纤溶治疗后 ST 段回落程度增加可改善 ST 段抬高型心肌梗死临床危险评分的危险分层。

Extent of ST-segment resolution after fibrinolysis adds improved risk stratification to clinical risk score for ST-segment elevation myocardial infarction.

机构信息

TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA 02115, USA.

出版信息

Am Heart J. 2010 Jan;159(1):55-62. doi: 10.1016/j.ahj.2009.10.033.

DOI:10.1016/j.ahj.2009.10.033

PMID:20102867

Abstract

BACKGROUND

The TIMI risk score (TRS) for ST-segment elevation myocardial infarction (STEMI) is a convenient validated clinical risk score for predicting mortality. Although not part of the risk score, ST-segment resolution (STRes) may provide a simple method of risk stratification based on the response to reperfusion. We sought to determine whether STRes provides incremental risk stratification to the TIMI risk score.

METHODS

The Clopidogrel as Adjunctive Reperfusion Therapy--Thrombolysis in Myocardial Infraction (CLARITY-TIMI 28) trial randomized STEMI patients receiving fibrinolysis to clopidogrel or placebo. A total of 2,340 patients had electrocardiograms (ECGs) valid to calculate STRes at 90 minutes, which was defined as complete (>70%), partial (30%-70%), or no resolution (30%). TRS was defined as low (0-2), medium (3-4), and high (> or =5). Clinical follow-up was through 30 days. Results were validated in 2,743 patients from the ExTRACT-TIMI 25 study.

RESULTS

The degree of STRes at 90 minutes after fibrinolysis correlated in a stepwise fashion with death or heart failure (5.1% complete STRes, 8.9% partial STRes, 13.4% no STRes, P < .001). Furthermore, the degree of STRes provided a consistent and significant gradient of risk across all risk score categories (low, medium, or high) and significantly improved the discriminatory ability of TIMI risk score to predict death or heart failure (c-statistic 0.69 for TIMI risk score alone and 0.74 with STRes added to the model, P < .001). With the inclusion of STRes to the TIMI risk score, 913 patients (39%) were reclassified to higher or lower risk groups, and the net reclassification improvement (NRI) was highly significant (P < .001). In the ExTRACT-TIMI 25 trial, addition of the STRes improved also the c-statistic (P = .012) and NRI (P < .001).

CONCLUSIONS

The extent of STRes based on routinely obtained ECGs is an independent predictor of death and heart failure when used together with the TIMI risk score and significantly improves the ability to risk stratify patients after fibrinolysis.

摘要

背景

TIMI 风险评分（TRS）用于 ST 段抬高型心肌梗死（STEMI），是一种预测死亡率的方便有效的临床风险评分。尽管 ST 段缓解（STRes）不在风险评分内，但它可能提供一种基于再灌注反应的简单风险分层方法。我们旨在确定 STRes 是否为 TIMI 风险评分提供了增量风险分层。

方法

Clopidogrel 作为辅助再灌注治疗-心肌梗死溶栓治疗（CLARITY-TIMI 28）试验将接受纤溶治疗的 STEMI 患者随机分为氯吡格雷组或安慰剂组。共有 2340 名患者的心电图（ECG）可用于计算 90 分钟时的 STRes，定义为完全缓解（>70%）、部分缓解（30%-70%）或无缓解（<30%）。TRS 定义为低（0-2）、中（3-4）和高（> =5）。临床随访至 30 天。结果在 2743 名来自 EXTRACT-TIMI 25 研究的患者中得到验证。

结果

纤溶后 90 分钟时的 STRes 程度呈逐步相关，与死亡或心力衰竭相关（完全缓解 5.1%，部分缓解 8.9%，无缓解 13.4%，P<0.001）。此外，STRes 的程度在所有风险评分类别（低、中或高）中提供了一致且显著的风险梯度，并显著提高了 TIMI 风险评分预测死亡或心力衰竭的区分能力（TIMI 风险评分单独的 C 统计量为 0.69，添加 STRes 后为 0.74，P<0.001）。将 STRes 纳入 TIMI 风险评分后，913 名患者（39%）被重新分类为更高或更低的风险组，净重新分类改善（NRI）具有统计学意义（P<0.001）。在 EXTRACT-TIMI 25 试验中，添加 STRes 也提高了 C 统计量（P=0.012）和 NRI（P<0.001）。