预测老年急性心肌梗死住院患者 6 个月死亡率的队列研究。
Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study.
机构信息
New York University School of Medicine, New York, New York (J.A.D.).
Yale School of Medicine, New Haven, Connecticut (A.M.H., M.G., T.E.M., S.T., M.E.T., T.M.G., S.I.C.).
出版信息
Ann Intern Med. 2020 Jan 7;172(1):12-21. doi: 10.7326/M19-0974. Epub 2019 Dec 10.
BACKGROUND
Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts.
OBJECTIVE
To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments.
DESIGN
Prospective cohort study. (ClinicalTrials.gov: NCT01755052).
SETTING
94 hospitals throughout the United States.
PARTICIPANTS
3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive.
MEASUREMENTS
Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality.
RESULTS
Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment.
LIMITATION
The model was not externally validated.
CONCLUSION
A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge.
PRIMARY FUNDING SOURCE
National Heart, Lung, and Blood Institute of the National Institutes of Health.
背景
与年轻患者相比，老年急性心肌梗死（AMI）患者的功能障碍更为常见，包括认知、力量和感觉等方面的缺陷。
目的
开发并评估一种包含功能障碍信息的老年 AMI 患者 6 个月后死亡率预测模型，并对其进行评估。
设计
前瞻性队列研究。（ClinicalTrials.gov：NCT01755052）。
地点
美国 94 家医院。
参与者
3006 名年龄在 75 岁及以上、因 AMI 住院且存活出院的患者。
测量方法
通过直接测量（认知、移动性、肌肉力量）或自我报告（视力、听力）在住院期间评估功能障碍。通过病历回顾确定与既往风险模型中死亡率相关的临床变量。选择了 72 个候选变量纳入，通过向后选择和贝叶斯模型平均法推导出（n=2004 名参与者）和验证（n=1002 名参与者）一个 6 个月死亡率模型。
结果
参与者的平均年龄为 81.5 岁，44.4%为女性，10.5%为非白人。6 个月内有 266 人死亡（8.8%）。最终的风险模型包含 15 个变量，其中 4 个变量未包含在既往风险模型中：听力障碍、移动性障碍、体重减轻和患者报告的健康状况较差。该模型具有良好的校准能力（验证队列的 Hosmer-Lemeshow P＞0.05），且具有良好的区分能力（验证队列的曲线下面积为 0.84）。功能障碍的加入显著提高了模型的性能，听力障碍和移动性障碍的无类别净重新分类改善指数分别为 0.21（P=0.008）和 0.26（P＜0.001）。
局限性
该模型未进行外部验证。
结论
为老年 AMI 患者 6 个月后死亡率开发的新模型具有良好的校准度和良好的区分能力。该模型可能有助于出院决策。
主要资金来源
美国国立卫生研究院下属的美国国立心肺血液研究所。
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