心肌梗死后射血分数降低但无房颤患者的卒中风险。
Stroke Risk in Patients With Reduced Ejection Fraction After Myocardial Infarction Without Atrial Fibrillation.
机构信息
National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France; Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal.
National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France.
出版信息
J Am Coll Cardiol. 2018 Feb 20;71(7):727-735. doi: 10.1016/j.jacc.2017.12.011.
BACKGROUND
Stroke can occur after myocardial infarction (MI) in the absence of atrial fibrillation (AF).
OBJECTIVES
This study sought to identify risk factors (excluding AF) for the occurrence of stroke and to develop a calibrated and validated stroke risk score in patients with MI and heart failure (HF) and/or systolic dysfunction.
METHODS
The datasets included in this pooling initiative were derived from 4 trials: CAPRICORN (Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction), OPTIMAAL (Optimal Trial in Myocardial Infarction With Angiotensin II Antagonist Losartan), VALIANT (Valsartan in Acute Myocardial Infarction Trial), and EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study); EPHESUS was used for external validation. A total of 22,904 patients without AF or oral anticoagulation were included in this analysis. The primary outcome was stroke, and death was treated as a "competing risk."
RESULTS
During a median follow-up of 1.9 years (interquartile range: 1.3 to 2.7 years), 660 (2.9%) patients had a stroke. These patients were older, more often female, smokers, and hypertensive; they had a higher Killip class; a lower estimated glomerular filtration rate; and a higher proportion of MI, HF, diabetes, and stroke histories. The final stroke risk model retained older age, Killip class 3 or 4, estimated glomerular filtration rate ≤45 ml/min/1.73 m, hypertension history, and previous stroke. The models were well calibrated and showed moderate to good discrimination (C-index = 0.67). The observed 3-year event rates increased steeply for each sextile of the stroke risk score (1.8%, 2.9%, 4.1%, 5.6%, 8.3%, and 10.9%, respectively) and were in agreement with the expected event rates.
CONCLUSIONS
Readily accessible risk factors associated with the occurrence of stroke were identified and incorporated in an easy-to-use risk score. This score may help in the identification of patients with MI and HF and a high risk for stroke despite their not presenting with AF.
背景
心肌梗死（MI）后可发生无房颤（AF）的卒中。
目的
本研究旨在确定 MI 合并心力衰竭（HF）和/或收缩功能障碍患者卒中发生的风险因素（除 AF 外），并建立校准和验证的卒中风险评分。
方法
本汇总研究纳入了 4 项试验的数据：CAPRICORN（卡维地洛对左心室功能障碍 MI 患者预后的影响）、OPTIMAAL（血管紧张素 II 拮抗剂洛沙坦对 MI 的最佳试验）、VALIANT（缬沙坦急性 MI 试验）和 EPHESUS（依普利酮急性 MI 后 HF 疗效和生存研究）；EPHESUS 用于外部验证。共纳入 22904 例无 AF 或口服抗凝的患者进行本分析。主要结局为卒中，死亡被视为“竞争风险”。
结果
中位随访 1.9 年（四分位距：1.3 至 2.7 年）期间，660 例（2.9%）患者发生卒中。这些患者年龄较大，女性、吸烟者和高血压患者比例更高；Killip 分级更高；估算肾小球滤过率更低；且有更高比例的 MI、HF、糖尿病和卒中病史。最终的卒中风险模型保留了年龄较大、Killip 分级 3 或 4 级、估算肾小球滤过率≤45ml/min/1.73m2、高血压病史和既往卒中。这些模型校准良好，具有中等到较好的区分度（C 指数=0.67）。观察到的 3 年事件发生率随卒中风险评分的每一个六分位数逐渐升高（分别为 1.8%、2.9%、4.1%、5.6%、8.3%和 10.9%），与预期的事件发生率一致。
结论
确定了与卒中发生相关的易于获得的风险因素，并将其纳入易于使用的风险评分中。该评分可能有助于识别 MI 合并 HF 且即使不伴 AF 也具有高卒中风险的患者。
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