Barra Sérgio, Providência Rui, Lourenço Gomes Pedro, Silva Joana, Seca Luís, Nascimento José, Leitão-Marques A M
Serviço de Cardiologia, Centro Hospitalar de Coimbra, Coimbra, Portugal.
Rev Port Cardiol. 2011 Jul;30(7-8):655-63. doi: 10.1016/S0870-2551(11)70004-X.
Patients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI).
We analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]).
During follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60ml/min/m(2) (p=0.029, OR 2.65, 95% CI 1.07-6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140 mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6-month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7mmol/l (OR 4.09; p=0.017) that fitted the data well (Hosmer-Lemeshow: p=0.916).
DISCUSSION/CONCLUSIONS: In patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.
冠心病（CAD）患者发生中风的风险增加。本研究的目的是分析心肌梗死（MI）后出院时选定的临床和实验室变量对中风风险预测的预后准确性。
我们分析了404例既往无中风的连续患者（年龄68.1±13.7岁；男性占63.4%；糖尿病患者占37.4%），这些患者因MI入院后以窦性心律出院。收集了以下数据：心血管危险因素、入院血糖（BG）、糖化血红蛋白（HbA1c）、肌酐、肌钙蛋白峰值水平；采用MDRD公式计算的肾小球滤过率（GFR）；最大Killip分级；GRACE院内及6个月死亡率评分；以及CAD的严重程度。对患者进行了两年的随访，并将每个变量作为脑血管事件（中风或短暂性脑缺血发作[TIA]）的可能预测指标进行测试。
随访期间，27例患者因中风或TIA入院。糖尿病、高血压、血脂异常、既往已知的CAD、MI类型（ST段抬高型心肌梗死与非ST段抬高型心肌梗死）以及CAD的严重程度均不能预测脑血管风险。以下变量与较高的中风风险相关：GFR<60ml/min/m²（p=0.029，OR 2.65，95%CI 1.07-6.55）；最大Killip分级>1（p=0.025，OR 2.71，95%CI 1.10-6.69）；GRACE院内死亡率>180（p=0.001，OR 4.09，95%CI 1.64-10.22）；入院BG>140mg/dl（p=0.001，OR 5.74，95%CI 1.87-17.58）；GRACE 6个月死亡率>150（p=0.001，OR 4.50，95%CI 1.80-6.27）；以及肌钙蛋白峰值>42ng/ml（p=0.032，OR 2.64，95%CI 1.06-6.59）。逻辑回归分析得出一个模型，其预测指标为GRACE 6个月死亡率>150（OR 3.26；p=0.014）和入院BG>7.7mmol/l（OR 4.09；p=0.017），该模型与数据拟合良好（Hosmer-Lemeshow检验：p=0.916）。
讨论/结论：在MI患者中，已知的院内死亡预测指标变量包括入院BG、肾功能、急性心力衰竭和GRACE评分，在2年随访期间被发现是中风的有用预测指标。虽然GRACE 6个月死亡率>150和入院BG>7.7mmol/l都是中风的独立预测指标，但心血管危险因素、既往已知的CAD以及冠状动脉造影评估的CAD严重程度并不能改善中风风险预测。这项研究强调了对高危患者进行更积极二级预防的必要性。
