Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
J Am Heart Assoc. 2017 Oct 20;6(10):e005958. doi: 10.1161/JAHA.117.005958.
Current American Heart Association/American College of Cardiology guidelines recommend the GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) scores to assess myocardial infarction (MI) prognosis. Changes in the epidemiological characteristics of MI and the availability of new biomarkers warrant an assessment of the performance of these scores in contemporary practice. We assessed the following: (1) the performance of GRACE and TIMI to predict 1-year mortality in a cohort of patients stratified by ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) and (2) the incremental discriminatory power of soluble suppression of tumorigenicity-2, a myocardial fibrosis biomarker.
Olmsted County, Minnesota, residents with incident MI (N=1401) were recruited prospectively from November 1, 2002 to December 31, 2012 (mean age, 67 years; 61% men; 79% with NSTEMI). Baseline data were used to calculate risk scores; soluble suppression of tumorigenicity-2 was measured in stored plasma samples obtained at index MI. -statistics adapted to survival data were used to assess the discriminatory power of the risk scores and the improvement gained by adding other markers. During the first year of follow-up, 190 patients (14%) died. The discriminatory performance to predict death was reasonable for GRACE and poor for TIMI, and was generally worse in those with NSTEMI versus those with STEMI. In people with NSTEMI, sequential addition of comorbidities and soluble suppression of tumorigenicity-2 substantially improved the -statistic over GRACE (from 0.78 to 0.80 to 0.84) and TIMI (from 0.61 to 0.73 to 0.81), respectively (all ≤0.05).
Guideline-recommended scores for risk assessment after MI underperform in contemporary community patients, particularly those with NSTEMI, which now represents most infarcts. Incorporating comorbidities and soluble suppression of tumorigenicity-2 substantially improves risk prediction, thereby delineating opportunities to improve clinical care.
目前，美国心脏协会/美国心脏病学会指南推荐 GRACE（全球急性冠状动脉事件注册）和 TIMI（心肌梗死溶栓）评分来评估心肌梗死（MI）的预后。MI 的流行病学特征的变化和新生物标志物的出现，需要评估这些评分在当代实践中的表现。我们评估了以下内容：（1）GRACE 和 TIMI 在 ST 段抬高型心肌梗死（STEMI）和非 ST 段抬高型心肌梗死（NSTEMI）分层患者队列中预测 1 年死亡率的表现；（2）可溶性肿瘤抑制物 2（一种心肌纤维化生物标志物）的增量判别能力。
明尼苏达州奥姆斯特德县从 2002 年 11 月 1 日至 2012 年 12 月 31 日前瞻性招募了发生 MI（N=1401）的居民（平均年龄 67 岁；61%为男性；79%为 NSTEMI）。使用基线数据计算风险评分；在索引 MI 时获得的储存血浆样本中测量可溶性肿瘤抑制物 2。使用适应生存数据的 -统计量评估风险评分的判别能力以及添加其他标记物所获得的改善。在随访的第一年，有 190 名患者（14%）死亡。GRACE 预测死亡的判别性能尚可，而 TIMI 较差，且 NSTEMI 患者一般比 STEMI 患者差。在 NSTEMI 患者中，连续添加合并症和可溶性肿瘤抑制物 2 可大大提高 GRACE 的 -统计量（从 0.78 提高到 0.80 再提高到 0.84）和 TIMI（从 0.61 提高到 0.73 再提高到 0.81），差异均有统计学意义（均≤0.05）。
指南推荐的 MI 后风险评估评分在当代社区患者中的表现不佳，特别是在 NSTEMI 患者中，NSTEMI 现在代表了大多数梗死。合并症和可溶性肿瘤抑制物 2 的纳入可大大提高风险预测，从而为改善临床护理提供机会。
