Elbarouni Basem, Goodman Shaun G, Yan Raymond T, Welsh Robert C, Kornder Jan M, Deyoung J Paul, Wong Graham C, Rose Barry, Grondin François R, Gallo Richard, Tan Mary, Casanova Amparo, Eagle Kim A, Yan Andrew T
Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Am Heart J. 2009 Sep;158(3):392-9. doi: 10.1016/j.ahj.2009.06.010.
The Global Registry of Acute Coronary Event (GRACE) risk score was developed in a large multinational registry to predict in-hospital mortality across the broad spectrum of acute coronary syndromes (ACS). Because of the substantial regional variation and temporal changes in patient characteristics and management patterns, we sought to validate this risk score in a contemporary Canadian population with ACS.
The main GRACE and GRACE(2) registries are prospective, multicenter, observational studies of patients with ACS (June 1999 to December 2007). For each patient, we calculated the GRACE risk score and evaluated its discrimination and calibration by the c statistic and the Hosmer-Lemeshow goodness-of-fit test, respectively. To assess the impact of temporal changes in management on the GRACE risk score performance, we evaluated its discrimination and calibration after stratifying the study population into prespecified subgroups according to enrollment period, type of ACS, and whether the patient underwent coronary angiography or revascularization during index hospitalization.
A total of 12,242 Canadian patients with ACS were included; the median GRACE risk score was 127 (25th and 75th percentiles were 103 and 157, respectively). Overall, the GRACE risk score demonstrated excellent discrimination (c statistic 0.84, 95% CI 0.82-0.86, P < .001) for in-hospital mortality. Similar results were seen in all the subgroups (all c statistics >/=0.8). However, calibration was suboptimal overall (Hosmer-Lemeshow P = .06) and in various subgroups.
GRACE risk score is a valid and powerful predictor of adverse outcomes across the wide range of Canadian patients with ACS. Its excellent discrimination is maintained despite advances in management over time and is evident in all patient subgroups. However, the predicted probability of in-hospital mortality may require recalibration in the specific health care setting and with advancements in treatment.
全球急性冠状动脉事件注册研究（GRACE）风险评分是在一项大型跨国注册研究中制定的，用于预测广泛的急性冠状动脉综合征（ACS）患者的院内死亡率。由于患者特征和管理模式存在显著的地区差异和时间变化，我们试图在当代加拿大ACS患者人群中验证该风险评分。
主要的GRACE和GRACE(2)注册研究是对ACS患者进行的前瞻性、多中心观察性研究（1999年6月至2007年12月）。对于每位患者，我们计算GRACE风险评分，并分别通过c统计量和Hosmer-Lemeshow拟合优度检验评估其区分度和校准度。为了评估管理方面的时间变化对GRACE风险评分性能的影响，我们根据入组时间、ACS类型以及患者在首次住院期间是否接受冠状动脉造影或血运重建，将研究人群分层为预先指定的亚组后，评估其区分度和校准度。
共纳入12242例加拿大ACS患者；GRACE风险评分中位数为127（第25和第75百分位数分别为103和157）。总体而言，GRACE风险评分对院内死亡率显示出优异的区分度（c统计量0.84，95%可信区间0.82 - 0.86，P <.001）。在所有亚组中均观察到类似结果（所有c统计量≥0.8）。然而，总体校准效果欠佳（Hosmer-Lemeshow P =.06），在各个亚组中也是如此。
GRACE风险评分是广泛的加拿大ACS患者不良结局的有效且强大的预测指标。尽管随着时间推移管理有所进步，但其优异的区分度得以保持，且在所有患者亚组中均很明显。然而，在特定的医疗环境和治疗进展情况下，院内死亡率的预测概率可能需要重新校准。
