Tunisian Journal of Emergency Medicine

Prognostic Value of the ACTION ICU Score Compared to GRACE and TIMI Scores in Non-ST-Segment Elevation Acute Coronary Syndromes

Authors

  • hela ben turkia

    regional hospital of Ben Arous

  • hanene ghazali

  • Ibtissem Ben Taher

  • Raja Fadhel

    emergency departement of university hospital of ben arous

  • Amira Bekir

  • syrine keskes

  • Sami Souissi

DOI:
https://doi.org/10.66759/dy5r4q27
Keywords:
Emergency department, Evaluation, risk factors, Acute coronary syndrome;, Myocardial infarction
Abstract

Non-ST-segment elevation acute coronary syndromes (NSTE-ACS) represent the primary manifestation of acute coronary syndromes, accounting for 60% to 70% of hospital admissions. Effective management in the emergency department (ED) relies on accurate risk stratification to guide triage. While established scores like GRACE and TIMI are widely used for long-term prognosis, they lack specific validation for predicting immediate in-hospital complications in the acute ED phase. This study compared the prognostic value of the ACTION ICU, GRACE, and TIMI scores for short-term complications and 6-month major adverse cardiovascular events (MACE).

Methods We conducted a retrospective observational analysis of a prospective registry at the Ben Arous Regional Hospital, Tunisia, over a nine-year period (2014–2022). Inclusion of patients admitted for NSTE-ACS in the ED. Diagnostic performance was evaluated using Receiver Operating Characteristic (ROC) curves to identify optimal cut-off values for acute in-hospital complications (acute pulmonary edema, arrhythmias, death) and 6-month MACE.

Results

 The cohort had a mean age of 60 ± 12 years with 59.3% males. In-hospital complications occurred in 6.3% of patients. For predicting these acute events, the ACTION ICU score significantly outperformed other models with an Area Under the Curve (AUC) of 0.88 (95% CI: 0.836–0.941), compared to 0.77 for GRACE and 0.59 for TIMI. An ACTION ICU cut-off value of >5.5 provided 80% sensitivity, 77.39% specificity, and a negative predictive value of 98.29%. Conversely, the GRACE score was the most accurate for 6-month MACE (AUC 0.707).

Conclusion The ACTION ICU score is a superior tool for immediate ED triage, providing high accuracy in predicting short-term complications. Its systematic implementation could optimize intensive care unit resource allocation in constrained healthcare settings without compromising patient safety.

References

1. Cohen M, Visveswaran G. Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types. Clin Cardiol. 2020 Mar;43(3):242–50. doi:10.1002/clc.23308 PubMed PMID: 31923336; PubMed Central PMCID: PMC7068071. DOI: https://doi.org/10.1002/clc.23308

2. Timmis A, Vardas P, Townsend N, Torbica A, Katus H, De Smedt D, et al. European Society of Cardiology: cardiovascular disease statistics 2021. Eur Heart J. 2022 Feb 22;43(8):716–99. doi:10.1093/eurheartj/ehab892 PubMed PMID: 35016208. DOI: https://doi.org/10.1093/ehjqcco/qcac014

3. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16;284(7):835–42. doi:10.1001/jama.284.7.835 PubMed PMID: 10938172.

4. Eggers KM, Baron T, Hjort M, Nordenskjöld AM, Tornvall P, Lindahl B. GRACE 2.0 Score for Risk Prediction in Myocardial Infarction With Nonobstructive Coronary Arteries. J Am Heart Assoc. 2021 Sep 7;10(17):e021374. doi:10.1161/JAHA.121.021374 PubMed PMID: 34472364; PubMed Central PMCID: PMC8649242. DOI: https://doi.org/10.1161/JAHA.121.021374

5. Fanaroff AC, Chen AY, Thomas LE, Pieper KS, Garratt KN, Peterson ED, et al. Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc. 2018 May 25;7(11):e008894. doi:10.1161/JAHA.118.008894 PubMed PMID: 29802146; PubMed Central PMCID: PMC6015341. DOI: https://doi.org/10.1161/JAHA.118.008894

6. Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016 Jan 14;37(3):267–315. doi:10.1093/eurheartj/ehv320 PubMed PMID: 26320110. DOI: https://doi.org/10.1093/eurheartj/ehv320

7. Poudel I, Tejpal C, Rashid H, Jahan N. Major Adverse Cardiovascular Events: An Inevitable Outcome of ST-elevation myocardial infarction? A Literature Review. Cureus. 2019 Jul 30;11(7):e5280. doi:10.7759/cureus.5280 PubMed PMID: 31423405; PubMed Central PMCID: PMC6695291. DOI: https://doi.org/10.7759/cureus.5280

8. Saluveer O, Redfors B, Angerås O, Dworeck C, Haraldsson I, Ljungman C, et al. Hypertension is associated with increased mortality in patients with ischaemic heart disease after revascularization with percutaneous coronary intervention - a report from SCAAR. Blood Press. 2017 Jun;26(3):166–73. doi:10.1080/08037051.2016.1270162 PubMed PMID: 28092977. DOI: https://doi.org/10.1080/08037051.2016.1270162

9. Risk factors for acute coronary syndrome in patients below the age of 40 years - PubMed [Internet]. [cited 2026 May 1]. Available from: https://pubmed.ncbi.nlm.nih.gov/30591735/

10. Ghazali H, Gammoudi M, Yahmadi A, Zoubli A, Azouzi A, Souissi S. Acute coronary syndrome without persistent ST segment elevation in the emergency department: Epidemiology, clinical features and prognosis. Tunis Med. 2017 Dec;95(12):229–35. PubMed PMID: 29878290.

11. Sarkees ML, Bavry AA. Acute coronary syndrome (unstable angina and non-ST elevation MI). BMJ Clin Evid. 2009 Jan 13;2009:0209. PubMed PMID: 19445778; PubMed Central PMCID: PMC2907796.

12. 2024 Elevated Blood Pressure and Hypertension [Internet]. [cited 2026 May 1]. Available from: https://www.escardio.org/guidelines/clinical-practice-guidelines/all-esc-practice-guidelines/elevated-blood-pressure-and-hypertension/

13. Sanchis J, Bueno H, García-Blas S, Alegre O, Martí D, Martínez-Sellés M, et al. Invasive Treatment Strategy in Adults With Frailty and Non-ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2024 Mar 4;7(3):e240809. doi:10.1001/jamanetworkopen.2024.0809 PubMed PMID: 38446482; PubMed Central PMCID: PMC10918507. DOI: https://doi.org/10.1001/jamanetworkopen.2024.0809

14. Bai L, Li YM, Yang BS, Cheng YH, Zhang YK, Liao GZ, et al. Performance of the Risk Scores for Predicting In-Hospital Mortality in Patients with Acute Coronary Syndrome in a Chinese Cohort. Rev Cardiovasc Med. 2023 Dec;24(12):356. doi:10.31083/j.rcm2412356 PubMed PMID: 39077082; PubMed Central PMCID: PMC11272866. DOI: https://doi.org/10.31083/j.rcm2412356

15. Parco C, Brockmeyer M, Kosejian L, Quade J, Tröstler J, Bader S, et al. Modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort. Int J Cardiol. 2021 Apr 15;329:28–35. doi:10.1016/j.ijcard.2020.12.085 PubMed PMID: 33412182. DOI: https://doi.org/10.1016/j.ijcard.2020.12.085

16. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16;284(7):835–42. doi:10.1001/jama.284.7.835 PubMed PMID: 10938172. DOI: https://doi.org/10.1001/jama.284.7.835

17. Fox KAA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006 Nov 25;333(7578):1091. doi:10.1136/bmj.38985.646481.55 PubMed PMID: 17032691; PubMed Central PMCID: PMC1661748.

18. Fox KAA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006 Nov 25;333(7578):1091. doi:10.1136/bmj.38985.646481.55 PubMed PMID: 17032691; PubMed Central PMCID: PMC1661748. DOI: https://doi.org/10.1136/bmj.38985.646481.55

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Published
30-09-2026
Issue
Vol. 4 No. 3 (2026): TJEM 2026: Vol.4 Issue 3
Section
Prospective study
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How to Cite

Prognostic Value of the ACTION ICU Score Compared to GRACE and TIMI Scores in Non-ST-Segment Elevation Acute Coronary Syndromes. (2026). Tunisian Journal of Emergency Medicine, 4(3). https://doi.org/10.66759/dy5r4q27