Predicting postresection hydrocephalus in pediatric patients with posterior fossa tumors

2009 ◽  
Vol 3 (5) ◽  
pp. 378-385 ◽  
Author(s):  
Jay Riva-Cambrin ◽  
Allan S. Detsky ◽  
Maria Lamberti-Pasculli ◽  
Michael A. Sargent ◽  
Derek Armstrong ◽  
...  
Keyword(s):  
High Risk ◽  
Posterior Fossa ◽  
Validation Cohort ◽  
Tumor Resection ◽  
Prediction Rule ◽  
Low Risk ◽  
Third Ventriculostomy ◽  
Posterior Fossa Tumors ◽  
Derivation Cohort ◽  
Preoperative Prediction

Object Approximately 30% of children with posterior fossa tumors exhibit hydrocephalus after tumor resection. Recent literature has suggested that prophylactic endoscopic third ventriculostomy diminishes the risk of this event. Because the majority of patients will not have postoperative hydrocephalus, a preoperative clinical prediction rule that identifies patients at high or low risk for postresection hydrocephalus would be helpful to optimize the care of these children. Methods The authors evaluated a derivation cohort of 343 consecutive children with posterior fossa tumors who underwent treatment between 1989 and 2003. Multivariate methods were used on these data to generate the Canadian Preoperative Prediction Rule for Hydrocephalus. The rule's estimated risk of postresection hydrocephalus was compared with risk observed in 111 independent patients in the validation cohort. Results Variables identified as significant in predicting postresection hydrocephalus were age < 2 years (score of 3), papilledema (score of 1), moderate to severe hydrocephalus (score of 2), cerebral metastases (score of 3), and specific estimated tumor pathologies (score of 1). Patients with scores ≥ 5 were deemed as high risk. Predicted probabilities for the high- and low-risk groups were 0.73 and 0.25, respectively, from the derivation cohort, and 0.59 and 0.14 after prevalence adjustment compared with the observed values of 0.42 and 0.17 in the validation cohort. Conclusions A patient's score on the Preoperative Prediction Rule for Hydrocephalus will allow improved patient counseling and surgical planning by identifying patients at high risk of developing postresection hydrocephalus. These patients might selectively be exposed to the risks of preresection CSF diversion to improve outcome.

scholarly journals A clinical scoring system for predicting tumor recurrence after percutaneous radiofrequency ablation for 3 cm or less hepatocellular carcinoma

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Yong Zhu He ◽  
Kun He ◽  
Rui Qin Huang ◽  
Li Wen Liu ◽  
Shao Wei Ye ◽  
...  
Keyword(s):  
High Risk ◽  
Scoring System ◽  
Tumor Recurrence ◽  
Validation Cohort ◽  
Risk Group ◽  
High Risk Group ◽  
Low Risk ◽  
Derivation Cohort ◽  
Medium Risk ◽  
Clinical Scoring

AbstractPreoperative prediction of tumor recurrence after radiofrequency ablation (RFA) in patients with early hepatocellular carcinoma (HCC) is helpful for clinical decision-making before treatment. A total of 162 patients with HCC of 3 cm or less who were completely ablated by percutaneous RFA were divided into a derivation cohort (n = 108) and a validation cohort (n = 54). Based on X-Tiles software, Kaplan–Meier curve analysis and COX multivariate analysis to obtain valuable predictive indicators, a clinical scoring system for predicting tumor recurrence was established. In the verall cohort, derivation cohort and validation cohort, we found circulating tumor cells (CTC) > 2/3.2 mL, alpha-fetoprotein (AFP) > 20 ng/mL, and des-γ-carboxyprothrombin (DCP) > 40 mAU/mL, maximum tumor diameter > 20 mm, and the number of multiple tumors (≥ 2) are independent risk factors affecting tumor recurrence. Each independent risk factor was assigned a score of 1 to construct a predictive clinical scoring system, and X-Tiles software was used to divide the clinical score into a low-risk group (0 score–1 score), a medium-risk group (2 scores–3 scores), and a high-risk group (4 scores–5 scores). The cumulative tumor recurrence rates of patients in the low-risk group, middle-risk group, and high-risk group in 1 year, 2 years, and 3 years were 19.4%/27.5%/30.9%, 37.0%/63.2%/79.9% and 68.2%/100%/100%, respectively (Low-risk group vs medium-risk group: P < 0.001; medium-risk group vs high-risk group: P < 0.001). This clinical scoring system can predict the prognosis of patients with HCC of 3 cm or smaller undergoing percutaneous RFA, which has certain application value for making preoperative clinical decisions.

scholarly journals Development and validation of a prediction rule for estimating gastric cancer risk in the Chinese high-risk population: a nationwide multicentre study

Gut ◽  
2019 ◽  
Vol 68 (9) ◽  
pp. 1576-1587 ◽  
Author(s):  
Quancai Cai ◽  
Chunping Zhu ◽  
Yuan Yuan ◽  
Qi Feng ◽  
Yichao Feng ◽  
...  
Keyword(s):  
Gastric Cancer ◽  
High Risk ◽  
Risk Prediction ◽  
Prediction Rule ◽  
Low Risk ◽  
High Risk Population ◽  
Igg Antibody ◽  
Risk Population ◽  
Derivation Cohort ◽  
Medium Risk

ObjectiveTo develop a gastric cancer (GC) risk prediction rule as an initial prescreening tool to identify individuals with a high risk prior to gastroscopy.DesignThis was a nationwide multicentre cross-sectional study. Individuals aged 40–80 years who went to hospitals for a GC screening gastroscopy were recruited. Serum pepsinogen (PG) I, PG II, gastrin-17 (G-17) and anti-Helicobacter pylori IgG antibody concentrations were tested prior to endoscopy. Eligible participants (n=14 929) were randomly assigned into the derivation and validation cohorts, with a ratio of 2:1. Risk factors for GC were identified by univariate and multivariate analyses and an optimal prediction rule was then settled.ResultsThe novel GC risk prediction rule comprised seven variables (age, sex, PG I/II ratio, G-17 level, H. pylori infection, pickled food and fried food), with scores ranging from 0 to 25. The observed prevalence rates of GC in the derivation cohort at low-risk (≤11), medium-risk (12–16) or high-risk (17–25) group were 1.2%, 4.4% and 12.3%, respectively (p<0.001).When gastroscopy was used for individuals with medium risk and high risk, 70.8% of total GC cases and 70.3% of early GC cases were detected. While endoscopy requirements could be reduced by 66.7% according to the low-risk proportion. The prediction rule owns a good discrimination, with an area under curve of 0.76, or calibration (p<0.001).ConclusionsThe developed and validated prediction rule showed good performance on identifying individuals at a higher risk in a Chinese high-risk population. Future studies are needed to validate its efficacy in a larger population.

Management of hydrocephalus in pediatric patients with posterior fossa tumors: the role of endoscopic third ventriculostomy

2001 ◽  
Vol 95 (5) ◽  
pp. 791-797 ◽  
Author(s):  
Christian Sainte-Rose ◽  
Giuseppe Cinalli ◽  
Franck E. Roux ◽  
Wirginia Maixner ◽  
Paul D. Chumas ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Endoscopic Third Ventriculostomy ◽  
Tumor Resection ◽  
Third Ventriculostomy ◽  
Posterior Fossa Surgery ◽  
Posterior Fossa Tumors ◽  
Content Type ◽  
Group A ◽  
Group B ◽  
Fine Print

Object. The authors undertook a study to evaluate the effectiveness of endoscopic third ventriculostomy in the management of hydrocephalus before and after surgical intervention for posterior fossa tumors in children. Methods. Between October 1, 1993, and December 31, 1997, a total of 206 consecutive children with posterior fossa tumors underwent surgery at Hôpital Necker—Enfants Malades in Paris. Excluded were 10 patients in whom shunts had been placed at the referring hospital. The medical records and neuroimaging studies of the remaining 196 patients were reviewed and categorized into three groups: Group A, 67 patients with hydrocephalus present on admission in whom endoscopic third ventriculostomy was performed prior to tumor removal; Group B, 82 patients with hydrocephalus who did not undergo preliminary third ventriculostomy but instead received conventional treatment; and Group C, 47 patients in whom no ventricular dilation was present on admission. There were no significant differences between patients in Group A or B with respect to the following variables: age at presentation, evidence of metastatic disease, extent of tumor resection, or follow-up duration. In patients in Group A, however, more severe hydrocephalus was demonstrated (p < 0.01); the patients in Group C were in this respect different from those in the other two groups. Ultimately, there were only four patients (6%) in Group A compared with 22 patients (26.8%) in Group B (p = 0.001) in whom progressive hydrocephalus required treatment following removal of the posterior fossa tumor. Sixteen patients (20%) in Group B underwent insertion of a ventriculoperitoneal shunt, which is similar to the incidence reported in the literature and significantly different from that demonstrated in Group A (p < 0.016). The other six patients (7.3%) were treated by endoscopic third ventriculostomy after tumor resection. In Group C, two patients (4.3%) with postoperative hydrocephalus underwent endoscopic third ventriculostomy. In three patients who required placement of CSF shunts several episodes of shunt malfunction occurred that were ultimately managed by endoscopic third ventriculostomy and definitive removal of the shunt. There were no deaths; however, there were four cases of transient morbidity associated with third ventriculostomy. Conclusions. Third ventriculostomy is feasible even in the presence of posterior fossa tumors (including brainstem tumors). When performed prior to posterior fossa surgery, it significantly reduces the incidence of postoperative hydrocephalus. The procedure provides a valid alternative to placement of a permanent shunt in cases in which hydrocephalus develops following posterior fossa surgery, and it may negate the need for the shunt in cases in which the shunt malfunctions. Furthermore, in patients in whom CSF has caused spread of the tumor at presentation, third ventriculostomy allows chemotherapy to be undertaken prior to tumor excision by controlling hydrocephalus. Although the authors acknowledge that the routine application of third ventriculostomy in selected patients results in a proportion of patients undergoing an “unnecessary” procedure, they believe that because patients' postoperative courses are less complicated and because the incidence of morbidity is low and the success rate is high in those patients with severe hydrocephalus that further investigation of this protocol is warranted.

A validation study of the modified Canadian Preoperative Prediction Rule for Hydrocephalus in children with posterior fossa tumors

2021 ◽  
pp. 1-7
Author(s):  
Marina Pitsika ◽  
Jack Fletcher ◽  
Ian C. Coulter ◽  
Christopher J. A. Cowie
Keyword(s):  
Posterior Fossa ◽  
Roc Curve ◽  
Clinical Judgment ◽  
Statistical Significance ◽  
External Ventricular Drain ◽  
Prediction Rule ◽  
Posterior Fossa Tumors ◽  
Time To Surgery ◽  
Preoperative Prediction ◽  
Csf Diversion

OBJECTIVE Perioperative management of hydrocephalus in children with posterior fossa tumors (PFTs) remains challenging. The modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) has been previously described as a useful tool in predicting which children are at higher risk for permanent hydrocephalus following PFT resection and can be used in guiding treatment. The aim of this study was to externally validate this predictive model. METHODS A retrospective review of the children treated in a single unit was conducted, recording all of the mCPPRH parameters (age, preoperative radiological diagnosis, presence of moderate/severe hydrocephalus, transependymal edema, and metastatic disease at the time of diagnosis), the need for a CSF diversion procedure at 6 months, time to surgery, and management of hydrocephalus. A receiver operating characteristic (ROC) curve was plotted using the mCPPRH, age, Evans index (EI), and frontooccipital horn ratio (FOHR), and an area under the curve (AUC) was calculated. A point-biserial correlation was run to determine the relationship between time to surgery, the insertion of an external ventricular drain (EVD), or initial EVD clamping and the development of postoperative persistent hydrocephalus. RESULTS From a total of 75 patients (mean age 6.99 years, 62.7% male) who were included in the study, 8 (10.7%) required permanent CSF diversion following PFT resection. The AUC of the ROC curve was 0.618 for the mCPPRH (p = 0.18, SE 0.088, 95% CI 0.446–0.791), 0.633 for age (p = 0.26, SE 0.119, 95% CI 0.4–0.867), 0.604 for the EI (p = 0.34, SE 0.11, 95% CI 0.389–0.818), and 0.663 for the FOHR (p = 0.17, SE 0.121, 95% CI 0.427–0.9). A significant positive correlation between EVD insertion (r = 0.239, p = 0.03) and insertion of a ventriculoperitoneal shunt was found. A negative correlation between the postoperative clamping of the EVD (r = −0.158, p = 0.4) and the time to PFT surgery (r = −0.06, p = 0.6) did not reach statistical significance. CONCLUSIONS The implementation of the mCPPRH score failed to reliably predict which children would require permanent CSF diversion following PFT resection when applied to this cohort. Clinical judgment remains the mainstay of choosing the perioperative treatment of hydrocephalus.

scholarly journals Simple risk scores to predict hospitalization or death in outpatients with COVID-19

2022 ◽  
Author(s):  
Mark Ebell ◽  
Roya Hamadani ◽  
Autumn Kieber-Emmons
Keyword(s):  
Validation Cohort ◽  
Prediction Rule ◽  
Clinical Prediction Rule ◽  
Low Risk ◽  
Polymerase Chain Reaction Test ◽  
Risk Scores ◽  
Clinical Prediction ◽  
Positive Polymerase Chain Reaction ◽  
Derivation Cohort ◽  
Temporal Validation

Importance Outpatient physicians need guidance to support their clinical decisions regarding management of patients with COVID-19, in particular whether to hospitalize a patient and if managed as an outpatient, how closely to follow them. Objective To develop and prospectively validate a clinical prediction rule to predict the likelihood of hospitalization for outpatients with COVID-19 that does not require laboratory testing or imaging. Design Derivation and temporal validation of a clinical prediction rule, and prospective validation of two externally derived clinical prediction rules. Setting Primary and Express care clinics in a Pennsylvania health system. Participants Patients 12 years and older presenting to outpatient clinics who had a positive polymerase chain reaction test for COVID-19. Main outcomes and measures Classification accuracy (percentage in each risk group hospitalized) and area under the receiver operating characteristic curve (AUC). Results Overall, 7.4% of outpatients in the early derivation cohort (5843 patients presenting before 3/1/21) and 5.5% in the late validation cohort (3806 patients presenting 3/1/21 or later) were ultimately hospitalized. We developed and temporally validated three risk scores that all included age, dyspnea, and the presence of comorbidities, adding respiratory rate for the second score and oxygen saturation for the third. All had very good overall accuracy (AUC 0.77 to 0.78) and classified over half of patients in the validation cohort as very low risk with a 1.7% or lower likelihood of hospitalization. Two externally derived risk scores identified more low risk patients, but with a higher overall risk of hospitalization (2.8%). Conclusions and relevance Simple risk scores applicable to outpatient and telehealth settings can identify patients with very low (1.6% to 1.7%), low (5.2% to 5.9%), moderate (14.7% to 15.6%), and high risk (32.0% to 34.2%) of hospitalization. The Lehigh Outpatient COVID Hospitalization (LOCH) risk score is available online as a free app: https://ebell-projects.shinyapps.io/LehighRiskScore/.

Validation and modification of a predictive model of postresection hydrocephalus in pediatric patients with posterior fossa tumors

2013 ◽  
Vol 12 (3) ◽  
pp. 220-226 ◽  
Author(s):  
Paul Foreman ◽  
Samuel McClugage ◽  
Robert Naftel ◽  
Christoph J. Griessenauer ◽  
Benjamin J. Ditty ◽  
...  
Keyword(s):  
Predictive Model ◽  
Posterior Fossa ◽  
Pediatric Patients ◽  
Prediction Rule ◽  
Retrospective Chart Review ◽  
Risk Groups ◽  
Patient Counseling ◽  
Likelihood Ratios ◽  
Posterior Fossa Tumors ◽  
Preoperative Prediction

Object Postresection hydrocephalus is observed in approximately 30% of pediatric patients with posterior fossa tumors. However, which patients will develop postresection hydrocephalus is not known. The Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) was developed in an attempt to identify this subset of patients, allowing for the optimization of their care. The authors sought to validate and critically appraise the CPPRH. Methods The authors conducted a retrospective chart review of 99 consecutive pediatric patients who presented between 2002 and 2010 with posterior fossa tumors and who subsequently underwent resection. The data were then analyzed using bivariate and multivariate analyses, and a modified CPPRH (mCPPRH) was applied. Results Seventy-six patients were evaluated. Four variables were found to be significant in predicting postresection hydrocephalus: age younger than 2 years, moderate/severe hydrocephalus, preoperative tumor diagnosis, and transependymal edema. The mCPPRH produced observed likelihood ratios of 0.737 (95% CI 0.526–1.032) and 4.688 (95% CI 1.421–15.463) for low- and high-risk groups, respectively. Conclusions The mCPPRH utilizes readily obtainable and reliable preoperative variables that together stratify children with posterior fossa tumors into high- and low-risk categories for the development of postresection hydrocephalus. This new predictive model will aid patient counseling and tailor the intensity of postoperative clinical and radiographic monitoring for hydrocephalus, as well as provide evidence-based guidance for the use of prophylactic CSF diversion.

scholarly journals The REDS score: a new scoring system to risk-stratify emergency department suspected sepsis: a derivation and validation study

BMJ Open ◽  
2019 ◽  
Vol 9 (8) ◽  
pp. e030922 ◽  
Author(s):  
Narani Sivayoham ◽  
Lesley A Blake ◽  
Shafi E Tharimoopantavida ◽  
Saad Chughtai ◽  
Adil N Hussain ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Prediction Rule ◽  
Clinical Prediction Rule ◽  
Risk Category ◽  
Suspected Sepsis ◽  
Suspected Infection ◽  
Derivation Cohort ◽  
High Risk Category ◽  
Component Scores

ObjectiveTo derive and validate a new clinical prediction rule to risk-stratify emergency department (ED) patients admitted with suspected sepsis.DesignRetrospective prognostic study of prospectively collected data.SettingED.ParticipantsPatients aged ≥18 years who met two Systemic Inflammatory Response Syndrome criteria or one Red Flag sepsis criteria on arrival, received intravenous antibiotics for a suspected infection and admitted.Primary outcome measureIn-hospital all-cause mortality.MethodThe data were divided into derivation and validation cohorts. The simplified-Mortality in Severe Sepsis in the ED score and quick-SOFA scores, refractory hypotension and lactate were collectively termed ‘component scores’ and cumulatively termed the ‘Risk-stratification of ED suspected Sepsis (REDS) score’. Each patient in the derivation cohort received a score (0–3) for each component score. The REDS score ranged from 0 to 12. The component scores were subject to univariate and multivariate logistic regression analyses. The receiver operator characteristic (ROC) curves for the REDS and the components scores were constructed and their cut-off points identified. Scores above the cut-off points were deemed high-risk. The area under the ROC (AUROC) curves and sensitivity for mortality of the high-risk category of the REDS score and component scores were compared. The REDS score was internally validated.Results2115 patients of whom 282 (13.3%) died in hospital. Derivation cohort: 1078 patients with 140 deaths (13%). The AUROC curve with 95% CI, cut-off point and sensitivity for mortality (95% CI) of the high-risk category of the REDS score were: derivation: 0.78 (0.75 to 0.80); ≥3; 85.0 (78 to 90.5). Validation: 0.74 (0.71 to 0.76); ≥3; 84.5 (77.5 to 90.0). The AUROC curve and the sensitivity for mortality of the REDS score was better than that of the component scores. Specificity and mortality rates for REDS scores of ≥3, ≥5 and ≥7 were 54.8%, 88.8% and 96.9% and 21.8%, 36.0% and 49.1%, respectively.ConclusionThe REDS score is a simple and objective score to risk-stratify ED patients with suspected sepsis.

Ventriculoperitoneal Shunt versus Endoscopic Third Ventriculostomy in the treatment of Obstructive Hydrocephalus in Pediatric Midline Posterior Fossa tumors

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Mohammed Tarek ◽  
Hamdy Ibrahim ◽  
H Jalalod'din ◽  
SR Tawadros
Keyword(s):  
Posterior Fossa ◽  
Ventriculoperitoneal Shunt ◽  
Endoscopic Third Ventriculostomy ◽  
Obstructive Hydrocephalus ◽  
Clinical Findings ◽  
Third Ventriculostomy ◽  
Posterior Fossa Tumors ◽  
Shunt Insertion ◽  
Vp Shunt ◽  
Csf Diversion

Abstract Background Treatment of secondary hydrocephalus due to posterior fossa tumors in these children is still a matter of controversy, although preoperative ventriculo-peritoneal shunt (VP shunt) insertion before tumor excision is widely accepted among neurosurgeons but many attempts are rising to minimize permanent VP shunt insertion and associated complications and introducing third endoscopic ventriculostomy (ETV) as one of the options of 2ry hydrocephalus. Objectives Comparing the post-operative clinical success with resolution of the manifestations and post-operative complications between endoscopic third ventriculostomy and ventriculoperitoneal shunt as different modes of CSF diversion in children with 2ry hydrocephalus due to midline posterior fossa tumors. Methods The following electronic databases were searched from June 2009 to june2019: PubMed, Google scholar search engine. Cochrane database of systematic reviews, EMBASE and science Direct, using the keywords ―hydrocephalus; posterior fossa tumors; pediatrics; ventriculoperitoneal shunt; endoscopic third ventriculostomy‖. Studies were eligible if they contain the target keywords in title or abstract, addressing the Pediatric age group with 2ry hydrocephalus due to de novo posterior fossa tumor manifested by signs of increase the intra cranial tension including persistent headache and vomiting, blurred vision, 6th nerve palsy, papilledema in fundus examination, acute DCL and 2ry hydrocephalus confirmed by brain imaging. Exclusion criteria included studies including age group below 1yr or above 18 yr, or patients with recurrent post fossa tumors and operated before or patients presented by failed previously attempt of CSF diversion. Results: A total of 1255 citations were screened for eligibility,6 studies were included in our systematic review discussing, comparing and evaluating the durability of ETV versus VP shunt in treatment the 2ry hydrocephalusdue to pediatric posterior fossa tumor.. Overall study population reached 474 patients. the overall clinical findings at presentation and postoperative outcomes regarding the clinical findings improvement, radiological improvement and postoperative complications between ETV and VP shunt are compared and showing that ETV should be considered as an alternative procedure to VP shunt in controlling severe hydrocephalus related to posterior fossa tumors to relieve symptoms quickly during the preoperative period when patients should wait for their definite tumor excision. Conclusion The shorter duration of surgery, the lower incidence of morbidity, the absence of mortality, the lower incidence of procedure failure of endoscopic third ventriculostomy as compared to ventriculoperitoneal shunt, and the significant advantage of not becoming shunt dependent make endoscopic third ventriculostomy to be recommended as the first choice in the treatment of pediatric patients with marked obstructive hydrocephalus due to posterior fossa tumors. It is a preliminary, simple, safe, effective, physiological, minimally invasive procedure for the relief of elevated intracranial pressure before direct tumor removal.

scholarly journals Simple electrocardiographic measures improve sudden arrhythmic death prediction in coronary disease

2020 ◽  
Vol 41 (21) ◽  
pp. 1988-1999 ◽  
Author(s):  
Neal A Chatterjee ◽  
Jani T Tikkanen ◽  
Gopi K Panicker ◽  
Dhiraj Narula ◽  
Daniel C Lee ◽  
...  
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Risk Stratification ◽  
Validation Cohort ◽  
Clinical Risk Factors ◽  
Left Ventricular Ejection ◽  
Derivation Cohort ◽  
Arrhythmic Death ◽  
Clinical Risk ◽  
Ecg Score

Abstract Aims To determine whether the combination of standard electrocardiographic (ECG) markers reflecting domains of arrhythmic risk improves sudden and/or arrhythmic death (SAD) risk stratification in patients with coronary heart disease (CHD). Methods and results The association between ECG markers and SAD was examined in a derivation cohort (PREDETERMINE; N = 5462) with adjustment for clinical risk factors, left ventricular ejection fraction (LVEF), and competing risk. Competing outcome models assessed the differential association of ECG markers with SAD and competing mortality. The predictive value of a derived ECG score was then validated (ARTEMIS; N = 1900). In the derivation cohort, the 5-year cumulative incidence of SAD was 1.5% [95% confidence interval (CI) 1.1–1.9] and 6.2% (95% CI 4.5–8.3) in those with a low- and high-risk ECG score, respectively (P for Δ &lt; 0.001). A high-risk ECG score was more strongly associated with SAD than non-SAD mortality (adjusted hazard ratios = 2.87 vs. 1.38 respectively; P for Δ = 0.003) and the proportion of deaths due to SAD was greater in the high vs. low risk groups (24.9% vs. 16.5%, P for Δ = 0.03). Similar findings were observed in the validation cohort. The addition of ECG markers to a clinical risk factor model inclusive of LVEF improved indices of discrimination and reclassification in both derivation and validation cohorts, including correct reclassification of 28% of patients in the validation cohort [net reclassification improvement 28 (7–49%), P = 0.009]. Conclusion For patients with CHD, an externally validated ECG score enriched for both absolute and proportional SAD risk and significantly improved risk stratification compared to standard clinical risk factors including LVEF. Clinical Trial Registration https://clinicaltrials.gov/ct2/show/NCT01114269. ClinicalTrials.gov ID NCT01114269.

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