity Index (CCI) score of 3 or higher. The CCI is a useful measure of comorbidity to standardize the evaluation of patients. Infectious pathologies affecting the qSOFA score were excluded. A total of 1,996 patients were evaluated. Of these, 126 were discharged from the ED. There were 641 patients with a CCI score of 3 or higher, 126 had chest pain due to other causes, 146 patients were hospitalized in non-cardiology departments, and 43 refused treatments. Definitions and variables All patients were managed as per the institutional protocol. The blood sample and scores were calculated in the first 6 h of observation in the ED. Documentation that was previously produced was used to record the collected variables, including demographic data, comorbidities, laboratory test results, vital parameters, and physical examination findings. The GRACE and qSOFA scores were calculated. We selected the GRACE score, which is recommended for long-term prognosis and mortality prediction, as the appropriate score for comparison. GRACE score parameters include age, heart rate, blood pres- sure, Killip class, ST segment, creatinine, and troponin level. By definition, the qSOFA score consists of three parameters, namely, blood pressure, respiratory rate, and Glasgow Coma Scale9. We defined the qSOFA-T score by combining these characteristics with the troponin value. Anyone with a cTnI value greater than 40 ng/L received 1 point (the value where the corporate reference value is positive). The precision of the qSOFA-T score obtained by adding troponin to the qSOFA score has never been investigated in any previous study. Two emergency medicine physicians worked independently during the acquisition of the data. The serum high-sensitive cTnI levels were based on patients’ baseline values at admission (the nor- mal reference range in our biochemistry laboratory was 0–40 ng/L; Abbott Lab., Chicago, IL, USA). Receiver operating characteristic (ROC) curve analysis was used to determine the threshold value for the prognostic markers (GRACE score and qSOFA-T score) that were investigated in the study. All  patients with ACS who required cardiac follow-up constituted the study sample (medical or CABG in their follow-up). In a sample of size n=869, we had 80% power at an α value of 0.05 to find a difference of 1%. Statistical analysis Centralization and measures of variance, such as mean±stan- dard deviation (SD), were used to express quantitative vari- ables. Fisher’s exact test and the chi-square test were used to identify differences in the ratios and relationships between cat- egorical variables. To determine the behavioral differences in the group averages, the Mann-Whitney U test was used when the assumptions of normality and equivalence were not met. The ROC analysis was used to determine the threshold values of the numerical parameters that were used to predict disease status and to evaluate the indicators’ accuracy. The statistical significance level was set at p=0.05 and below. For this pur- pose, the IBM SPSS Statistics for Windows software package (Armonk, NY) was used. Distribution statistics for the categor- ical demographic variables are shown as n (%), and distribution statistics for the numerical variables are shown as mean±SD// median (min-max). RESULTS Of the 914 patients, 628 (68.7%) were male and 286 (31.3%) were female (p=0.478). The mean age was 52.95±13.73 years (p=0.003). The number of in-hospital deaths was 31 (3.4%). The most common chronic diseases in deceased patients were coronary artery disease, hypertension, and diabetes mellitus, and in living patients, they were hypertension, diabetes mellitus, and coronary artery disease. There was no statistically significant difference between the hemogram and routine biochemistry tests between the two groups. The mean GRACE score in the in-hospital deceased group was 149.77±29.31. In the survivor group, it was found to be 103.3±34.58 (p<0.001) (Table 1). The mean qSOFA-T score for the in-hospital deaths group was 2.03±1.09. It was calculated as 1.09±0.34 in the survi- vor group (p<0.001) (Table 1). The GRACE score has already been a proven prognostic scoring system. In our study, the area under the ROC curve was 0.840 (95% confidence interval (CI): 0.782–0.899) with a cutoff value of 139.5. The  ROC anal- ysis was also performed to determine whether the qSOFA-T Table 1. Risk scores. Deceased patients Living patients p GRACE score 149.7±29.3 103.3±34.5 <0.001 qSOFA-T 2.03±1.09 1.09±0.34 <0.001 https://www.cureus.com/publish/articles/108695-investigation-of-the-effectiveness-of-the-grace-and-qsofa-t-scores-for-mortality-prediction-in-non-st-elevation-myocardial-infarction/preview#table-anchor-422107 https://www.cureus.com/publish/articles/108695-investigation-of-the-effectiveness-of-the-grace-and-qsofa-t-scores-for-mortality-prediction-in-non-st-elevation-myocardial-infarction/preview#table-anchor-422107 The efficiency of Quick Sequential Organ Failure Assessment-Troponin score in non-ST elevation myocardial infarction 322 Rev Assoc Med Bras 2023;69(2):320-324 score had a diagnostic value for in-hospital mortality. The area under the ROC curve was 0.826 (95%CI 0.743–0.91) with a cutoff value of 1.5 (Table 2; Figure 1). Considering the area covered by the ROC curve, the GRACE score was 139.5 and the qSOFA-T score was 1.5. DISCUSSION When compared to participants in similar previous stud- ies, our patients were younger, more often male, and had similar prevalence rates of diabetes and hypertension11. This study examined the predictive value of GRACE score, and qSOFA-T score in a large sample of patients who were diagnosed with non-STEMI. qSOFA is widely used to pre- dict mortality in many diseases. For example, it has been demonstrated to have a significant correlation with mor- tality from conditions such as acute decompensated heart failure and sepsis12. These successful results were due to the precise selection of the reviewed parameters. Systolic blood pressure is a combination of cardiac output and systemic peripheral resistance. A normal-to-high measurement may indicate better-preserved cardiac function. Another param- eter, respiratory rate, was found to be a predictor of mor- tality in patients with ACS in selected studies13, owing to changes in respiratory control due to cardiac dysfunction manifested themselves as an increase in respiratory rate. This suggests that respiratory rate should be included in risk assessment strategies for patients with ACS14. Many studies15 have shown that the third parameter, the Glasgow Coma Scale, has a predictive value for survival after hospi- tal discharge. Despite these features, the effectiveness of the qSOFA score in determining prognosis in ACS (especially non-STEMI) patients at high risk of adverse events has not been adequately studied. To increase the logistic regression power of qSOFA, we added the cTnI level as a fourth param- eter in the score. In doing so, we found that the AUC of the qSOFA-T score reached 0.826 (an excellent discriminatory power). As a result, the qSOFA-T score is appropriate for use in EDs since it is easy, quick, inexpensive, and effective. Studies have shown that the GRACE score has the highest predictive accuracy for mortality in patients with ACS16. In addition, the European Society of Cardiology guideline accepts GRACE as a method of risk scoring. GRACE score has been thoroughly validated for assessing prognosis in non-STEMI, based on registries and large trials16. Our study found that the AUC of the GRACE score was 0.840 (the qSOFA-T score was found to be 0.826). When the results obtained are found to be 0.8≤AUC<0.9, it indicates excel- lent discriminating power17. In a similar study, GRACE score (AUC=0.80) for non-STEMI patients was found to have excellent discriminatory power18. The qSOFA-T score has never been studied before for predicting mortality in ACS patients. According to the study, both scores can be used to identify patients at high risk of coronary events in the con- text of non-STEMI. In a study, it was shown that a GRACE score >133 is significant in terms of acute conditions19. In our study, the mean GRACE score in the in-hospital mortality group was 149.77 with a cutoff value of 139.5. According to GRACE’s guidelines, in-hospital mortality is above 3% when the score is above 140 points20. In our study, this rate was similarly found to be 3.4%. The mean value for qSO- FA-T was 2.03 with a cutoff value of 1.5. For this reason, it is necessary to ensure that the qSOFA-T score is positive for at least two of the four parameters. Table 2. Comparison of scores by receiver operating characteristic analysis. Variable AUC 95%CI Sensitivity Specificity Threshold GRACE score 0.840 0.782–0.899 0.710 0.831 139.5 qSOFA-T score 0.826 0.743–0.91 0.710 0.928 1.5 Figure 1. Comparison of in-hospital mortality using Global Registry of Acute Coronary Events and qSOFA-T. https://www.cureus.com/publish/articles/108695-investigation-of-the-effectiveness-of-the-grace-and-qsofa-t-scores-for-mortality-prediction-in-non-st-elevation-myocardial-infarction/preview#table-anchor-422108 Cander, B. et al. 323 Rev Assoc Med Bras 2023;69(2):320-324 REFERENCES 1. Shah P, Patel K, Vasudev R, Patel H, Thakkar S, Adalja D, et al. Gender differences in the revascularization rates and in-hospital outcomes in hospitalizations with ST segment elevation myocardial infarction. Ir J Med Sci. 2020;189(3):873-84. https://doi.org/10.1007/ s11845-019-02147-9 2. Penumetsa SC, Mallidi J, Friderici JL, Hiser W, Rothberg MB. Outcomes of patients admitted for observation of chest pain. Arch Intern Med. 2012;172(11):873-7. https://doi.org/10.1001/ archinternmed.2012.940 3. Neves VB, Roman RM, Vendruscolo T, Heineck G, Mattos CAS, Mattos EI, et al. 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Second, anyone with a cTnI value above 40 received 1 point. This could be a bias point. CONCLUSION A reliable predictor is needed for non-STEMI patients with mortal- ity risk. The GRACE score is a previously known score with proven effectiveness. Difficulty in calculating the GRACE score, which requires a computer, can be considered a limitation of this method. The qSOFA-T score, obtained by adding cTnI level to the qSOFA score, has excellent discriminatory power for predicting in-hospital mortality. The AUC of the GRACE score was 0.840, and the AUC of the qSOFA-T score was 0.826; both scores had excellent discrimi- natory power for predicting in-hospital mortality (0.8≤AUC<0.9, an excellent discriminating power). In estimating the qSOFA-T score as a predictor of in-hospital mortality, the cutoff value was 1.5, and the mean value was 2.03. Care should be taken if the calculated qSOFA-T score is 2 or higher. According to the results of this study, patients who have a high qSOFA-T score, which can be calculated easily, quickly, and inexpensively, are at a higher risk of short-term mortality. ETHICAL APPROVAL The study was approved by the ethics committee of the Bezmialem Vakif University (approval number 2022-45; dated August 2, 2022). HUMAN RIGHTS STATEMENTS AND INFORMED CONSENT All procedures followed were in accordance with the ethical standards of the responsible committee on human experimen- tation and with the Helsinki Declaration of 1964 and its later amendments. Informed consent was obtained from all patients to participate in the study. AUTHORS’ CONTRIBUTIONS BT: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation Methodology, Validation, Visualization, Writing – original draft, Writing – review & edit- ing. ES: Formal Analysis, Project administration, Resources, Writing – original draft, Writing – review & editing. 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