Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.
Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.
BMC Cardiovasc Disord. 2020 Apr 25;20(1):199. doi: 10.1186/s12872-020-01476-3.
The Global Registry of Acute Coronary Events (GRACE) score is recommended for stratifying chest pain. However, there are six formulas used to calculate the GRACE score for different outcomes of acute coronary syndrome (ACS), including death (Dth) or composite of death and myocardial infarction (MI), while in hospital (IH), within 6 months after discharge (OH6m) or from admission to 6 months later (IH6m). We aimed to perform the first comprehensive evaluation and comparison of six GRACE models to predict 30-day major adverse cardiac events (MACEs) in patients with acute chest pain in the emergency department (ED).
Patients with acute chest pain were consecutively recruited from August 24, 2015 to September 30, 2017 from the EDs of two public hospitals in China. The 30-day MACEs included death, acute myocardial infarction (AMI), emergency revascularization, cardiac arrest and cardiogenic shock. The correlation, calibration, discrimination, reclassification and diagnostic accuracy at certain cutoff values of six GRACE models were evaluated. Comparisons with the History, ECG, Age, Risk Factors, and Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) scores were conducted.
A total of 2886 patients were analyzed, with 590 (20.4%) patients experiencing outcomes. The GRACE (IHDthMI), GRACE (IH6mDthMI), GRACE (IHDth), GRACE (IH6mDth), GRACE (OH6mDth) and GRACE (OH6mDthMI) showed positive linear correlations with the actual MACE rates (r ≥ 0.568, P < 0.001). All these models had good calibration (Hosmer-Lemeshow test, P ≥ 0.073) except GRACE (IHDthMI) (P < 0.001). The corresponding C-statistics were 0.83(0.81,0.84), 0.82(0.81,0.83), 0.75(0.73,0.76), 0.73(0.72,0.75), 0.72(0.70,0.73) and 0.70(0.68,0.71), respectively, first two of which were comparable to HEART (0.82, 0.80-0.83) and superior to TIMI (0.71, 0.69-0.73). With a sensitivity ≥95%, GRACE (IHDthMI) ≤81 and GRACE (IH6mDthMI) ≤79 identified 868(30%) and 821(28%) patients as low risk, respectively, which were significantly better than other GRACEs and HEART ≤3(22%). With a specificity ≥95%, GRACE (IHDthMI) > 186 and GRACE (IH6mDthMI) > 161 could recognize 12% and 11% patients as high risk, which were greater than other GRACEs, HEART ≥8(9%) and TIMI ≥5(8%).
In this Chinese setting, certain strengths of GRACE models beyond HEART and TIMI scores were still noteworthy for stratifying chest pain patients. The validation and reasonable application of appropriate GRACE models in the evaluation of undifferentiated chest pain should be recommended.
全球急性冠脉事件注册（GRACE）评分推荐用于分层胸痛。然而，有六种公式用于计算急性冠脉综合征（ACS）不同结局的 GRACE 评分，包括死亡（Dth）或死亡和心肌梗死（MI）的复合，以及住院（IH）、出院后 6 个月内（OH6m）或入院后 6 个月内（IH6m）。我们旨在对六种 GRACE 模型进行首次全面评估和比较，以预测急诊科（ED）急性胸痛患者 30 天内的主要不良心脏事件（MACEs）。
从 2015 年 8 月 24 日至 2017 年 9 月 30 日，连续从中国两家公立医院的 ED 招募急性胸痛患者。30 天 MACEs 包括死亡、急性心肌梗死（AMI）、紧急血运重建、心脏骤停和心源性休克。评估了六种 GRACE 模型的相关性、校准、区分、重新分类和在特定截断值处的诊断准确性。并与历史、心电图、年龄、危险因素和肌钙蛋白（HEART）和心肌梗死溶栓（TIMI）评分进行了比较。
共分析了 2886 例患者，其中 590 例（20.4%）患者出现结局。GRACE（IHDthMI）、GRACE（IH6mDthMI）、GRACE（IHDth）、GRACE（IH6mDth）、GRACE（OH6mDth）和 GRACE（OH6mDthMI）与实际 MACE 率呈正线性相关（r≥0.568，P<0.001）。除 GRACE（IHDthMI）（P<0.001）外，所有这些模型的校准都很好（Hosmer-Lemeshow 检验，P≥0.073）。相应的 C 统计量分别为 0.83（0.81、0.84）、0.82（0.81、0.83）、0.75（0.73、0.76）、0.73（0.72、0.75）、0.72（0.70、0.73）和 0.70（0.68、0.71），前两个与 HEART（0.82、0.80-0.83）相当，优于 TIMI（0.71、0.69-0.73）。灵敏度≥95%时，GRACE（IHDthMI）≤81 和 GRACE（IH6mDthMI）≤79 分别识别出 868（30%）和 821（28%）例低危患者，明显优于其他 GRACE 和 HEART≤3（22%）。特异性≥95%时，GRACE（IHDthMI）>186 和 GRACE（IH6mDthMI）>161 可以识别出 12%和 11%的高危患者，高于其他 GRACE、HEART≥8（9%）和 TIMI≥5（8%）。
在这种中国环境下，GRACE 模型除了 HEART 和 TIMI 评分之外，在分层胸痛患者方面仍具有一定的优势。建议在评估未分化胸痛患者时，验证并合理应用适当的 GRACE 模型。
