Würtz Morten, Olesen Kevin Kris Warnakula, Mortensen Martin Bødtker, Eikelboom John W, Mohammad Moman Aladdin, Erlinge David, Kristensen Steen Dalby, Maeng Michael
Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark.
Population Health Research Institute, Hamilton Health Sciences 237 Barton Street East Hamilton, ON L8L 2X2, Canada, and McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada.
Eur Heart J. 2022 Mar 7;43(10):996-1004. doi: 10.1093/eurheartj/ehab785.
According to the 2019 European Society of Cardiology (ESC) guidelines on chronic coronary syndromes (CCS), adding a P2Y12 inhibitor or rivaroxaban to aspirin should be considered in high-risk patients. We estimated the proportion of patients eligible for treatment with the ESC criteria and examined if a recently validated risk score (CHADS-P2A2RC) could improve risk prediction.
We included 61 338 CCS patients undergoing first-time coronary angiography in Western Denmark (2003-16) and classified them according to the ESC criteria and the CHADS-P2A2RC score. The ESC criteria identified 33.9% as high risk, 53.3% as moderate risk, and 12.8% as low risk. The CHADS-P2A2RC score identified 24.9% as high risk (≥4 points), 48.1% as moderate risk (2-3 points), and 27.0% as low risk (≤1 points). Major adverse cardiovascular events per 100 person-years were 4.8 [95% confidence interval (CI) 4.6-5.0] in patients considered high risk with both schemes, 2.1 (95% CI 2.0-2.2) in patients considered high risk with the ESC but low-to-moderate risk with the CHADS-P2A2RC criteria, 3.8 (95% CI 3.6-4.1) in patients considered low-to-moderate risk with the ESC but high risk with the CHADS-P2A2RC criteria, and 1.5 (95% CI 1.5-1.6) in patients considered low-to-moderate risk with both schemes. The CHADS-P2A2RC score enabled correct downward risk reclassification of 5161 patients (8%) without events, yielding an improved specificity of 9.7%, a loss of sensitivity of 4.4%, and an overall net reclassification index of 0.053.
Based on the 2019 ESC guidelines, dual antithrombotic treatment should be considered in one-third of CCS patients. The CHADS-P2A2RC score improved risk classification and may particularly identify low-risk patients with limited benefit from treatment.
根据2019年欧洲心脏病学会（ESC）慢性冠状动脉综合征（CCS）指南，对于高危患者，应考虑在阿司匹林基础上加用P2Y12抑制剂或利伐沙班。我们估算了符合ESC标准进行治疗的患者比例，并检验了最近验证的风险评分（CHADS-P2A2RC）是否能改善风险预测。
我们纳入了丹麦西部61338例首次接受冠状动脉造影的CCS患者（2003年至2016年），并根据ESC标准和CHADS-P2A2RC评分对他们进行分类。ESC标准将33.9%的患者归为高危，53.3%为中危，12.8%为低危。CHADS-P2A2RC评分将24.9%的患者归为高危（≥4分），48.1%为中危（2 - 3分），27.0%为低危（≤1分）。两种方案均判定为高危的患者每100人年的主要不良心血管事件发生率为4.8[95%置信区间（CI）4.6 - 5.0]，ESC判定为高危但CHADS-P2A2RC标准判定为低至中危的患者为2.1（95%CI 2.0 - 2.2），ESC判定为低至中危但CHADS-P2A2RC标准判定为高危的患者为3.8（95%CI 3.6 - 4.1），两种方案均判定为低至中危的患者为1.5（95%CI 1.5 - 1.6）。CHADS-P2A2RC评分使5161例（8%）无事件发生的患者风险得到正确下调重新分类，特异性提高了9.7%，敏感性降低了4.4%，总体净重新分类指数为0.053。
基于2019年ESC指南，三分之一的CCS患者应考虑双联抗栓治疗。CHADS-P2A2RC评分改善了风险分类，尤其可能识别出从治疗中获益有限的低危患者。
