影响急诊入院急性冠脉综合征病人近期预后的危险因素

目的 探讨影响急诊入院急性冠脉综合征(ACS)病人近期预后的危险因素。 方法 回顾性分析因胸痛胸闷入急诊科诊断为ACS后由急诊科转入心内科或心内科重症病房（CCU）的154例患者的临床资料进行分析。根据出院后1个月内是否死亡分成存活组(n=134)与死亡组(n=20),用多因素Cox回归分析影响急诊入院ACS病人近期预后的危险因素。 结果 与存活组比,死亡组病人年龄明显较大（76.0±11.3 vs.62.5±10.3 岁;P < 0.05）,合并糖尿病的比例较存活组明显增加（35% vs. 18.7%;P < 0.05）;平均住院时间显著短于存活组(5.0±5.3 vs.12.3±6.0天,P < 0.05);死亡组胸痛就诊时间显著长于存活组(12.3±6.0 vs.5.0±5.3天,P < 0.05)。死亡组舒张压水平较存活组显著下降（P<0.05）,死亡组心率较存活组心率增快（P<0.05）,死亡组BNP水平及cTnI最高值均较存活组增加。Cox多因素回归分析发现,年龄(OR:95%CI, 1.134: 1.061-1.212, P <0.001);院前心脏骤停(OR:95%CI, 8.946: 1.607-49.815, P =0.012);舒张压(OR:95%CI, 0.965: 0.938-0.994, P = 0.016);心率(OR:95%CI, 1.049:1.020-1.079, P=0.001);胸痛就诊时间(OR:95%CI, 1.023: 1.002-1.045, P =0.032)是影响急诊入院ACS病人近期预后的危险因素。 结论：年龄较大、院前心脏骤停、胸痛延误时间较长、舒张压、心率均是影响急诊入院ACS病人近期预后的危险因素。     

A modified HEART risk score in chest pain patients with suspected non-ST-segment elevation acute coronary syndrome

Objective To validate a modified HEART [History, Electrocardiograph (ECG), Age, Risk factors and Troponin] risk score in chest pain patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in the emergency department (ED). Methods This retrospective cohort study used a prospectively acquired database and chest pain patients admitted to the emergency department with suspected NSTE-ACS were enrolled. Data recorded on arrival at the ED were used. The serum sample of high-sensitivity cardiac Troponin I other than conventional cardiac Troponin I used in the HEART risk score was tested. The modified HEART risk score was calculated. The end point was the occurrence of major adverse cardiac events (MACE) defined as a composite of acute myocardial infarction (AMI), percutaneous intervention (PCI), coronary artery bypass graft (CABG), or all-cause death, within three months after initial presentation. Results A total of 1,300 patients were enrolled. A total of 606 patients (46.6%) had a MACE within three months: 205 patients (15.8%) were diagnosed with AMI, 465 patients (35.8%) underwent PCI, and 119 patients (9.2%) underwent CABG. There were 10 (0.8%) deaths. A progressive, significant pattern of increasing event rate was observed as the score increased (P < 0.001 by χ² for trend). The area under the receiver operating characteristic curve was 0.84. All patients were classified into three groups: low risk (score 0–2), intermediate risk (score 3–4), and high risk (score 5–10). Event rates were 1.1%, 18.5%, and 67.0%, respectively (P < 0.001). Conclusions The modified HEART risk score was validated in chest pain patients with suspected NSTE-ACS and may complement MACE risk assessment and patients triage in the ED. A prospective study of the score is warranted.     

ST段抬高型心肌梗死患者D-二聚体与GRACE评分的关系

目的：探讨ST段抬高型心肌梗死（STEMI）患者血浆D-二聚体水平与全球急性冠状动脉事件注册（GRACE）评分的关系。方法：选择2013年1月——2014年6月在我科住院的急性ST段抬高型心肌梗死患者81例，入院后立即测定血浆D-二聚体浓度（采血时间距发病2 h-72 h），计算GRACE 评分并进行危险分层，分析STEMI患者血浆D-二聚体水平与GRACE评分及危险分层的关系。结果：根据GRACE评分将所有STEMI患者作危险分层，高危组患者D-二聚体含量的平方根明显高于中危组及低危组（P均＜0.01），中危组与低危组D-二聚体含量的平方根差异无统计学意义（P＞0.05）。将所有患者按D-二聚体含量的高低分为高DD组和低DD组，高DD组患者GRACE评分明显高于低DD组（P＜0.01）。STEMI患者D-二聚体的平方根与GRACE评分呈正相关（r=0. 457，P＜0.01）。结论：STEMI患者血浆D-二聚体水平越高，GRACE评分越高，两者具有良好的相关性。D-二聚体检测对于STEMI患者的危险分层具有参考意义。     

Complementary prognostic values of ST segment deviation and Thrombolysis In Myocardial Infarction (TIMI) risk score in non-ST elevation acute coronary syndromes: Insights from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) study

BACKGROUND:

Although the Thrombolysis In Myocardial Infarction (TIMI) score incorporates ST deviation, it does not account for characteristics of the ST deviations. In the present study, it was hypothesized that the magnitude and characteristics of ST deviation may add to the prognostic values of the TIMI risk score in acute coronary syndrome (ACS) patients, particularly in lower-risk patients with a TIMI risk score of less than 5.

OBJECTIVE:

To evaluate the prognostic value of combining the TIMI risk score and characteristics of ST deviation in patients with non-ST elevation ACS and a TIMI risk score of less than 5.

METHODS:

The death/myocardial infarction (MI) rates of 1296 patients enrolled in the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) angiographic substudy were examined.

RESULTS:

Patients without a TIMI risk score of 5 or greater, and without an ST deviation of 1 mm or greater had the lowest six-month rate of death/MI (5%). In patients with a TIMI risk score of less than 5, the six-month death/MI rate was increased in those with ST depression of 2 mm or greater compared with patients with a similar TIMI risk score and without ST deviation of 1 mm or greater (24% versus 5%, P<0.001). The presence of ST deviation of 2 mm or greater identified an additional 15% of patients with an increased six-month death/MI rate in patients with a TIMI risk score of less than 5.

CONCLUSION:

ST segment deviation of 2 mm or greater confers additional prognostic information in non-ST elevation ACS patients with a TIMI risk score of less than 5. Patients with a TIMI risk score of less than 5 and ST deviation of 2 mm or less had the lowest risk of six-month death/MI.     

Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better.

AIMS: Our objectives were (i) to compare the discriminatory performance of the Thrombolysis in Myocardial Infarction risk score (TIMI RS), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy risk score (PURSUIT RS), and Global Registry of Acute Cardiac Events risk score (GRACE RS) for in-hospital and 1 year mortality across the broad spectrum of non-ST-elevation acute coronary syndromes (ACS) and (ii) to determine their incremental prognostic utility beyond overall risk assessment by physicians. METHODS AND RESULTS: We calculated the TIMI RS, PURSUIT RS, and GRACE RS for 1,728 patients with non-ST-elevation ACS in the prospective, multicentre, Canadian ACS II Registry. Discriminatory performance was measured by the c-statistic (area under receiver-operating characteristic curve) and compared by the method described by DeLong. TIMI RS, PURSUIT RS, and GRACE RS all demonstrated good discrimination for in-hospital death (c-statistics = 0.68, 0.80, 0.81, respectively, all P < 0.001) and 1 year mortality (c-statistics = 0.69, 0.77, 0.79, respectively, all P < 0.0001). However, PURSUIT RS and GRACE RS performed significantly better than the TIMI RS in predicting in-hospital (P = 0.036 and 0.02, respectively) and 1 year (P = 0.006 and 0.001, respectively) outcomes. In multivariable analysis adjusting for the use of in-hospital revascularization, stratification by tertiles of risk scores (into low, intermediate, and high-risk groups) furnished independent and greater prognostic information compared with risk assessment by treating physicians for 1 year outcome. CONCLUSION: Compared with TIMI RS, both PURSUIT RS and GRACE RS allow better discrimination for in-hospital and 1 year mortality in patients presenting with a wide range of ACS. All three risk scores confer additional important prognostic value beyond global risk assessment by physicians. These validated risk scores may refine risk stratification, thereby improving patient care in routine clinical practice.     

Temporal trends in the use of invasive cardiac procedures for non-ST segment elevation acute coronary syndromes according to initial risk stratification

BACKGROUND:

Current guidelines support an early invasive strategy in the management of high-risk non-ST elevation acute coronary syndromes (NSTE-ACS). Although studies in the 1990s suggested that high-risk patients received less aggressive treatment, there are limited data on the contemporary management patterns of NSTE-ACS in Canada.

OBJECTIVE:

To examine the in-hospital use of coronary angiography and revascularization in relation to risk among less selected patients with NSTE-ACS.

METHODS:

Data from the prospective, multicentre Global Registry of Acute Coronary Events (main GRACE and expanded GRACE²) were used. Between June 1999 and September 2007, 7131 patients from across Canada with a final diagnosis of NSTE-ACS were included the study. The study population was stratified into low-, intermediate- and high-risk groups, based on their calculated GRACE risk score (a validated predictor of in-hospital mortality) and according to time of enrollment.

RESULTS:

While rates of in-hospital death and reinfarction were significantly (P<0.001) greater in higher-risk patients, the in-hospital use of cardiac catheterization in low- (64.7%), intermediate- (60.3%) and high-risk (42.3%) patients showed an inverse relationship (P<0.001). This trend persisted despite the increase in the overall rates of cardiac catheterization over time (47.9% in 1999 to 2003 versus 51.6% in 2004 to 2005 versus 63.8% in 2006 to 2007; P<0.001). After adjusting for confounders, intermediate-risk (adjusted OR 0.80 [95% CI 0.70 to 0.92], P=0.002) and high-risk (adjusted OR 0.38 [95% CI 0.29 to 0.48], P<0.001) patients remained less likely to undergo in-hospital cardiac catheterization.

CONCLUSION:

Despite the temporal increase in the use of invasive cardiac procedures, they remain paradoxically targeted toward low-risk patients with NSTE-ACS in contemporary practice. This treatment-risk paradox needs to be further addressed to maximize the benefits of invasive therapies in Canada.     

急性冠状动脉综合征非介入治疗中的抗血小板治疗

急性冠状动脉综合征(ACS)的特征是冠状动脉斑块破裂、血小板活化和血栓形成.因此抗血小板药物在ACS治疗中有着重要的地位.本文综述了抗血小板治疗在ACS非介入治疗中的研究现状和进展.     

Validation of the GRACE score for prognosis in Indian patients with acute coronary syndromes

AimTo validate the global registry of acute coronary events (GRACE) score in acute coronary syndromes (ACS) patients and study its angiographic correlation.Methods and resultsTwo-hundred and thirty-five ACS patients were studied for the combined endpoint of all-cause in-hospital mortality and non-fatal infarction/reinfarction. We tested the predictive accuracy of the composite GRACE score using the receiver operating characteristics (ROC) curve.Lower systolic blood pressure (SBP) (odds ratio [OR] 7.93, P=0.005), ST-segment deviation (OR 7.79, P=0.02) and cardiac biomarker positivity (OR > 6.52, P=0.01) were significantly associated with events. Serum creatinine > 1.4 mg/dL showed a trend towards statistical significance (OR 4.14, P=0.05), whereas age > 50 years (OR 3.62, P=not significant [NS]) and Killips class 4 (OR 2.71, P=NS) showed good association. The best value for predicting events was a GRACE score of > 217 and these patients were more likely to have double/triple vessel disease (P = 0.0009). The C statistic for the GRACE score was 0.75.ConclusionHigher GRACE score predicts in-hospital events and more severe angiographic coronary artery disease (CAD).     

急性冠脉综合征患者GRACE评分与冠脉病变的相互关系

目的 探讨急性冠脉综合征（ACS）患者全球急性冠状动脉事件注册（GRACE）评分与冠状动脉病变程度的关系,评价GRACE评分对冠状动脉病变预测的价值.方法 收集2008年5月至2010年10月住院的ACS患者共360例,对其进行GRACE评分.以评分差异分组,分为高危组、中危组和低危组,分析不同组别中患者冠状动脉病变的严重程度,以及与GRACE评分的关系.结果 随着GRACE评分分值的增加,ACS患者冠状动脉狭窄支数及狭窄程度呈增加的趋势.结论 GRACE评分对ACS患者冠状动脉病变支数、狭窄严重程度有一定的预测价值.     

急性冠脉综合征TIMI风险积分与脑钠尿肽及临床预后的关系

目的探讨TIM I风险积分对介入治疗后急性冠脉综合征（ACS）患者短期预后的预测作用及比较不同积分组血浆脑钠尿肽（BNP）水平。方法连续入选2004年11月至2005年4月因ST段抬高的心肌梗死（STEM I）在我院行经皮冠状动脉介入（PC I）治疗者75例,因不稳定型心绞痛（UAP）/非ST段抬高的心肌梗死（NSTEM I）在我院行PC I治疗者47例,入院时对入选患者进行心肌梗死溶栓试验（TIM I）风险积分。采用荧光免疫方法测定血浆BNP水平。结果在STEM I患者组,根据TIM I风险积分分为04分,59分,1014分3组。随着TIM I风险积分升高,各组病死率呈明显递增趋势。在多变量的Logistic回归分析中,TIM I风险积分能够独立预测住院期间、1个月和3个月病死率及住院期间、1个月主要心血管不良事件（MACE）发生率（均P<0.01）。不同的TIM I风险积分各组间血浆BNP水平有显著性差异（P<0.01）。在多元回归分析中,TIM I风险积分分组不受年龄、性别、家族史、吸烟、高胆固醇血症、高血压、糖尿病等因素的影响,而与血浆BNP水平呈独立正相关（r=0.52,P<0.01）。在UAP/NSTEM I患者组,根据TIM I风险积分分为02分,35分,57分3组。随着TIM I风险积分升高,各组病死率呈明显递增趋势。在多变量的Logistic回归分析中,TIM I风险积分能够独立预测3个月病死率及1个月和3个月MACE发生率（均P<0.01）。各组间血浆BNP水平有显著性差异（P<0.01）。在多元回归分析中,TIM I风险积分分组经年龄、性别、高胆固醇血症因素校正后与血浆BNP水平呈正相关（r=0.41,P<0.01）。结论TIM I风险积分能够较好地对ACS患者进行危险分层,预测短期病死率和MACE发生率。ACS患者按TIM I风险积分递增分组与血浆BNP水平呈正相关。TIM I风险积分越高组血浆BNP水平越高。     

The use of risk scores for stratification of non-ST elevation acute coronary syndrome patients

OBJECTIVE:

To review the methods available for the risk stratification of non-ST elevation (NSTE) acute coronary syndrome (ACS) patients and to evaluate the use of risk scores for their initial risk assessment.

DATA SOURCES:

The data of the present review were identified by searching PUBMED and other databases (1996 to 2008) using the key terms “risk stratification”, “risk scores”, “NSTEMI”, “UA” and “acute coronary syndrome”.

STUDY SELECTION:

Mainly original articles, guidelines and critical reviews written by major pioneer researchers in this field were selected.

RESULT:

After evaluation of several risk predictors and risk scores, it was found that estimating risk based on clinical characteristics is challenging and imprecise. Risk predictors, whether used alone or in simple binary combination, lacked sufficient precision because they have high specificity but low sensitivity. Risk scores are more accurate at stratifying NSTE ACS patients into low-, intermediate- or high-risk groups. The Global Registry of Acute Cardiac Events risk score was found to have superior predictive accuracy compared with other risk scores in ACS population. Treatments based according to specific clinical and risk grouping show that certain benefits may be predominantly or exclusively restricted to higher risk patients.

CONCLUSION:

Based on the trials in the literature, the Global Registry of Acute Cardiac Events risk score is more advantageous and easier to use than other risk scores. It can categorize a patient’s risk of death and/or ischemic events, which can help tailor therapy to match the intensity of the patient’s NSTE ACS.     

Prognostic significance of multiple-detector computed tomography in conjunction with TIMI risk score for patients with non-ST elevation acute coronary syndrome

Risk stratification among patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) has been made by clinical scoring. Recently, multiple-detector computed tomography (MDCT) appeared to provide noninvasive coronary angiography (CAG). To clarify the prognostic significance of MDCT, we aimed to evaluate the clinical utility of MDCT in the early management and in predicting the long-term prognosis of NSTE-ACS with low to intermediate risk. Among 84 consecutive patients with NSTEACS, risk stratification using a TIMI risk score was done. A total of 48 patients were categorized as low to intermediate risk. Multiple-detector CT was performed in 30 patients using 16-slice MDCT. MDCT detected coronary stenoses in 18 patients. Compared to invasive CAG, MDCT successfully depicted the coronary stenosis (P < 0.005), with sensitivity of 100% and specificity of 86%. The incidence of in-hospital major adverse clinical events (death, subsequent myocardial infarction, revascularization) was significantly higher in patients with a positive MDCT than in those with a negative MDCT test (44% vs 0%, P < 0.005). Moreover, a Kaplan-Meier analysis showed a significant difference in the event — free survival between MDCT positive and negative groups (33% vs 100%, respectively, P < 0.0001) during the mean follow-up period of 9.9 ± 7.5 months. Sixteen-slice MDCT in conjunction with a TIMI risk score appeared to demonstrate prognostic significance in patients with NSTE-ACS.     

Antithrombotic treatment tailoring and risk score evaluation in elderly patients diagnosed with an acute coronary syndrome

Age is an important prognostic factor in the outcome of acute coronary syndromes (ACS). A substantial percentage of patients who experience ACS is more than 75 years old, and they represent the fastest-growing segment of the population treated in this setting. These patients present different patterns of responses to pharmacotherapy, namely, a higher ischemic and bleeding risk than do patients under 75 years of age. Our aim was to identify whether the currently available ACS ischemic and bleeding risk scores, which has been validated for the general population, may also apply to the elderly population. The second aim was to determine whether the elderly benefit more from a specific pharmacological regimen, keeping in mind the numerous molecules of antiplatelet and antithrombotic drugs, all validated in the general population. We concluded that the GRACE (Global Registry of Acute Coronary Events) risk score has been extensively validated in the elderly. However, the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) bleeding score has a moderate correlation with outcomes in the elderly. Until now, there have not been head-to-head scores that quantify the ischemic versus hemorrhagic risk or scores that use the same end point and timeline (e.g., ischemic death rate versus bleeding death rate at one month). We also recommend that the frailty score be considered or integrated into the current existing scores to better quantify the overall patient risk. With regard to medical treatment, based on the subgroup analysis, we identified the drugs that have the least adverse effects in the elderly while maintaining optimal efficacy.     

合并2型糖尿病的急性冠脉综合征患者GRACE评分与冠脉病变严重程度的相关性研究

目的 探讨GRACE评分与合并2型糖尿病的急性冠脉综合征(acute coronary syndromes,ACS)患者冠状动脉病变相关性及相关程度。方法 选取2014年1月至2014年12月在沧州市中心医院住院治疗的合并有2型糖尿病的ACS患者262例,并对所有患者行急性全球急性冠脉综合征注册评分(GRACE评分),并根据评分结果分为低危组、中危组和高危组,比较3组患者临床参数差异,所有患者均行冠脉造影术,并根据造影结果采用Gensini积分对冠脉病变程度进行量化评价,同时记录冠脉病变支数,用Spearman相关分析GRACE评分与冠脉病变的关系,并用ROC曲线分析GRACE评分对三支或左主干病变的预测价值。结果 3组中年龄、心率、入院随机血糖、空腹血糖、低密度脂蛋白(LDL)、心肌标志物、糖尿病病程、冠脉病变支数、弥漫性病变和Gensini积分的差异均有统计学意义,Spearman相关分析显示GRACE评分和Gensini积分呈正相关(r =0.651,R<0.001),GRACE评分危险分层和冠脉病变支数呈正相关(r =0.695 ,R<0.001),GRACE评分(ROC曲线下面积0.870,95％CI=0.826~0.914;R<0.001)比糖尿病病程(ROC曲线下面积0.627,95％CI=0.558~.696;R<0.001)对3支或左主干病变更有预测价值。结论 GRACE评分对急性冠脉综合征合并2型糖尿病患者的冠脉病变支数和病变程度有较好的预测价值。     

Platelet reactivity and the identification of acute coronary syndromes in the emergency department

Risk stratifying patients with potential acute coronary syndromes (ACS) in the Emergency Department is an imprecise and resource-consuming process. ACS cannot be ruled in or out efficiently in a majority of patients after initial history, physical exam, and ECG are analyzed. This has led to a reliance on cardiac markers of myocardial necrosis as a key means of making the diagnosis. Commonly used markers, CK-MB and troponin-I, have the drawback of delayed sensitivity. This has led to an ongoing search for one or more marker(s) that would be more sensitive in early ACS. With the central role that platelets play in the pathophysiology of coronary thrombosis, measures of platelet function represent one potential area where an early ACS marker might be identified. This review will focus on selected tests/markers of platelet function that have shown some promise with respect to the risk stratification of patients with potential ACS.     

地尔硫(艹,卓)对急性冠状动脉综合征患者冠状动脉介入治疗后的影响

目的:探讨地尔硫对急性冠状动脉综合征(ACS)患者冠状动脉介入治疗(PCI)后的影响。方法:选取入住四川大学华西医院心内科、经冠状动脉造影确诊为ACS,并接受PCI的患者共53例,随机分为地尔硫组和对照组,地尔硫组于PCI后即刻给予地尔硫5μg·kg-1·min-1,持续24h。观察2组心绞痛发作次数,2组术前,术后即刻、24、48、72h血压、心率、心肌氧耗指数变化,以及C反应蛋白(CRP)和氨基末端脑钠肽前体(NT-proBNP)水平。结果:①2组在观察期内心绞痛发作次数差异无统计学意义[地尔硫组(2·6±1·2)次,对照组(2·8±1·5)次]。②2组在术前和术后即刻血压、心率并无显著差异,但术后24h地尔硫组较对照组血压、心率均有明显降低[地尔硫组:血压(122·8±16·6)/(72·5±6·7)mmHg,心率(67·4±8·5)次/min;对照组:血压(135·6±18·9)/(86·2±9·7)mmHg,心率(78·9±10·6)次/min],2组比较差异有统计学意义(均P<0·01),且一直保持到术后72h,地尔硫组可有效降低心肌氧耗指数。③2组在术前和术后即刻CRP、NT-proBNP并无显著差异,但术后较术前CRP、NT-proBNP水平升高[地尔硫组:术前CRP(20·4±4·3)mg/L,NT-proBNP(254·2±31·7)ng/L,术后即刻CRP(39·8±8·6)mg/L,NT-proBNP(448·9±51·2)ng/L;对照组:术前CRP(18·6±5.2)mg/L,NT-proBNP(210.5±29.8)ng/L,术后即刻CRP(41.2±9.1)mg/L,NT-proBNP(502.6±57.4)ng/L]。术后24h地尔硫组较对照组CRP、NT-proBNP均有明显降低[地尔硫组:CRP(25.2±3.2)mg/L,NT-proBNP(202.5±21.4)ng/L;对照组:CRP(39.7±8.5)mg/L,NT-proBNP(482.3±49.7)ng/L,2组比较差异有统计学意义(P<0·05),且一直保持到术后72h。结论:地尔硫可降低ACS患者PCI后的心率、血压和心肌氧耗指数,并可显著降低PCI后CRP和NT-proBNP水平,有可能改善ACS患者PCI的预后。     

A prospective validation of the HEART score for chest pain patients at the emergency department

Background

The focus of the diagnostic process in chest pain patients at the emergency department is to identify both low and high risk patients for an acute coronary syndrome (ACS). The HEART score was designed to facilitate this process. This study is a prospective validation of the HEART score.

Methods

A total of 2440 unselected patients presented with chest pain at the cardiac emergency department of ten participating hospitals in The Netherlands. The HEART score was assessed as soon as the first lab results and ECG were obtained. Primary endpoint was the occurrence of major adverse cardiac events (MACE) within 6 weeks.Secondary endpoints were (i) the occurrence of AMI and death, (ii) ACS and (iii) the performance of a coronary angiogram. The performance of the HEART score was compared with the TIMI and GRACE scores.

Results

Low HEART scores (values 0–3) were calculated in 36.4% of the patients. MACE occurred in 1.7%. In patients with HEART scores 4–6, MACE was diagnosed in 16.6%. In patients with high HEART scores (values 7–10), MACE occurred in 50.1%. The c-statistic of the HEART score (0.83) is significantly higher than the c-statistic of TIMI (0.75)and GRACE (0.70) respectively (p < 0.0001).

Conclusion

The HEART score provides the clinician with a quick and reliable predictor of outcome, without computer-required calculating. Low HEART scores (0–3), exclude short-term MACE with > 98% certainty. In these patients one might consider reserved policies. In patients with high HEART scores (7–10) the high risk of MACE may indicate more aggressive policies.     

Cardiac CT in the emergency department

Current triage strategies are not effective in correctly identifying patients suffering from acute coronary syndrome (ACS). The diagnostic workup of patients presenting with acute chest pain continues to represent a major challenge for emergency department (ED) personnel. This statement holds especially true for patients with a low to intermediate likelihood for ACS. Taking current concepts for the diagnosis and management of patients presenting with acute chest pain to the ED into account, this article discusses the evidence and potential role of coronary computed tomography angiography to improve management of patients with possible ACS.     

冠状动脉侧支循环形成的相关因素及其临床意义

目的:探讨冠状动脉(冠脉)侧支循环形成的相关因素及其临床意义。方法:通过分析269例急性冠脉综合征患者的选择性冠脉造影及临床资料,利用BinaryLogistic回归分析,评估年龄、性别、吸烟史、高血压、糖尿病、血脂水平、血管内皮生长因子(VEGF)、内皮他丁浓度及冠脉狭窄程度对冠脉侧支形成的影响;同时比较有、无侧支循环间血清高敏C-反应蛋白(hs-CRP)、脑钠肽(BNP)、肌钙蛋白I(cTnI)及左室射血分数(LVEF)差异。结果:高血压、糖尿病及冠脉狭窄程度与冠脉侧支形成独立相关(均P<0·01);无侧支循环者cTnI较有侧支循环者显著升高[(0·91±1·13)∶(0·29±0·23)μg/L],LVEF较有侧支循环者显著降低[(43±11)%∶(48±11)%],均P<0·01;两者间VEGF、内皮他丁、hs-CRP及BNP均差异无统计学意义(均P>0·05)。结论:高血压、糖尿病、内皮他丁及冠脉病变狭窄程度是冠脉侧支循环形成的独立影响因素,侧支循环形成有助于减少急性冠脉综合征患者的心肌损伤,保护心功能。     

Prognostic value of serum biomarkers in association with TIMI risk score for acute coronary syndromes

BACKGROUND: Markers of neurohormonal activation and inflammation play a pivotal role in non-ST-elevation acute coronary syndromes (NSTE-ACS). HYPOTHESIS: We hypothesized that other biochemical markers could add prognostic value on Thrombolysis In Myocardial Infarction (TIMI) risk score to predict major cardiovascular events in patients with NSTE-ACS. METHODS: In a cohort of 172 consecutive patients with NSTE-ACS, TIMI score was assessed in the first 24 h, and blood samples were collected for measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein, CD40 ligand, and creatinine. Major clinical outcomes (death and cardiovascular hospitalization) were accessed at 30 days and 6 months. Multivariate logistic regression was applied to identify markers significantly associated with outcomes and, based on individual coefficients, an expanded score was developed. RESULTS: Of 172 patients, 42% had acute myocardial infarction. The unadjusted 30-day event rate increased with age (odds ratio [OR] = 1.03; 95% confidence interval [CI] 1.00-1.06), creatinine (OR = 2.4; 1.4-4.1), TIMI score (OR = 1.6; 1.2-2.2), troponin I (OR = 3.4; 1.5-7.7), total CK (OR = 2.7; 1.2-6.1), and NT-proBNP (OR = 2.9; 1.3-6.3) levels. In multivariate analysis, TIMI risk score, creatinine, and NT-proBNP remained associated with worse prognosis. Multimarker Expanded TIMI Risk Score [TIMI score + (2 X creatinine [in mg/dl]) + (3, if NT-proBNP > 400 pg/ml)] showed good accuracy for 30-day (c statistic 0.77; p < 0.001) and 6-month outcomes (c statistic 0.75; p < 0.001). The 30-day event rates according to tertiles of expanded score were 7, 26, and 75%, respectively (p < 0.01). CONCLUSION: In NSTE-ACS, baseline levels of NT-proBNP and creatinine are independently related to cardiovascular events. Both markers combined with TIMI risk score provide a better risk stratification than either test alone.