Cardiology Division, State University of Campinas (Unicamp), Brazil.
Escola Superior de Ciências da Saúde (ESCS), Brazil.
Eur Heart J Acute Cardiovasc Care. 2019 Oct;8(7):643-651. doi: 10.1177/2048872617753049. Epub 2018 Jan 23.
In ST-elevation myocardial infarction, 7-15% of patients admitted as Killip I will develop symptomatic heart failure or decreased ejection fraction. However, available clinical scores do not predict the risk of severe outcomes well, such as heart failure, recurrent myocardial infarction, and sudden death in these Killip I individuals. Therefore, we evaluated whether one vs two measurements of BNP would improve prediction of adverse outcomes in addition to the GRACE score in ST-elevation myocardial infarction/Killip I individuals.
Consecutive patients with ST-elevation myocardial infarction/Killip I (=167) were admitted and followed for 12 months. The GRACE score was calculated and plasma BNP levels were obtained in the first 12 h after symptom onset (D1) and at the fifth day (D5).
Fifteen percent of patients admitted as Killip I developed symptomatic heart failure and/or decreased ejection fraction in 12 months. The risk of developing symptomatic heart failure or ejection fraction <40% at 30 days was increased by 8.7-fold (95% confidence interval: 1.10-662, =0.046) per each 100 pg/dl increase in BNP-change. Both in unadjusted and adjusted Cox-regressions, BNP-change as a continuous variable was associated with incident sudden death/myocardial infarction at 30 days (odds ratio 1.032 per each increase of 10 pg/dl, 95% confidence interval: 1.013-1.052, <0.001), but BNP-D1 was not. The GRACE score alone showed a moderate C-statistic=0.709 (=0.029), but adding BNP-change improved risk discrimination (C-statistic=0.831, =0.001). Net reclassification confirmed a significant improvement in individual risk prediction by 33.4% (95% confidence interval: 8-61%, =0.034). However, GRACE +BNP-D1 did not improve risk reclassification at 30 days compared to GRACE (=0.8). At 12 months, BNP-change was strongly associated with incident sudden death/myocardial infarction, but not BNP-D1.
Only BNP-change following myocardial infarction was associated with poorer short- and long-term outcomes. BNP-change also improves risk reclassification in addition to the GRACE score.
在 ST 段抬高型心肌梗死患者中，7-15%以 Killip I 级入院的患者会出现症状性心力衰竭或射血分数降低。然而，现有的临床评分并不能很好地预测这些 Killip I 级患者发生严重结局的风险，如心力衰竭、再发心肌梗死和猝死。因此，我们评估了在 ST 段抬高型心肌梗死/ Killip I 级患者中，与 GRACE 评分相比，BNP 的单次或两次测量是否可以改善对不良结局的预测。
连续纳入 ST 段抬高型心肌梗死/ Killip I 级（=167）患者，在发病后 12 个月内进行随访。计算 GRACE 评分，并在症状发作后 12 小时内（D1）和第 5 天（D5）获得血浆 BNP 水平。
15%的以 Killip I 级入院的患者在 12 个月时出现症状性心力衰竭和/或射血分数降低。与 BNP 变化相关的 30 天内出现症状性心力衰竭或射血分数<40%的风险增加了 8.7 倍（95%置信区间：1.10-662，=0.046），每增加 100 pg/dl 的 BNP 变化。在未调整和调整后的 Cox 回归中，BNP 变化作为连续变量与 30 天内的新发猝死/心肌梗死相关（优势比为每增加 10 pg/dl 的 1.032，95%置信区间：1.013-1.052，<0.001），但 BNP-D1 无相关性。单独的 GRACE 评分显示中等 C 统计量=0.709（=0.029），但添加 BNP 变化可改善风险区分度（C 统计量=0.831，=0.001）。净重新分类证实个体风险预测的显著改善率为 33.4%（95%置信区间：8-61%，=0.034）。然而，与 GRACE 相比（=0.8），GRACE+BNP-D1 在 30 天内并未改善风险再分类。在 12 个月时，BNP 变化与新发猝死/心肌梗死密切相关，但 BNP-D1 无相关性。
只有心肌梗死后的 BNP 变化与短期和长期结局不良相关。BNP 变化除了 GRACE 评分外，还可以改善风险再分类。
