Barra Sérgio, Providência Rui, Paiva Luís, Almeida Inês, Caetano Francisca, Dinis Paulo, Leitão Marques António
Cardiology Department, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK.
Cardiology Department, Clinique Pasteur, Toulouse, France.
J Atr Fibrillation. 2013 Dec 31;6(4):897. doi: 10.4022/jafib.897. eCollection 2013 Dec.
We hypothesize that the discriminative performance of GRACE, ACHTUNG-Rule, CHADS or CHADS-VASc may be lower in patients with a Myocardial Infarction (MI) and concurrent atrial fibrillation (AF), as none of these scores seem able to fully capture both atherothrombotic/thromboembolic risks. This study aims to evaluate the mid-term prognostic performance of these algorithms in patients with these two conditions and to analyze the utility of a score combining GRACE and CHADS-VASc. Observational retrospective single-centre cohort study including 1852 patients admitted with a MI. We tested the prognostic performance of the aforementioned risk stratification schemes in patients with vs. without AF at admission or during hospitalization. Primary endpoints: a) total all-cause mortality, comprising intrahospital and post-discharge all-cause mortality; b) intrahospital all-cause mortality and c) all-cause mortality during follow-up. Furthermore, all three versions of the ACHTUNG-Rule were directly compared to their equivalent GRACE score versions, and a new score, entitled GRACE-CHADS-VASc, was developed and compared with GRACE. The mid-term prognostic performance of all scores was considerably lower in patients with AF, corroborating our hypothesis. The ACHTUNG-Rule seemed superior to GRACE in the prediction of post-discharge (AUC 0.790±0.032 vs. 0.685±0.038, p=0.079; integrated discrimination improvement index [IDI] of 0.166 and relative IDI of 83.7%) and total mortality (0.762±0.031 vs. 0.712±0.033, p=0.144; IDI of 0.042, relative IDI of 11.7%), but its performance decreased in those with AF as well. GRACE-CHADS-VASc was only marginally superior to GRACE in discriminative performance, but detected truly low- (CHADS-VASc <2; total mortality 0%) and high-risk patients (GRACE high-risk stratum, and CHADS-VASc >4; total mortality 44.3%) with considerable efficacy. In patients with MI and concurrent AF, the GRACE, CHADS and CHADS-VASc scores seemed less accurate in the prediction of all-cause mortality. A hypothetic GRACE-CHADS-VASc score or the recently developed ACHTUNG-Rule may eventually provide a more rigorous approach to risk stratification in this high-risk setting.
我们假设，对于患有心肌梗死（MI）并发心房颤动（AF）的患者，GRACE评分、ACHTUNG规则、CHADS或CHADS-VASc的鉴别性能可能较低，因为这些评分似乎都无法完全捕捉动脉粥样硬化血栓形成/血栓栓塞风险。本研究旨在评估这些算法在患有这两种疾病的患者中的中期预后性能，并分析结合GRACE和CHADS-VASc的评分的效用。观察性回顾性单中心队列研究，纳入1852例因MI入院的患者。我们测试了上述风险分层方案在入院时或住院期间有AF与无AF患者中的预后性能。主要终点：a）全因总死亡率，包括院内和出院后全因死亡率；b）院内全因死亡率；c）随访期间全因死亡率。此外，将ACHTUNG规则的所有三个版本与其等效的GRACE评分版本直接进行比较，并开发了一个名为GRACE-CHADS-VASc的新评分，并与GRACE进行比较。在AF患者中，所有评分的中期预后性能均显著较低，证实了我们的假设。在预测出院后死亡率（AUC 0.790±0.032对0.685±0.038，p = 0.079；综合鉴别改善指数[IDI]为0.166，相对IDI为83.7%）和总死亡率（0.762±0.031对0.712±0.033，p = 0.144；IDI为0.042，相对IDI为11.7%）方面，ACHTUNG规则似乎优于GRACE，但其在AF患者中的性能也有所下降。GRACE-CHADS-VASc在鉴别性能上仅略优于GRACE，但在检测真正的低风险（CHADS-VASc<2；总死亡率0%）和高风险患者（GRACE高风险分层，且CHADS-VASc>4；总死亡率44.3%）方面具有相当的效力。在患有MI并发AF的患者中，GRACE、CHADS和CHADS-VASc评分在预测全因死亡率方面似乎不太准确。假设的GRACE-CHADS-VASc评分或最近开发的ACHTUNG规则最终可能为这种高风险情况下的风险分层提供一种更严格的方法。
