Mahaffey Kenneth W, Yang Qinghong, Pieper Karen S, Antman Elliott M, White Harvey D, Goodman Shaun G, Cohen Marc, Kleiman Neal S, Langer Anatoly, Aylward Philip E, Col Jacques J, Reist Craig, Ferguson James J, Califf Robert M
Duke Clinical Research Institute, Durham, NC 27715, USA.
J Gen Intern Med. 2008 Mar;23(3):310-6. doi: 10.1007/s11606-007-0498-4. Epub 2008 Jan 15.
Despite advances in pharmacologic therapy and invasive management strategies for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), these patients still suffer substantial morbidity and mortality.
The objective of this study was to analyze independent predictors of 1-year mortality in patients with high-risk NSTE ACS.
A total of 9,978 patients were assigned to receive enoxaparin or unfractionated heparin (UFH) in this prospective, randomized, open-label, international trial.
Vital status at 1 year was collected. Univariable and multivariable predictors of 1-year mortality were identified. Three different multivariable regression models were constructed to identify: (1) predictors of 30-day mortality; (2) predictors of 1-year mortality; (3) predictors of 1-year mortality in 30-day survivors. The last model is the focus of this paper.
Overall, 9,922 (99.4%) of patients had 1-year follow-up. Of the 56 patients (37 UFH-assigned and 19 enoxaparin-assigned) without 1-year data, 11 patients were excluded because of withdrawal of consent, and 45 could not be located. One-year mortality was 7.5% (7.7% enoxaparin-assigned patients; 7.3% UFH-assigned patients; P = 0.4). In patients surviving 30 days after enrollment, independent predictors of 1-year mortality included factors known at baseline such as increased age, male sex, decreased weight, having ever smoked, decreased creatinine clearance, ST-segment depression, history of diabetes, history of angina, congestive heart failure, coronary artery bypass grafting, increased heart rate, rales, increased hematocrit, lowered hemoglobin, and higher platelet count. Factors predictive of mortality during the hospitalization and 30-day follow-up period were decreased weight at 30 days from baseline, atrial fibrillation, decreased nadir platelet, no use of beta-blockers and statins up to 30 days, and not receiving an intervention (c-index = 0.82).
Easily determined baseline clinical characteristics can be used to predict 1-year mortality with reasonable discriminative power. These models corroborate prior work in a contemporary aggressively managed population. A model to predict 1-year mortality in patients surviving at least 30 days may be quite helpful to healthcare providers in setting expectations and goals with patients after ACS.
尽管非ST段抬高型急性冠状动脉综合征（NSTE ACS）患者在药物治疗和侵入性管理策略方面取得了进展，但这些患者仍有相当高的发病率和死亡率。
本研究的目的是分析高危NSTE ACS患者1年死亡率的独立预测因素。
在这项前瞻性、随机、开放标签的国际试验中，共有9978名患者被分配接受依诺肝素或普通肝素（UFH）治疗。
收集1年时的生命状态。确定1年死亡率的单变量和多变量预测因素。构建了三种不同的多变量回归模型以确定：（1）30天死亡率的预测因素；（2）1年死亡率的预测因素；（3）30天幸存者中1年死亡率的预测因素。最后一个模型是本文的重点。
总体而言，9922名（99.4%）患者进行了1年随访。在56名没有1年数据的患者（37名分配接受UFH治疗和19名分配接受依诺肝素治疗）中，11名患者因撤回同意而被排除，45名患者无法找到。1年死亡率为7.5%（分配接受依诺肝素治疗的患者为7.7%；分配接受UFH治疗的患者为7.3%；P = 0.4）。在入组后存活30天的患者中，1年死亡率的独立预测因素包括基线时已知的因素，如年龄增加、男性、体重减轻、曾经吸烟、肌酐清除率降低、ST段压低、糖尿病史、心绞痛史、充血性心力衰竭、冠状动脉旁路移植术、心率增加、啰音、血细胞比容增加、血红蛋白降低和血小板计数升高。在住院期间和30天随访期内预测死亡率的因素包括与基线相比30天时体重减轻、心房颤动、最低血小板计数降低、至30天时未使用β受体阻滞剂和他汀类药物以及未接受干预（c指数 = 0.82）。
易于确定的基线临床特征可用于以合理的鉴别力预测1年死亡率。这些模型证实了在当代积极管理人群中的先前研究结果。一个预测至少存活30天患者1年死亡率的模型可能对医疗保健提供者在为ACS后患者设定期望和目标方面非常有帮助。
