López de Sá Esteban, López-Sendón José, Anguera Ignasi, Bethencourt Armando, Bosch Xavier
Hospital General U. Gregorio Marañón, Madrid, Spain.
Medicine (Baltimore). 2002 Nov;81(6):434-42. doi: 10.1097/00005792-200211000-00004.
Patients with suspected non-ST-segment elevation acute coronary syndromes (NSTEACS) constitute a heterogeneous population with variable outcomes. Risk stratification in this population of patients is difficult due to the complexity in patient risk profile. We conducted this study to characterize the value of clinical and electrocardiographic variables for risk stratification in an unselected population of consecutive patients with NSTEACS on admission. Thirty-five clinical and electrocardiographic variables at presentation in the emergency room of 18 hospitals were prospectively analyzed in 4,115 patients with NSTEACS and related with the outcomes at 90 days. We also developed a risk score using the variables found to be independent predictors of ischemic events to facilitate risk stratification. Cardiovascular mortality was 4.3% and the rate for the outcome of either cardiovascular death or nonfatal myocardial infarction was 6.9%. The only independent predictors of mortality were age, diabetes, peripheral vascular disease, postinfarction angina, Killip class > or = 2, ST-segment depression, and elevation of cardiac markers. A risk profile using the variables found to be independent predictors of events was calculated for cardiovascular mortality and for the combination of either death or nonfatal myocardial infarction. Event rates increased significantly in all subgroups of patients based on the number of independent risk factors as the risk score increased. Using these factors, 90-day mortality ranged from as low as 0.4% in patients with no risk factors to 21.1% for those with more than 4 risk factors. In conclusion, simple clinical and electrocardiographic data obtained at hospital admission allow an accurate risk stratification of patients with NSTEACS. In the PEPA registry, simple variables easy to obtain at admission appear to be a valuable tool in discerning between patients at very low and very high risk according to the cluster of factors for each patient. The risk score developed was obtained from an unselected population, representative of the whole spectrum of patients with NSTEACS, allowing identification of patients at different risks for adverse outcomes, and, therefore, permitting optimization of therapy.
疑似非ST段抬高型急性冠状动脉综合征（NSTEACS）的患者构成了一个结局各异的异质性群体。由于患者风险特征的复杂性，对该群体患者进行风险分层很困难。我们开展这项研究，旨在描述临床和心电图变量在未经选择的连续NSTEACS患者入院时进行风险分层的价值。对18家医院急诊室中4115例NSTEACS患者就诊时的35项临床和心电图变量进行了前瞻性分析，并与90天时的结局相关联。我们还使用被发现为缺血事件独立预测因素的变量制定了一个风险评分，以促进风险分层。心血管死亡率为4.3%，心血管死亡或非致死性心肌梗死结局的发生率为6.9%。死亡率的唯一独立预测因素是年龄、糖尿病、外周血管疾病、梗死后心绞痛、Killip分级≥2级、ST段压低以及心脏标志物升高。针对心血管死亡率以及死亡或非致死性心肌梗死的组合，使用被发现为事件独立预测因素的变量计算了一个风险特征。随着风险评分增加，基于独立风险因素数量的所有患者亚组的事件发生率均显著增加。使用这些因素，无风险因素的患者90天死亡率低至0.4%，而有4个以上风险因素的患者则为21.1%。总之，入院时获得的简单临床和心电图数据可对NSTEACS患者进行准确的风险分层。在PEPA注册研究中，入院时易于获得的简单变量似乎是根据每位患者的因素集群区分极低风险和极高风险患者的有价值工具。所制定的风险评分来自未经选择的群体，代表了NSTEACS患者的整个谱系，能够识别不同不良结局风险的患者，从而实现治疗的优化。
