CRUSADE评分、HAS-BLED评分预测心房颤动并PCI患者院内及远期出血风险的比较

目的:探讨CRUSADE评分、HAS-BLED评分对心房颤动(AF)伴急性冠状动脉综合征(ACS)经冠状动脉介入治疗(PCI)患者主要出血的预测价值。方法:纳入北京地区12家三甲医院AF伴ACS并PCI干预患者共2 421例行CRUSADE评分、HAS-BLED评分,观察院内及远期主要出血事件,通过比较受试者工作(ROC)曲线下面积(AUC),评估2种评分对该队列患者主要出血风险的预测价值。结果:院内共观察到23例主要出血事件,平均随访(3.22±1.53)年,随访期间共发生45例主要出血事件。对于院内出血风险CRUSADE评分AUC为0.737(P=0.000),HAS-BLED评分AUC为0.682(P=0.003)。对于远期出血风险CRUSADE评分AUC为0.693(P=0.000),HAS-BLED评分AUC为0.649(P=0.001)。在含口服抗凝治疗亚组对于院内出血风险CRUSADE评分AUC为0.507(P=0.956),HASBLED评分AUC为0.563(P=0.599)。对于远期出血风险CRUSADE评分AUC为0.490(P=0.930),HASBLED评分AUC为0.661(P=0.147)。结论:在本队列中,AF并ACS经PCI干预患者,抗栓方案以双联抗血小板为主,CRUSADE评分及HAS-BLED评分均可预测院内短期及长期出血风险,但在远期出血风险方面二者的预测价值均有下降,CRUSADE评分有优于HAS-BLED的趋势。对于含口服抗凝剂抗栓治疗的患者CRUSADE评分及HAS-BLED评分对院内及远期出血风险均无预测价值。     

心血管风险评分预测经冠状动脉介入干预急性冠脉综合征合并心房颤动患者院内、远期死亡风险的比较

目的 评价心血管风险评分包括TIMI、GRACE、CRUSADE、C-ACS、ProACS、CHA₂DS₂-VASc、HAS-BLED、TIMI-AF对经冠状动脉介入(PCI)干预急性冠脉综合征(ACS)合并心房颤动(AF)患者院内、远期死亡的预测价值。方法 纳入北京地区12家三甲医院经PCI干预ACS伴AF患者共2429例,根据定义收集相关参数完成上述评分,随访观察住院死亡、长期全因死亡和心血管死亡,在该队列中比较多个评分系统对院内死亡和远期死亡的预测价值。结果 院内共观察到34例死亡,平均随访3.19±1.52年,随访期间共270例患者死亡,其中109例死于心血管事件。GRACE评分、C-ACS评分、ProACS评分和CRUSADE评分对院内死亡的预测能力相当(C值,0.813～0.868),优于其他评分。GRACE评分、ProACS评分、CRUSADE评分和TIMI-AF评分对远期全因死亡的预测能力相似(C值,0.659～0.698),优于其他评分。GRACE评分、ProACS评分、CRUSADE评分、CHA₂DS...     

红细胞分布宽度预测急性冠状动脉综合征合并慢性肾脏病患者院内病死率的价值

目的:探讨红细胞分布宽度(RDW)预测急性冠状动脉综合征(ACS)合并慢性肾脏病(CKD)患者院内死亡率的价值。方法:回顾性分析2011年1月至2014年12月,在北京朝阳医院接受治疗的ACS合并CKD患者的临床资料。根据住院期间治疗结果将患者分为死亡组和存活组,比较两组间RDW水平的差异。RDW预测患者院内死亡的准确性通过ROC曲线及曲线下面积AUC来评估。结果:本研究共入选346例患者,众位RDW水平为13.5%(12.9,14.1)%.院内死亡66例(19.1%),死亡患者RDW水平明显高于存活患者[14.3%(13.7,14.8)%vs.13.4%(12.8,13.9)%,P0.001]。多因素Logistic回归显示RDW是预测患者院内死亡的独立危险因素(OR=1.357,95%CI=1.067~1.724,P=0.013)。RDW预测患者院内死亡的ROC曲线下面积AUC=0.78(95%CI:0.721~0.84,P0.001);GRACE评分预测患者院内死亡的ROC曲线下面积AUC=0.866(95%CI:0.821~0.911,P0.001)。两者联合后预测患者院内死亡的ROC曲线下面积AUC=0.891(95%CI 0.883~0.962,P0.001),明显高于单独GRACE评分预测院内死亡的准确性(P=0.035)。结论:RDW预测ACS合并CKD患者院内死亡率有良好的价值,联合RDW可以明显提高GRACE评分预测ACS合并CKD患者院内死亡率的准确性。     

GRACE评分和N－末端脑利钠肽对急性冠脉综合征患者远期死亡风险的预测价值

目的对比全球急性冠状动脉事件注册（GRACE）评分及N一末端脑利钠肽（NT—proBNP）水平对急性冠脉综合征（ACS）患者远期（≥6个月）死亡风险的预测效力,同时探讨二者结合能否提高对死亡风险的预测效力。方法入选135例ACS患者,在首发胸痛24h内采血测定NT－proBNP血浆水平,并进行GRACE风险积分评定。对所纳入患者进行至少6个月的随访,随访终点为全因性死亡。结果平均随访（295±160）天,入选患者共死亡14例,死亡率为10．4％。远期死亡率与高GRACE评分密切相关（P〈0．001）。死亡患者的24hNT－proBNP血清浓度明显高于生存患者,远期死亡率与NT－proBNP水平之间有显著的正相关关系（P〈0．001）。多变量Cox比例风险回归分析表明,GRACE评分（HR0．99,95％C10．98～1．00,P〈0．05）和NT－proBNP水平的对数值（LogNT－proBNP）（HR1．61,95％C11．12～2．31,P〈O．05）均是ACS患者远期死亡率的独立预测因素。GRACE评分预测患者远期死亡率的ROC曲线下面积为0．89（95％C10．82～0．95,P〈O．001）,LogNT－proBNP水平预测患者远期死亡率的ROC曲线下面积为0．85（95％C10．76～0．95,P〈0．001）,GRACE评分与LogNT－proBNP联合ROC曲线下面积为0．91（95％C10．88～0．98,P〈0．001）。结论NT-proBNP水平及GRACE评分均是ACS患者远期的死亡风险可靠预测指标,两者联合使用可以形成更好和更有效的临床风险分层系统,可明显提高对远期死亡的预测效力。     

白细胞计数与GRACE评分联合检测对ACS患者近期死亡风险的预测价值

目的评价入院时白细胞计数联合全球急性冠状动脉事件注册(GRACE)风险评分对急性冠脉综合征(ACS)患者近期死亡风险的预测价值。方法回顾性分析309例ACS患者入院时白细胞计数水平及GRACE危险评分。随访观察入院时白细胞计数和GRACE评分对其近期死亡率的影响。结果通过ROC计算曲线下面积(AUC)分析发现,白细胞计数的AUC 0.732(95%CI 0.328~0.903 P0.01);白细胞预测近期死亡率的最佳界值为10.60×109/L;GRACE危险评分的AUC 0.784(95%CI 0.576~0.981,P0.01);白细胞计数与GRACE危险评分的联合预测因子AUC 0.826(95%CI 0.605~0.965,P0.01)。结论入院时白细胞计数与GRACE评分联合检测可以提高对ACS患者近期死亡风险的预测价值。     

胱抑素C改良的GRACE风险评分对急性冠状动脉综合征患者心血管事件的预测价值

目的 探讨入院时胱抑素C水平是否增强GRACE风险评分对急性冠状动脉综合征（ACS）患者12个月心血管事件的预测价值.方法 回顾性分析我院2011年6月至2012年6月400例ACS患者入院时的胱抑素C水平和GRACE风险评分.通过绘制受试者工作特征曲线（ROC）,分析胱抑素C对心血管事件的预测价值和最佳界值,并根据Logistic回归分析中的OR值,确定胱抑素C在评分中的分值,建立胱抑素C改良的GRACE风险评分.通过计算ROC曲线下面积（AUC）比较胱抑素C改良的GRACE风险评分和常规的GRACE风险评分对心血管事件的预测价值.结果 ACS患者12个月内的心血管事件发生率为33.5％.胱抑素C水平对12个月内的心血管事件有良好的预测价值（AUC：0.706,95％ CI：0.631～0.780,P=0.000）,而且在Logistic回归分析中经GRACE风险评分校正后仍保留其预测价值.GRACE风险评分预测12个月心血管事件的AUC为0.623（95％ CI：0.545～0.701）,增加胱抑素C参数后,增强了GRACE风险评分对12个月心血管事件的预测价值（AUC0.721,95％ CI：0.650 ～0.792）,差异有统计学意义（Z=2,P=0.03）.结论 入院时胱抑素C水平可以增强GRACE风险评分对ACS患者12个月心血管事件的预测价值.     

联合GRACE评分和CRUSADE评分对行介入的NSTE-ACS患者预后评估

目的 比较GRACE评分、CRUSADE评分与联合GRACE和CRUSADE评分对于行经皮冠脉支架术的急性非ST段抬高型急性冠脉综合征(Non-ST-segment elevation acute coronary syndrome,NSTE-ACS)患者预后的评估价值。方法 研究纳入明确诊断NSTE-ACS患者320名,均接受经皮冠状动脉介入治疗并置入药物涂层支架。所有患者随访至少1.5年,以GRACE评分141分及CRUSADE评分41分为截点,分为3个组,低危组( GRACE<141;CRUSADE<41)、中危组(GRACE<141,CRUSADE≥41;GRACE≥41,CRUSADE<41)、高危组(GRACE≥141;CRUSADE≥41),通过统计学方法比较亚组间患者院内及随访期间的死亡与出血事件。结果 从低危组~高危组,患者的临床基线情况逐渐加重的,临床预后结果亦是恶化的,生存分析曲线表明3组病死率是逐渐增加的。GRACE评分、CRUSADE评分和联合评分能较好拟合本组NSTE-ACS患者总事件的分布,Logistic分析和ROC曲线表明联合评分在死亡风险（AUC（联=0.758）>AUC（G=0.750）>AUC（c=0.662））和出血风险（AUC（联=0.770）>AUC（C=0.761）>AUC（G=0.737））上有预测价值,3种方法的评估价值差异均无统计学意义。结论 联合评分在死亡预测和出血风险上均有预测价值,联合评分进行评价是可行的,同时其预测效能最高,有助于指导NSTE-ACS患者早期的危险分层和介入术后的风险预测。     

SAMe-TT_2R_2及CRUSADE评分对高龄心房颤动合并冠心病患者抗凝后出血风险评估

目的探讨SAMe-TT_2R_2评分、CRUSADE评分对高龄心房颤动合并冠心病经抗凝治疗后患者主要出血的预测价值。方法将在我院经抗凝治疗且随访2年的221例心房颤动合并冠心病患者作为研究对象,观察院内及远期主要出血事件,计算患者SAMe-TT_2R_2评分和CRUSADE评分,运用ROC曲线分析比较两种评分方法对患者主要出血风险的预测价值。结果院内共发生主要出血事件15例,随访期间共发生43例。对于院内出血风险,SAMeTT_2R_2评分和CRUSADE评分AUC分别为0. 67(P 0. 01),0. 54(P 0. 05),De Long检验显示SAMe-TT_2R_2评分AUC显著高于CRUSADE评分,差异具有统计学意义(D=0. 04,P 0. 05);对于远期出血风险,SAMe-TT_2R_2评分AUC为0. 55(P 0. 05),CRUSADE评分AUC为0. 49(P 0. 05),De Long检验显示两种评分方法差异具有统计学意义(D=0. 04,P 0. 05)。SAMe-TT_2R_2评分预测院内和远期主要出血事件的最佳临界值分别为5分和2分。结论 SAMeTT2R2评分和CRUSADE评分均可预测心房颤动合并冠心病患者抗凝后院内及远期出血风险,但SAMe-TT_2R_2评分预测能力显著优于CRUSADE评分;患者SAMe-TT_2R_2评分分别高于5分和2分时,院内和远期主要出血风险显著增高。     

CAMI-NSTEMI评分优化NSTEMI患者院内死亡风险预测的临床研究

目的 在非ST段抬高型心肌梗死（NSTEMI）的中国人群中对中国急性心肌梗死注册研究的NSTEMI(CAMI-NSTEMI)评分进行验证并与全球急性冠状动脉事件（GRACE）评分进行比较,探索其对NSTEMI诊疗策略的影响。方法 入选NSTEMI患者466例,收集基线资料和院内死亡等数据,计算其CAMI-NSTEMI评分和GRACE评分,利用受试者工作曲线下面积（AUC）和重分类表等统计方法对评分进行验证和比较。结果 CAMI-NSTEMI评分（AUC=0.782,95%置信区间：0.731-0.827））与GRACE评分（AUC=0.743,95%置信区间：0.683-0.802）相比表现出更优秀的分辨能力,并且更准确有效地识别高危患者。结论 CAMI-NSTEMI评分能够更有效预测NSTEMI患者的院内死亡风险,并在此基础上优化NSTEMI患者诊疗策略的选择。     

GRACE评分联合MPVLR对NSTEMI经皮冠状动脉介入治疗后对比剂急性肾损伤的预测价值

目的 探讨非ST段抬高型急性心肌梗死（NSTEMI）患者行经皮冠状动脉介入治疗（PCI术后发生对比剂急性肾损伤（CI-AKI）与平均血小板体积/淋巴细胞计数比值（MPVLR）和GRACE评分的关系,并进一步比较MPVLR、GRACE评分以及两者联合对CI-AKI的预测价值。方法 回顾性选取2019年1月至2021年1月因NSTEMI于徐州医科大学附属医院行PCI的368例患者作为研究对象,依据是否发生CI-AKI,将所有患者分为CI-AKI组（n=47）及non-CI-AKI(n=321)组。比较两组患者的临床资料和不同水平MPVLR和GRACE评分患者CI-AKI的发生率。采用Logistic回归分析研究NSTEMI患者PCI术后发生CI-AKI的危险因素。绘制ROC曲线评价MPVLR、GRACE评分以及两者联合对PCI术后CI-AKI的预测价值。结果 CI-AKI组的MPVLR和GRACE评分明显高于non-CI-AKI组（P<0.05）。MPVLR联合GRACE评分预测NSTEMI患者PCI术后发生CI-AKI曲线下面积（AUC）为0.722(95%CI:0.644～0.7...     

中性粒细胞/淋巴细胞比值对PCI术后ACS患者预后评价的价值

目的:探讨中性粒细胞与淋巴细胞计数比值(NLR)对行经皮冠脉介入治疗(PCI)的急性冠脉综合征(ACS)患者主要不良心血管事件(MACE)的预测价值。方法:选择在我院行PCI的ACS患者125例,根据GRACE评分(GRS)患者被分为低危组(GRS≤108分,38例)、中危组(109分≤GRS≤140分,46例)、高危组(GRS>140分,41例)。比较不同危险分层组血清C反应蛋白(CRP)、心肌肌钙蛋白T(cTnT)和血浆N末端脑钠肽前体(NT-proBNP)水平及NLR值。根据住院期间和出院后1年内MACE发生情况,患者被分为MACE组(94例)和非MACE组(31例),比较两组GRS、NLR值及CRP水平。采用ROC曲线评价NLR对患者MACE的预测价值。结果:随着ACS的危险分层的上升,NLR值[1.80(0.76)比2.68(1.33)比3.82(3.25)]显著升高(P均=0.001)。与非MACE组比较,MACE组GRS[114.0(37.5)分比162.0(52.0)分]、NLR值[2.4(1.5)比3.9(4.8)]和CRP[3.5(6.9)mg/L比12.2(40.8)mg/L]水平均显著升高(P均=0.001)。ROC曲线分析NLR、GRS、GRS+NLR对发生MACE的预测价值,其曲线下面积(AUC)分别为:0.810(95%CI:0.722~0.897)、0.837(95%CI:0.756~0.917)、0.849(95%CI:0.774~0.925)。结论:NLR作为一项简便易获取的常规检验指标,联合GRACE评分可更加准确地预测PCI术后ACS患者的预后,具有重要临床价值。     

The Value of the GRACE Score for Predicting the SYNTAX Score in Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction

BackgroundIn patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), Global Registry for Acute Coronary Events (GRACE) score is a valid tool for risk stratification. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score is an angiographic scoring system to guide the decision-making between coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI). The aim of the present study was to assess the accuracy of the GRACE score in predicting the severity and extent of coronary artery stenosis by SYNTAX score.MethodsA total of 330 patients with acute coronary syndrome (ACS) were enrolled in the study. For every patient, the GRACE score was calculated. All patients underwent coronary angiography within 2 days and the SYNTAX scoring system was used to evaluate the severity and extent of coronary stenotic lesions. Based on ROC curve analysis, the cut-off value of GRACE score that could predict SYNTAX score ≥ 23 was calculated.ResultsGRACE score was 107.12 ± 34.4 in patients with SYNTAX SCORE < 23 and 134.80 ± 48.3 in patients with SYNTAX score ≥ 23 (p value = 0.001). A positive correlation was observed between the GRACE score and angiographic SYNTAX score (r = 0.34 p < 0.001). We found that a GRACE score of 109 is the optimal cut-off to predict SYNTAX score ≥ 23 with a sensitivity of 73.5% and specificity of 60% (p < 0.001). Its negative predictive value was 94.0%.ConclusionGRACE score had significant but modest value to predict the severity and extent of coronary artery stenosis in patients with ACS.     

急性心肌梗死患者直接经皮冠状动脉介入术后院内死亡的预测因素

目的分析急性心肌梗死(AMI)患者直接PCI术后发生院内死亡的预测因素,以寻找进一步改善AMI患者住院期间预后的可能途径。方法根据314例接受直接PCI的AMI患者住院期间存活与否,将其分为死亡组(26例)和非死亡组(288例),比较两组患者的临床和冠状动脉造影特点,确定发生院内死亡的预测因素。结果死亡组患者中女性(P=0.017)、年龄>75岁(P=0.004)、3支血管病变(P=0.015)、左主干闭塞(P=0.036)、就诊至球囊扩张时间>90min(P=0.013)、并发心源性休克(P=0.000)显著高于非死亡组患者;而PCI成功(P=0.000)、ST段下降>50%(P=0.000)显著低于非死亡组患者。多因素分析显示,心源性休克(P=0.000)、女性(P=0.029)、就诊至球囊扩张时间>90min(P=0.035)是发生院内死亡的独立预测因素。结论为进一步改善接受直接PCI的AMI患者住院期间的预后,未来治疗的重点在于降低高危(特别是心源性休克)患者的病死率,缩短就诊至球囊扩张时间,以及改善冠状动脉微循环和提高心肌水平的再灌注。     

Improved predictive value of GRACE risk score combined with platelet reactivity for 1-year cardiovascular risk in patients with acute coronary syndrome who underwent coronary stent implantation

Both high platelet reactivity (HPR) and Global Registry of Acute Coronary Events (GRACE) risk score have moderate predictive value for major adverse cardiovascular disease (CVD) events in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI), whereas the prognostic significance of GRACE risk score combined with platelet function testing remains unclear. A total of 596 patients with non-ST elevation ACS who underwent PCI were enrolled. The P2Y₁₂ reaction unit (PRU) value was measured by VerifyNow P2Y₁₂ assay and GRACE score was calculated by GRACE risk 2.0 calculator. Patients were stratified by a pre-specified cutoff value of PRU 230 and GRACE score 140 to assess 1-year risk of cardiovascular death, non-fatal myocardial infarction (MI), and stent thrombosis. Seventy-two (12.1%) patients developed CVD events during 1-year follow-up. Patients with CVD events had a higher PRU value (244.6 ± 50.9 vs. 203.7 ± 52.0, p < 0.001) and GRACE score (185.2 ± 45.6 vs. 149.7 ± 40.1, p < 0.001) than those without events. Multivariate logistic analysis showed that both platelet reactivity and GRACE score were associated with 1-year CVD risk independently. Compared to patients with normal platelet reactivity (NPR) and GRACE score < 140, those with HPR and GRACE score ≥ 140 were exposed to significantly elevated CVD risk (HR: 5.048; 95% CI: 2.268–11.237; p < 0.001). Adding platelet reactivity on the top of GRACE risk score yielded superior risk predictive capacity beyond GRACE score alone, which is shown by improved c-statistic value (0.871, p = 0.002) as well as net reclassification improvement (NRI 0.263, p < 0.001) and integrated discrimination improvement (IDI 0.018, p = 0.002). In patients with NSTE-ACS who underwent PCI, high on-treatment platelet reactivity and high GRACE score led to greater risk of adverse CVD events. The combination of platelet function testing and GRACE score predicted 1-year CVD risk better.     

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.     

A novel risk stratification system “Angiographic GRACE Score” for predicting in-hospital mortality of patients with acute myocardial infarction: Data from the K-ACTIVE Registry

BackgroundThe Global Registry of Acute Coronary Events (GRACE) score is the most accurate risk assessment system for acute myocardial infarction (AMI), which was proposed in Western countries. However, it is unclear whether GRACE score is applicable to the present Japanese patients with a high prevalence of emergent percutaneous coronary intervention (PCI) and vasospasm. This study aimed to clarify the usefulness of GRACE risk score for risk stratification of Japanese AMI patients treated with early PCI and to evaluate a novel risk stratification system, “angiographic GRACE score,” which is the GRACE risk score adjusted by the information of the culprit coronary artery and its flow at pre- and post-PCI, to improve its predicting availability.MethodsThe subjects were 1817 AMI patients who underwent PCI within 24 h of onset between October 2015 and August 2017 and were registered in Kanagawa Acute Cardiovascular (K-ACTIVE) Registry via survey form. The association between the clinical parameters and in-hospital mortality was investigated.ResultsA total of 79 (4.3%) in-hospital deaths were identified. The C-statistics for the in-hospital mortality of the GRACE score was 0.86, which was higher than that of the other conventional risk factors, including age (0.65), systolic blood pressure (0.70), heart rate (0.62), Killip classification (0.77), and serum levels of creatinine (0.68) and peak creatine kinase (0.74). The angiographic GRACE score improved the C-statistics from 0.86 of the original GRACE score to 0.89 (p < 0.05). In the setting of the cut-off value at 200, in-hospital mortality in the patients with the angiographic GRACE score <200 was 0.6%, which was relatively lower than those with ≥200, 9.4%.ConclusionsThe GRACE score is a useful predictor of in-hospital mortality among Japanese AMI patients in the PCI era. Moreover, the angiographic GRACE score could improve the predicting availability.     

Prognostic Value of TIMI Score versus GRACE Score in ST-segment Elevation Myocardial Infarction

Background

The TIMI Score for ST-segment elevation myocardial infarction (STEMI) was created and validated specifically for this clinical scenario, while the GRACE score is generic to any type of acute coronary syndrome.

Objective

Between TIMI and GRACE scores, identify the one of better prognostic performance in patients with STEMI.

Methods

We included 152 individuals consecutively admitted for STEMI. The TIMI and GRACE scores were tested for their discriminatory ability (C-statistics) and calibration (Hosmer-Lemeshow) in relation to hospital death.

Results

The TIMI score showed equal distribution of patients in the ranges of low, intermediate and high risk (39 %, 27 % and 34 %, respectively), as opposed to the GRACE Score that showed predominant distribution at low risk (80 %, 13 % and 7%, respectively). Case-fatality was 11%. The C-statistics of the TIMI score was 0.87 (95%CI = 0.76 to 0.98), similar to GRACE (0.87, 95%CI = 0.75 to 0.99) - p = 0.71. The TIMI score showed satisfactory calibration represented by χ2 = 1.4 (p = 0.92), well above the calibration of the GRACE score, which showed χ2 = 14 (p = 0.08). This calibration is reflected in the expected incidence ranges for low, intermediate and high risk, according to the TIMI score (0 %, 4.9 % and 25 %, respectively), differently to GRACE (2.4%, 25% and 73%), which featured middle range incidence inappropriately.

Conclusion

Although the scores show similar discriminatory capacity for hospital death, the TIMI score had better calibration than GRACE. These findings need to be validated populations of different risk profiles.     

非ST段抬高急性冠状动脉综合征的预后危险因素与危险评分

目的：探讨非 ST 段抬高急性冠状动脉综合征的预后危险因素及不同危险评分的预测预后价值。方法：2003年1月至2004年4月期间,连续入院且资料完整的非 ST 段抬高急性冠状动脉综合征患者337例,随访 30天与1年的终点事件(心原性死亡和非致命性心肌梗死)。根据入院时的临床指标分别计算每例患者的心肌梗死溶栓治疗临床试验(TIMI)评分和全球急性冠状动脉事件注册(GRACE)评分,进行多变量回归分析,筛查30天和1年时心血管事件的预测危险因素(根据有无终点事件发生分为30天事件组、30天无事件组和1年事件组、1年无事件组)；分析 TIMI 评分和 GRACE 评分的预后价值,以及与血运重建的相互关系。结果：随访1年共发生终点事件57例(16.9%)。死亡19例(5.6%),非致死性心肌梗北38例(11.3%)。预测危险因素包括：年龄、血肌酐升高、入院时心率、左心室射血分数＜0.40和高血压。TIMI 评分和 GRACE 评分方法预测30天终点事件的敏感性和特异性相似,但 GRACE 评分预测1年终点事件的敏感性和特异性优于 TIMI 评分,GRACE 评分＞ 133分的患者进行血运重建治疗后远期终点事件发生率明显下降(P=0.01)。结论：除传统危险因素外,血肌酐水平升高是非 ST 段抬高急性冠状动脉综合征患者预后的重要危险因素；GRACE 评分较 TIMI 评分能更好的预测非 ST 段抬高急性冠状动脉综合征患者1年的终点事件危险,GRACE 评分＞133分的患者进行血运重建的获益更多。     

Comparison of different risk scores in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background The early detection of high-risk patients with primary percutaneous coronary intervention(PPCI) is important in reducing the risk of death in patients with acute ST elevation myocardial infarction(STEMI). We aimed to compare the prognostic value of validated risk scores for in-hospital and one-year death. Methods This study enrolled a series of patients with acute STEMI who underwent PPCI. Thrombolysis in Myocardial Infarction(TIMI) risk score, Korea Acute Myocardial Infarction Registry(KAMIR) score, Canada Acute Coronary Syndrome(C-ACS) and Age, Glomerular filtration rate, and Ejection Fraction(AGEF) were calculated. The prognostic accuracy of the 4 scores for in-hospital and one-year death was assessed. Results A total of 489 patients with acute STEMI were retrospectively included in the present study. There were 16(3.3%) patients died while in hospital. AGEF had higher predictive power for in-hospital death than KAMIR score(0.894 vs. 0.816,P = 0.048) and C-ACS(0.894 vs. 0.728, P = 0.038). No statistical significance was found when comparing with TIMI risk score(0.894 vs. 0.795, P = 0.124). There were 33 patients died in 459(93.9%) included patients completed one-year follow up. The AUC of TIMI risk score, KAMIR score, C-ACS and AGEF in predicting one-year death was 0.728, 0.718, 0.681 and 0.772, respectively. They had similarly prognostic value for one-year mortality(P 0.05). Conclusion The AGEF risk scores appear to have slightly better prognostic value for the in-hospital and one-year mortality in patients with acute STEMI receiving PPCI.     

GRACE与TIMI评分对ST段抬高型心肌梗死患者预后评估的价值

目的 比较全球急性冠状动脉事件注册研究(Global Registry for Acute Coronary Events,GRACE）评分及心肌梗死溶栓治疗评分系统（The Thrombolysis in Myocardial Infarction,TIMI)评分对ST段抬高型心肌梗死（ST segment elevation myocardial infarction,STEMI）患者预后评估的临床价值。方法 280例因STEMI接受急诊经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗的患者的临床资料,分别计算GRACE及TIMI评分,根据评分结果分为低、中、高危组。随访患者发病后12个月主要心血管不良事件（major adverse cardiac events,MACE）发生情况,通过计算两种评分系统的受试者工作特征曲线（ROC曲线）的面积评估其预测价值,并比较两者预测价值的能力。结果 不论是GRACE评分还是TIMI评分,危险分层越高,患者术后12个月MACE发生率越高（P<0.01）,而且TIMI评分的高危组患者MACE的发生率显著高于GRACE评分的高危组患者（P<0.05）。TIMI评分和GRACE评分ROC曲线下面积无统计学差异。GRACE预测MACE的灵敏度为87%,特异度为58%,正确指数（Youden index）为0.45;TIMI 灵敏度为54%,特异度为90%,正确指数为0.44,GRACE评分预测STEMI预后的灵敏度显著高于TIMI评分（87% vs. 54%,P<0.01）,而其特异度显著低于TIMI评分（58% vs. 90%,P<0.01）,两组正确指数的差异则无统计学意义(0.45 vs. 0.44)。结论 两种评分体系总体预测能力的差异无统计学意义。但GRACE评分灵敏度高,而TIMI评分特异度高。