Prospective Validation of the MIRACLE(2) Score for Early Neurological Stratification After Out-of-Hospital Cardiac-Arrest: The GLOBAL-MIRACLE Registry

Abstract

BACKGROUND: The purpose of this study was to prospectively validate the MIRACLE(2) score in the GLOBAL-MIRACLE registry, a multicenter, international, prospective registry of patients admitted with resuscitated out-of-hospital cardiac arrest of presumed cardiac cause. METHODS: From January 1, 2022 to May 31, 2023, 770 patients were recruited from 11 centers across 5 countries. The primary end point was poor neurological outcome (Cerebral Performance Category 3-5) at hospital discharge. Model discrimination was assessed by the area under the receiver operating characteristic curve. We compared the discriminatory performance of the MIRACLE(2) score against Cardiac Arrest Hospital Prognosis, out-of-hospital cardiac arrest, Target Temperature Management, NULL-PLEASE, C-GRAPH, and rCAST. RESULTS: The primary end point occurred in 395 (51.2%) patients. The MIRACLE(2) score had an area under the curve of 0.861 (95% CI, 0.835-0.887). A MIRACLE(2) score =2 had a negative predictive value of 87.8%, while a score of =7 had a positive predictive value of 98.3%. The MIRACLE(2) score had equal performance to the TTM risk tool (P=0.12) but better discriminatory performance than other risk tools (P<0.0001). The MIRACLE(2) score showed good performance in those with ST-segment-elevation myocardial infarction (0.851 [95% CI, 0.816-0.886]) and without ST-segment-elevation myocardial infarction (0.873 [95% CI, 0.834-0.912]) and in those with cardiogenic shock (0.832 [95% CI, 0.789-0.875]) and without cardiogenic shock (0.853 [95% CI, 0.810-0.895]). CONCLUSIONS: The MIRACLE(2) score is a practical risk tool that shows excellent discrimination performance for poor neurological outcome after presumed cardiac cause out-of-hospital cardiac arrest, including based on hemodynamic status and admission 12-lead ECG. Early stratification of out-of-hospital cardiac arrest patients using the MIRACLE(2) score should be evaluated in future randomized controlled trials.