Department of Cardiology, Concord Hospital, 1A Hospital Road, Concord, Sydney, NSW, Australia.
Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, 30 Bond St, Toronto, Ontario, Canada.
Eur Heart J Qual Care Clin Outcomes. 2018 Oct 1;4(4):309-317. doi: 10.1093/ehjqcco/qcy002.
There is little information on clinical risk stratification (CRS) compared to objective risk tools in patients with non-ST elevation acute coronary syndromes (NSTEACS). We quantified CRS use, its agreement with Global Registry of Acute Coronary Events (GRACE) risk scores (GRS), and association with outcomes.
Data were extracted from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE), a multi-centre NSTEACS registry. From February 2009 to December 2015, 4512 patients from 41 sites were included. Predictors of CRS use and association with treatment were identified, CRS-GRS agreement determined and prediction of in-hospital and 6-month mortality compared. Clinical risk stratification was documented in 21% of patients. Family history of coronary disease was the only independent predictor of CRS use [odds ratio (OR) 1.23, 95% confidence interval (95% CI) 1.04-1.45]; electrocardiogram changes (OR 0.8, 95% CI 0.68-0.96), elevated biomarkers (OR 0.59, 95% CI 0.48-0.73), dementia (OR 0.56, 95% CI 0.36-0.84), and an urban hospital setting (OR 0.41, 95% CI 0.19-0.89) were independent negative predictors. A treatment-risk paradox was observed: high CRS risk patients received less anticoagulation (79% vs. 88%, P = 0.001) and angiography (83% vs. 71%, P < 0.001). CRS-GRS agreement was poor (kappa coefficient = 0.034) and CRS less predictive for in-hospital (c-statistic 0.54 vs. 0.87, P < 0.001) and 6-month (c-statistic 0.55 vs. 0.74, P < 0.01) mortality.
In Australia, CRS does not guide treatment, correlate with GRS or predict outcomes. This study suggests the need for greater awareness and integration of validated tools such as the GRACE score to optimally direct treatment and potentially improve outcomes.
在非 ST 段抬高型急性冠状动脉综合征（NSTEACS）患者中，与客观风险工具相比，临床风险分层（CRS）的信息较少。我们量化了 CRS 的使用情况、其与全球急性冠状动脉事件注册（GRACE）风险评分（GRS）的一致性，并探讨了其与预后的关系。
数据来自澳大利亚合作国家急性冠状动脉护理、指南依从性和临床事件（CONCORDANCE）登记处，这是一个多中心 NSTEACS 登记处。从 2009 年 2 月至 2015 年 12 月，来自 41 个地点的 4512 名患者被纳入研究。确定了 CRS 使用的预测因素及其与治疗的关系，确定了 CRS-GRS 的一致性，并比较了住院期间和 6 个月的死亡率预测。21%的患者记录了临床风险分层。家族史是 CRS 使用的唯一独立预测因素[比值比（OR）1.23，95%置信区间（95%CI）1.04-1.45]；心电图改变（OR 0.8，95%CI 0.68-0.96）、标志物升高（OR 0.59，95%CI 0.48-0.73）、痴呆（OR 0.56，95%CI 0.36-0.84）和城市医院环境（OR 0.41，95%CI 0.19-0.89）是独立的负预测因素。观察到治疗风险悖论：高 CRS 风险患者接受抗凝治疗（79%对 88%，P = 0.001）和血管造影（83%对 71%，P < 0.001）的可能性较低。CRS-GRS 的一致性较差（kappa 系数为 0.034），CRS 对住院期间（c 统计量为 0.54 对 0.87，P < 0.001）和 6 个月（c 统计量为 0.55 对 0.74，P < 0.01）的死亡率预测作用较低。
在澳大利亚，CRS 不能指导治疗，与 GRS 不相关，也不能预测结局。本研究表明，需要提高对经过验证的工具（如 GRACE 评分）的认识并将其纳入，以最佳指导治疗并可能改善预后。
