Limitations of the MIRACLE₂ score in coronary cardiac arrest: Findings from a French interventional cohort - 21/11/25

Doi : 10.1016/j.acvd.2025.09.007

Nicolas Martin, MD ^a,⁎ , Alexis Hermida, MD, PhD ^a, Christophe Beyls, MD, PhD ^b, Yohann Bohbot, MD, PhD ^a, Dan Rusinaru, MD, PhD ^a, Laurent Leborgne, MD, PhD ^a, Michel Zeitouni, MD, PhD ^c, Alexandre Fournier, MD ^a
^a Department of Cardiology, Amiens-Picardie University Hospital, 80054 Amiens, France
^b Intensive Care Unit, Amiens-Picardie University Hospital, 80054 Amiens, France
^c Department of Cardiology, La Pitié-Salpêtrière Hospital, 75013 Paris, France

^⁎Corresponding author. Amiens-Picardie University Hospital, 1, rond-point du Professeur-Christian-Cabrol, 80054 Amiens cedex 1, France.Amiens-Picardie University Hospital1, rond-point du Professeur-Christian-CabrolAmiens cedex 180054France

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Friday 21 November 2025

Graphical abstract

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Highlights

•	MIRACLE₂ score tested in arrest from confirmed type 1 myocardial infarction.
•	Discrimination and calibration were good in this interventional population.
•	One in five high-risk patients had good neurological recovery at discharge.
•	Most false predictions involved arrests in front of physician-led teams.
•	Further studies are required to evaluate this score in different settings.

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Abstract

Background

In patients resuscitated from out-of-hospital cardiac arrest caused by acute coronary syndrome, interventional cardiologists must rapidly assess neurological prognosis to guide immediate decisions regarding revascularization and advanced life support strategies.

Aim

To evaluate the performance of the MIRACLE₂ score for predicting poor neurological outcome in this specific population.

Methods

We retrospectively included 77 consecutive patients admitted between 2015 and 2023 to the catheterization laboratory of a tertiary cardiac arrest centre with final confirmation of acute coronary syndrome on coronary angiography. The primary outcome was neurological status at hospital discharge. The MIRACLE₂ score was evaluated for discrimination, calibration and predictive values at the recommended threshold. Patients misclassified as high risk despite favourable outcomes were compared with correctly classified patients.

Results

The study population was predominantly male (75.3%), with a median age of 60 (52–68) years. Poor neurological outcomes occurred in 40 of the 77 patients (51.9%). The MIRACLE₂ score showed good discrimination (area under the curve 0.81) and acceptable calibration. However, at the threshold of 5, the positive predictive value was only 79.3%, with 20.7% of high-risk patients ultimately discharged with favourable neurological outcomes. Most misclassified cases involved cardiac arrests occurring after the arrival of advanced prehospital teams. Excluding these cases increased the score's specificity to 90.3%, and its positive predictive value to 87.5%.

Conclusions

In acute coronary syndrome-related cardiac arrest, early advanced care may alter the prognostic accuracy of the MIRACLE₂ score. Until prospectively validated in this context, it should not be used as a standalone decision tool to guide treatment intensity.

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Keywords : Out-of-hospital cardiac arrest, Acute coronary syndrome, Prognosis, Risk assessment, Extracorporeal membrane oxygenation