衰弱与非ST段抬高型急性冠状动脉综合征的不良预后相关：来自“旨在明确急性冠状动脉综合征药物治疗最佳策略的靶向血小板抑制（TRILOGY ACS）试验”的见解。
Frailty is associated with worse outcomes in non-ST-segment elevation acute coronary syndromes: Insights from the TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes (TRILOGY ACS) trial.
作者信息
White Harvey D, Westerhout Cynthia M, Alexander Karen P, Roe Matthew T, Winters Kenneth J, Cyr Derek D, Fox Keith Aa, Prabhakaran Dorairaj, Hochman Judith S, Armstrong Paul W, Ohman E Magnus
机构信息
Green Lane Cardiovascular Service, Auckland City Hospital and University of Auckland, Auckland, New Zealand
Canadian VIGOUR Centre, University of Alberta, Canada.
出版信息
Eur Heart J Acute Cardiovasc Care. 2016 Jun;5(3):231-42. doi: 10.1177/2048872615581502. Epub 2015 Apr 20.
AIMS
Little is known regarding consequences of frailty in patients with acute coronary syndrome (ACS). We assessed the associations of frailty and outcomes in ACS patients who were participating in a clinical trial.
METHODS AND RESULTS
The TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes (TRILOGY ACS) trial randomized 9326 patients planned for medical management to prasugrel or clopidogrel. The primary endpoint was a composite of cardiovascular death, myocardial infarction (MI), or stroke over a period of 30 months. A frailty score based upon the Fried score was self-reported at baseline in patients aged ⩾65 years. Five frailty questions were recorded for 4996/5102 (97.9%) patients: 72.3% were classified as not-frail (0 items), 23.0% as pre-frail (1-2 items), and 4.7% as frail (⩾3 items). Increasing frailty score was associated with older age, diabetes, and higher Global Registry of Acute Coronary Events (GRACE) scores. Frailty was associated with a higher unadjusted incidence of the primary endpoint (pre-frail vs not-frail: 29.2% vs 23.1%; hazard ratio [HR]: 1.39; 95% confidence interval [CI]: 1.19-1.61; p<0.001; frail vs not-frail: 39.7% vs 23.1%; HR: 1.76; 95% CI: 1.36-2.28; p<0.001), and all-cause mortality (pre-frail vs not-frail: 21.7% vs 15.0%; HR: 1.45; 95% CI: 1.22-1.73; p<0.001; frail vs not-frail: 30.2% vs 15.0%; HR: 1.98; 95% CI: 1.47-2.68; p<0.001). After adjustment for baseline characteristics and GRACE covariates, frailty remained independently associated with the primary endpoint: pre-frail vs not-frail, HR: 1.33; 95% CI: 1.15-1.54; p<0.001; frail vs not-frail, HR: 1.52; 95% CI: 1.18-1.98; p=0.002. There was no association of frailty with bleeding.
CONCLUSION
Frailty is associated with the composite of cardiovascular death, MI, or stroke. Frailty assessment contributes to risk prediction and adds to the GRACE score.
目的
关于急性冠状动脉综合征（ACS）患者虚弱的后果，人们了解甚少。我们评估了参与一项临床试验的ACS患者中虚弱与预后的关联。
方法与结果
“旨在通过血小板抑制明确急性冠状动脉综合征最佳药物治疗策略”（TRILOGY ACS）试验将9326例计划接受药物治疗的患者随机分为普拉格雷组或氯吡格雷组。主要终点是30个月内心血管死亡、心肌梗死（MI）或卒中的复合终点。基于弗里德评分的虚弱评分由年龄≥65岁的患者在基线时自行报告。对4996/5102（97.9%）例患者记录了5个虚弱问题：72.3%被分类为非虚弱（0项），23.0%为虚弱前期（1 - 2项），4.7%为虚弱（≥3项）。虚弱评分增加与年龄较大、糖尿病和较高的急性冠状动脉事件全球注册（GRACE）评分相关。虚弱与未调整的主要终点发生率较高相关（虚弱前期与非虚弱：29.2%对23.1%；风险比[HR]：1.39；95%置信区间[CI]：1.19 - 1.61；p<0.001；虚弱与非虚弱：39.7%对23.1%；HR：1.76；95% CI：1.36 - 2.28；p<0.001），以及全因死亡率（虚弱前期与非虚弱：21.7%对15.0%；HR：1.45；95% CI：1.22 - 1.73；p<0.001；虚弱与非虚弱：30.2%对15.0%；HR：1.98；95% CI：1.47 - 2.68；p<0.001）。在对基线特征和GRACE协变量进行调整后，虚弱仍与主要终点独立相关：虚弱前期与非虚弱，HR：1.33；95% CI：1.15 - 1.54；p<0.001；虚弱与非虚弱，HR：1.52；95% CI：1.18 - 1.98；p = 0.002。虚弱与出血无关联。
结论
虚弱与心血管死亡、MI或卒中的复合终点相关。虚弱评估有助于风险预测，并可补充GRACE评分。
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