Title:Validation of the Zwolle Risk Score in STEMI Patients Undergoing Primary PCI: Insights from the ISCAS-STEMI COVID-19 Registry
Volume: 24
Issue: 1
Author(s): Giuseppe De Luca*, Magdy Algowhary, Berat Uguz, Dinaldo C. Oliveira, Vladimir Ganyukov, Zan Zimbakov, Miha Cercek, Lisette Okkels Jensen, Poay Huan LOH, Lucian Calmac, Gerard Roura i Ferrer, Alexandre Quadros, Marek MIlewski, Fortunato Scotto Di Uccio, Clemens Von Birgelen, Francesco Versaci, Jurrien Ten Berg, Gianni Casella, Aaron Wong Sung Lung, Petr Kala, José Luis Díez Gil, Xavier Carrillo, Maurits T. Dirksen, Victor Manuel Becerra-Munoz, Michael Kang-yin Lee, Dafsah Arifa Juzar, Rodrigo de Moura Joaquim, Roberto Paladino, Davor Milicic, Periklis Davlouros, Nikola Bakraceski, Filippo Zilio, Luca Donazzan, Adriaan Kraaijeveld, Gennaro Galasso, Lux Arpad, Lucia Marinucci, Vincenzo Guiducci, Maurizio Menichelli, Alessandra Scoccia, Aylin Hatice Yamac, Kadir Ugur Mert, Xacobe Flores Rios, Tomas Kovarnik, Michal Kidawa, Jose Moreu, Flavien Vincent, Enrico Fabris, Inigo Lozano Martinez-Luengas, Marco Boccalatte, Francisco Bosa Ojeda, Carlos Arellano-Serrano, Gianluca Caiazzo, Giuseppe Cirrincione, Hsien-Li Kao, Juan Sanchis Fores, Luigi Vignali, Helder Pereira, Stephane Manzo-Silbermann, Santiago Ordonez, Alev Arat Ozkan, Bruno Scheller, Heidi Lehtola, Rui Teles, Christos Mantis, Ylitalo Antti, Joao Antonio Brum Silveira, Rodrigo Zoni, Ivan Bessonov, Stefano Savonitto, George Kochiadakis, Dimitrios Alexopoulos, Carlos E Uribe, John Kanakakis, Benjamin Faurie, Gabriele Gabrielli, Alejandro Gutierrez Barrios, Juan Pablo Bachini, Alex Rocha, Frankie Chor-Cheung Tam, Alfredo Rodriguez, Antonia Anna Lukito, Veauthyelau Saint-Joy, Gustavo Pessah, Giuliana Cortese, Guido Parodi, Mohammed Abed Burgadha, Elvin Kedhi, Pablo Lamelas, Harry Suryapranata, Matteo Nardin and Monica Verdoia
Affiliation:
- Division of Cardiology, AOU Policlinico G Martino, University of Messina, Messina, Italy
- Division of Cardiology, IRCSS Hospital Galeazzi-Sant’Ambrogio, Milan, Italy
Keywords:
Zwolle Risk Score, STEMI patients, COVID-19 registry, mechanical reperfusion, pandemic, ISACS-STEMI.
Abstract:
Background: Several scores have been developed to facilitate risk stratification and early discharge following primary
angioplasty, particularly the Zwolle Risk Score (ZRS). However, validation in large-sized studies is still lacking. Therefore, the
aim of the current study was to validate the use of the ZRS in a contemporary global population, including patients who were
treated during the SARS-CoV-2 pandemic and enrolled in a large intercontinental observational study.
Methods: The ISACS-STEMI COVID-19 is a large-scale retrospective multicenter registry involving primary PCI centers from
Europe, Latin America, South-East Asia, and NorthAfrica, including patients treated from March 1st until June 30th, in 2019 and
2020]. ZRS was calculated for each patient. The patients were additionally categorized according to the following values of the
ZRS [≤3; 4-6; 7-9; ≥10]. Our study outcomes were in-hospital and 30-day mortality. The discriminatory capacity of the ZRS was
assessed by the area under the ROC curve [c statistic] as an index of model performance.
Results: Our population is represented by 16084 STEMI patients undergoing mechanical reperfusion enrolled in 109 centers. The
score showed a very good performance in the predicting mortality both in-hospital [AUC=0.83 [0.82-0.85], p<0.0001] and at 30-
day follow-up [AUC=0.82 [0.81-0.84, p<0.0001]. The results were confirmed when the ZRS was separately applied to patients
treated in 2019 and 2020, with good stability across time. ZRS was able to identify a large cohort [n=10672, 66.3%] of low-risk
patients [score ≤3] with a very low mortality rate at 2 days [1%] and between 3 and 10 days [0.7%], with a very good negative
predictive value for in-hospital [98.3%] and 30-day mortality [97.7%], with similar results in 2019 and 2020.
Conclusion: This study is the first to demonstrate the good prognostic performance of the ZRS in a large-scale contemporary
global multicenter validation set. Similar results were obtained both in the pre-pandemic and the COVID-19 era. ZRS ≤3 identified
a very low-risk population that could be discharged early, even during the COVID-19 pandemic, with expected advantages in the
availability of hospital beds and nursing staff, costs of medical care, and in-hospital risk of contagion.
