Paiva Luis, Providência Rui, Barra Sérgio N, Dinis Paulo, Faustino Ana C, Costa Marco, Gonçalves Lino
Coimbra's Hospital and University Centre, Coimbra, Portugal.
Coimbra's Hospital and University Centre, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
Arch Cardiovasc Dis. 2014 Dec;107(12):681-9. doi: 10.1016/j.acvd.2014.06.008. Epub 2014 Sep 11.
Risk assessment is fundamental in the management of acute coronary syndromes (ACS), enabling estimation of prognosis.
To evaluate whether the combined use of GRACE and CRUSADE risk stratification schemes in patients with myocardial infarction outperforms each of the scores individually in terms of mortality and haemorrhagic risk prediction.
Observational retrospective single-centre cohort study including 566 consecutive patients admitted for non-ST-segment elevation myocardial infarction. The CRUSADE model increased GRACE discriminatory performance in predicting all-cause mortality, ascertained by Cox regression, demonstrating CRUSADE independent and additive predictive value, which was sustained throughout follow-up. The cohort was divided into four different subgroups: G1 (GRACE<141; CRUSADE<41); G2 (GRACE<141; CRUSADE≥41); G3 (GRACE≥141; CRUSADE<41); G4 (GRACE≥141; CRUSADE≥41).
Outcomes and variables estimating clinical severity, such as admission Killip-Kimbal class and left ventricular systolic dysfunction, deteriorated progressively throughout the subgroups (G1 to G4). Survival analysis differentiated three risk strata (G1, lowest risk; G2 and G3, intermediate risk; G4, highest risk). The GRACE+CRUSADE model revealed higher prognostic performance (area under the curve [AUC] 0.76) than GRACE alone (AUC 0.70) for mortality prediction, further confirmed by the integrated discrimination improvement index. Moreover, GRACE+CRUSADE combined risk assessment seemed to be valuable in delineating bleeding risk in this setting, identifying G4 as a very high-risk subgroup (hazard ratio 3.5; P<0.001).
Combined risk stratification with GRACE and CRUSADE scores can improve the individual discriminatory power of GRACE and CRUSADE models in the prediction of all-cause mortality and bleeding. This combined assessment is a practical approach that is potentially advantageous in treatment decision-making.
风险评估是急性冠状动脉综合征（ACS）管理的基础，有助于估计预后。
评估在心肌梗死患者中联合使用GRACE和CRUSADE风险分层方案在预测死亡率和出血风险方面是否优于各自单独的评分。
观察性回顾性单中心队列研究，纳入566例因非ST段抬高型心肌梗死连续入院的患者。CRUSADE模型在预测全因死亡率方面提高了GRACE的鉴别性能，通过Cox回归确定，显示出CRUSADE的独立和附加预测价值，该价值在整个随访过程中持续存在。该队列分为四个不同亚组：G1（GRACE<141；CRUSADE<41）；G2（GRACE<141；CRUSADE≥41）；G3（GRACE≥141；CRUSADE<41）；G4（GRACE≥141；CRUSADE≥41）。
估计临床严重程度的结果和变量，如入院时的Killip-Kimbal分级和左心室收缩功能障碍，在各亚组（G1至G4）中逐渐恶化。生存分析区分了三个风险层（G1，最低风险；G2和G3，中度风险；G4，最高风险）。GRACE+CRUSADE模型在预测死亡率方面显示出比单独使用GRACE更高的预后性能（曲线下面积[AUC]为0.76），综合鉴别改善指数进一步证实了这一点。此外，GRACE+CRUSADE联合风险评估在确定该情况下的出血风险方面似乎很有价值，将G4确定为非常高风险亚组（风险比3.5；P<0.001）。
GRACE和CRUSADE评分联合风险分层可提高GRACE和CRUSADE模型在预测全因死亡率和出血方面的个体鉴别能力。这种联合评估是一种实用方法，在治疗决策中可能具有优势。
