Bank Ingrid E M, de Hoog Vince C, de Kleijn Dominique P V, Pasterkamp Gerard, Doevendans Pieter A, den Ruijter Hester M, Dalmeijer Geertje, Wildbergh Thierry X, Mosterd Arend, Timmers Leo
Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands.
Department of Cardiology, Meander Medical Center, Amersfoort, the Netherlands.
J Am Heart Assoc. 2017 Jun 21;6(6):e005373. doi: 10.1161/JAHA.116.005373.
Sex-based differences in clinical presentation, pathophysiology, and outcomes of patients with acute chest pain are increasingly being recognized, but are not implemented in guidelines and clinical prediction tools. We evaluated the performance of the HEART score in women versus men, because sex-based differences may exist among the algorithm's components: history, electrocardiogram, age, risk factors, and admission troponin level.
The HEART score was retrospectively assessed in 831 women and 1084 men presenting to the emergency department with acute chest pain, assigning patients to the low-, intermediate-, or high-risk category for the occurrence of major adverse cardiac events (MACE) within 6 weeks. MACE, consisting of myocardial infarction, coronary revascularization, and all-cause death, also included events during index visit. Six-week MACE rates were 2 times lower in women than men (10.0% versus 20.8%; <0.01). Despite similar discriminatory accuracy of the HEART score among women and men (c-statistic, 0.80 [0.75-0.84] versus 0.77 [0.74-0.81]; =0.43), 6-week MACE rates were significantly lower in women than men across all HEART risk categories: 2.1% versus 6.5% (<0.01) in the low-risk category, 12.7% versus 21.3% (<0.01) in intermediate-risk category, and 53.1% versus 77.0% (=0.02) in the high-risk category. The HEART score-adjusted risk ratio for men was 1.6 (1.3-2.0; <0.01).
The markedly higher 6-week MACE risk in men across all HEART risk categories should be taken into account when using the HEART score to guide clinical decision making; early discharge with a low-risk HEART score appears less safe for men than women with acute chest pain.
急性胸痛患者在临床表现、病理生理学及预后方面的性别差异日益受到关注，但这些差异在指南和临床预测工具中并未得到体现。我们评估了HEART评分在女性和男性中的表现，因为基于性别的差异可能存在于该算法的各个组成部分中，包括病史、心电图、年龄、危险因素及入院肌钙蛋白水平。
对831例因急性胸痛就诊于急诊科的女性和1084例男性患者进行了HEART评分的回顾性评估，将患者分为低、中、高风险类别，以预测6周内发生主要不良心脏事件（MACE）的风险。MACE包括心肌梗死、冠状动脉血运重建和全因死亡，也包括首次就诊期间的事件。女性的6周MACE发生率比男性低2倍（10.0%对20.8%；<0.01）。尽管HEART评分在女性和男性中的鉴别准确性相似（c统计量，0.80[0.75-0.84]对0.77[0.74-0.81]；P=0.43），但在所有HEART风险类别中，女性的6周MACE发生率均显著低于男性：低风险类别中为2.1%对6.5%（<0.01），中风险类别中为12.7%对21.3%（<0.01），高风险类别中为53.1%对77.0%（P=0.02）。男性经HEART评分调整后的风险比为1.6（1.3-2.0；<0.01）。
在使用HEART评分指导临床决策时，应考虑到所有HEART风险类别中男性6周MACE风险明显更高的情况；对于急性胸痛男性患者，低风险HEART评分下的早期出院似乎不如女性安全。
