University of Toronto, Toronto, ON, Canada.
University of Toronto, Toronto, ON, Canada; Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, Canadian Heart Research Centre, Toronto, ON, Canada.
Int J Cardiol. 2017 Oct 1;244:24-29. doi: 10.1016/j.ijcard.2017.06.055. Epub 2017 Jun 15.
Although there are sex differences in management and outcome of acute coronary syndromes (ACS), sex is not a component of Global Registry of Acute Coronary Events (GRACE) risk score (RS) for in-hospital mortality prediction. We sought to determine the prognostic utility of GRACE RS in men and women, and whether its predictive accuracy would be augmented through sex-based modification of its components.
Canadian men and women enrolled in GRACE and Canadian Registry of Acute Coronary Events were stratified as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS). GRACE RS was calculated as per original model. Discrimination and calibration were evaluated using the c-statistic and Hosmer-Lemeshow goodness-of-fit test, respectively. Multivariable logistic regression was undertaken to assess potential interactions of sex with GRACE RS components.
For the overall cohort (n=14,422), unadjusted in-hospital mortality rate was higher in women than men (4.5% vs. 3.0%, p<0.001). Overall, GRACE RS c-statistic and goodness-of-fit test p-value were 0.85 (95% CI 0.83-0.87) and 0.11, respectively. While the RS had excellent discrimination for all subgroups (c-statistics >0.80), discrimination was lower for women compared to men with STEMI [0.80 (0.75-0.84) vs. 0.86 (0.82-0.89), respectively, p<0.05]. The goodness-of-fit test showed good calibration for women (p=0.86), but suboptimal for men (p=0.031). No significant interaction was evident between sex and RS components (all p>0.25).
The GRACE RS is a valid predictor of in-hospital mortality for both men and women with ACS. The lack of interaction between sex and RS components suggests that sex-based modification is not required.
尽管急性冠状动脉综合征（ACS）的治疗和预后存在性别差异，但全球急性冠状动脉事件注册（GRACE）风险评分（RS）并未将性别纳入院内死亡率预测因素。本研究旨在评估 GRACE RS 在男性和女性中的预后价值，以及是否可以通过对其组成部分进行基于性别的修正来提高其预测准确性。
加拿大的男性和女性患者被纳入 GRACE 和加拿大急性冠状动脉事件注册研究，分为 ST 段抬高型心肌梗死（STEMI）或非 ST 段抬高型 ACS（NSTE-ACS）。按照原始模型计算 GRACE RS。使用 C 统计量和 Hosmer-Lemeshow 拟合优度检验分别评估区分度和校准度。采用多变量逻辑回归评估性别与 GRACE RS 组成部分之间的潜在交互作用。
在整个队列（n=14422）中，女性未调整的院内死亡率高于男性（4.5% vs. 3.0%，p<0.001）。总体而言，GRACE RS 的 C 统计量和拟合优度检验 p 值分别为 0.85（95%CI 0.83-0.87）和 0.11。尽管 RS 对所有亚组均具有良好的区分能力（C 统计量>0.80），但 STEMI 患者中女性的区分能力低于男性[0.80（0.75-0.84）vs. 0.86（0.82-0.89），p<0.05]。拟合优度检验显示女性的拟合度较好（p=0.86），但男性较差（p=0.031）。性别与 RS 组成部分之间无显著交互作用（p 值均>0.25）。
GRACE RS 是 ACS 男性和女性院内死亡率的有效预测因子。性别与 RS 组成部分之间无交互作用表明，无需进行基于性别的修正。
