Department of Vascular Medicine, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, USA.
Eur Heart J. 2017 Nov 14;38(43):3211-3218. doi: 10.1093/eurheartj/ehx102.
To validate and assess performance of the current ACC/AHA very high risk criteria in patients with clinically manifest arterial disease.
Data were used from the SMART study (n = 7216) and REACH Registry (n = 48 322), two prospective cohorts of patients with manifest atherosclerotic arterial disease. Prevalence and incidence rates of recurrent major adverse cardiovascular events (MACE) were calculated, according to the ACC/AHA VHR criteria (cardiovascular disease combined with diabetes, smoking, dyslipidaemia, and/or recent recurrent coronary events). Performance of the ACC/AHA criteria was compared with single very high risk factors in terms of C-statistics and Net Reclassification Index. All patients were at VHR according to the ESC guidelines (incidence of recurrent MACE in SMART was 2.4/100PY, with 95% CI 2.3-2.5/100PY and in REACH 5.1/100PY with 95% CI 5.0-5.3/100PY). In SMART 57% of the patients were at VHR according to the ACC/AHA criteria (incidence of recurrent MACE 2.7/100PY, 95% CI 2.5-2.9/100PY) and in REACH this was 64% (5.9/100PY, 95% CI 5.7-6.1/100PY). The C-statistic for the ACC/AHA VHR criteria was 0.53 in REACH and 0.54 in SMART. Very high risk factors with comparable or slightly better performance were eGFR < 45, polyvascular disease and age >70 years. Around two third of the patients meeting the ACC/AHA VHR criteria had a predicted 10-year risk of recurrent MACE <30%.
The ACC/AHA VHR criteria have limited discriminative power. Identifying patients with clinically manifest arterial disease at VHR for recurrent vascular events using eGFR <45, polyvascular disease, or age >70 years performs as well as the ACC/AHA VHR criteria.
验证并评估当前 ACC/AHA 极高危标准在有临床明显动脉疾病的患者中的表现。
本研究使用了 SMART 研究（n=7216）和 REACH 注册研究（n=48322）的数据，这两个前瞻性队列研究的患者均有明显的动脉粥样硬化性动脉疾病。根据 ACC/AHA 的 VHR 标准（心血管疾病合并糖尿病、吸烟、血脂异常和/或近期复发性冠状动脉事件），计算复发主要不良心血管事件（MACE）的患病率和发生率。根据 C 统计量和净重新分类指数，比较了 ACC/AHA 标准与单一高危因素的表现。根据 ESC 指南，所有患者均处于 VHR（SMART 中复发 MACE 的发生率为 2.4/100 人年，95%CI 为 2.3-2.5/100 人年，REACH 为 5.1/100 人年，95%CI 为 5.0-5.3/100 人年）。在 SMART 中，根据 ACC/AHA 标准，57%的患者处于 VHR（复发 MACE 的发生率为 2.7/100 人年，95%CI 为 2.5-2.9/100 人年），在 REACH 中，这一比例为 64%（5.9/100 人年，95%CI 为 5.7-6.1/100 人年）。REACH 中 ACC/AHA 的 VHR 标准的 C 统计量为 0.53，SMART 为 0.54。具有相当或略优性能的高危因素包括 eGFR<45、多血管疾病和年龄>70 岁。符合 ACC/AHA 的 VHR 标准的患者中，约有三分之二的患者预计 10 年内复发 MACE 的风险<30%。
ACC/AHA 的 VHR 标准的区分能力有限。使用 eGFR<45、多血管疾病或年龄>70 岁来识别有临床明显动脉疾病的患者，其处于 VHR 状态以发生复发性血管事件的风险与 ACC/AHA 的 VHR 标准相当。
