Publication details

Validation of the Zwolle Risk Score in STEMI Patients Undergoing Primary PCI: Insights from the ISCAS-STEMI COVID-19 Registry

Authors	GIUSEPPE De Luca ALGOWHARY Magdy UGUZ Berat OLIVEIRA Dinaldo C GANYUKOV Vladimir ZIMBAKOV Zan CERCEK Miha JENSEN Lisette Okkels LOH Poay Huan CALMAC Lucian FERRER Gerard QUADROS Alexandre MILEWSKI Marek SCOTTO Di Uccio Fortunato CLEMENS von Birgelen VERSACI Francesco JURRIEN Ten Berg CASELLA Gianni LUNG Aaron Wong Sung KALA Petr LUIS Diez Gil Jose CARRILLO Xavier DIRKSEN Maurits T BECERRA-MUNOZ Victor Manuel LEE Michael Kang-yin JUZAR Dafsah Arifa RODRIGO de Moura Joaquim PALADINO Roberto MILICIC Davor DAVLOUROS Periklis BAKRACESKI Nikola ZILIO Filippo DONAZZAN Luca KRAAIJEVELD Adriaan GALASSO Gennaro ARPAD Lux MARINUCCI Lucia GUIDUCCI Vincenzo MENICHELLI Maurizio SCOCCIA Alessandra YAMAC Aylin Hatice MERT Kadir Ugur RIOS Xacobe Flores KOVARNIK Tomas KIDAWA Michal MOREU Jose VINCENT Flavien FABRIS Enrico MARTINEZ-LUENGAS Inigo Lozano BOCCALATTE Marco OJEDA Francisco Bosa ARELLANO-SERRANO Carlos CAIAZZO Gianluca CIRRINCIONE Giuseppe KAO Hsien-Li FORES Juan Sanchis VIGNALI Luigi PEREIRA Helder MANZO-SILBERMANN Stephane ORDONEZ Santiago OZKAN Alev Arat SCHELLER Bruno LEHTOLA Heidi TELES Rui MANTIS Christos ANTTI Ylitalo SILVEIRA Joao Antonio Brum ZONI Rodrigo BESSONOV Ivan SAVONITTO Stefano KOCHIADAKIS George ALEXOPOULOS Dimitrios URIBE Carlos E KANAKAKIS John FAURIE Benjamin GABRIELLI Gabriele BARRIOS Alejandro Gutierrez BACHINI Juan Pablo ROCHA Alex TAM Frankie Chor-Cheung RODRIGUEZ Alfredo LUKITO Antonia Anna SAINT-JOY Veauthyelau PESSAH Gustavo CORTESE Giuliana PARODI Guido BURGADHA Mohammed Abed KEDHI Elvin LAMELAS Pablo SURYAPRANATA Harry NARDIN Matteo VERDOIA Monica
Year of publication	2026
Type	Peer-reviewed scientific article
Magazine / Source	CURRENT VASCULAR PHARMACOLOGY
MU Faculty or unit	Faculty of Medicine
Citation
Doi	https://doi.org/10.2174/0115701611335913250408214530
Keywords	Zwolle Risk Score; STEMI patients; COVID-19 registry; mechanical reperfusion; pandemic
Description	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.