Department of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland. Electronic address: https://twitter.com/@BiascoDr.
AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
Rev Esp Cardiol (Engl Ed). 2023 Aug;76(8):626-634. doi: 10.1016/j.rec.2023.01.008. Epub 2023 Feb 4.
The risk prediction scores adopted in acute coronary syndromes (ACS) use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, previous studies reported a nonlinear relationship between HR and events, suggesting that low HR may have an unrecognized prognostic role. We aimed to assess the prognostic impact of low HR in ACS, defined as admission HR <50 bpm.
This study analyzed data from the AMIS Plus registry, a cohort of hospitalized patients with ACS between 1999 and 2021. The primary endpoint was in-hospital all-cause mortality, while a composite of all-cause mortality, major cardiac/cerebrovascular events was set as the secondary endpoint. A multilevel statistical method was used to assess the prognostic role of low HR in ACS.
The study included 51 001 patients. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. A nonlinear relationship between HR and in-hospital mortality was observed on restricted cubic spline analysis. An HR of 50 to 75 bpm showed lower mortality than HR <50 bpm (OR, 0.67; 95%CI, 0.47-0.99) only after primary multivariable analysis, which was not confirmed after multiple sensitivity analyses. After propensity score matching, progressive fading of the prognostic role of HR <50 bpm was evident.
Low admission HR in ACS is associated with a higher crude rate of adverse events. Nonetheless, after correction for baseline differences, the prognostic role of low HR was not confirmed. Therefore, low HR probably represents a marker of underlying morbidity. These results may be clinically relevant in improving the accuracy of risk scores in ACS.
急性冠状动脉综合征（ACS）中采用的风险预测评分采用增量模型来估计心率（HR）超过 60 bpm 的死亡率。然而，之前的研究报告 HR 与事件之间存在非线性关系，表明低 HR 可能具有未被认识到的预后作用。我们旨在评估 ACS 中低 HR 的预后影响，定义为入院时 HR <50 bpm。
本研究分析了 1999 年至 2021 年期间住院 ACS 患者的 AMIS Plus 登记处的数据。主要终点是院内全因死亡率，而全因死亡率、主要心脏/脑血管事件的复合终点为次要终点。采用多水平统计方法评估低 HR 在 ACS 中的预后作用。
该研究纳入了 51001 名患者。粗估计显示主要和次要终点呈双峰分布，HR 低值和高值处呈峰形。限制性立方样条分析显示 HR 与院内死亡率之间存在非线性关系。HR 为 50-75 bpm 时死亡率低于 HR <50 bpm（OR，0.67；95%CI，0.47-0.99），仅在初步多变量分析后得到证实，多次敏感性分析后并未得到证实。经过倾向评分匹配后，低 HR 预后作用逐渐减弱。
ACS 入院时的低 HR 与较高的不良事件粗发生率相关。然而，在纠正基线差异后，低 HR 的预后作用并未得到证实。因此，低 HR 可能代表潜在发病率的标志物。这些结果可能与改善 ACS 风险评分的准确性具有临床相关性。
