GRACE 风险评分在急性冠状动脉综合征患者风险预测中的修正。

Modification of the GRACE Risk Score for Risk Prediction in Patients With Acute Coronary Syndromes.

机构信息

Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.

Translational and Clinical Research Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.

出版信息

JAMA Cardiol. 2023 Oct 1;8(10):946-956. doi: 10.1001/jamacardio.2023.2741.

DOI:10.1001/jamacardio.2023.2741

PMID:37647046

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10469286/

Abstract

IMPORTANCE

The Global Registry of Acute Coronary Events (GRACE) risk score, a guideline-recommended risk stratification tool for patients presenting with acute coronary syndromes (ACS), does not consider the extent of myocardial injury.

OBJECTIVE

To assess the incremental predictive value of a modified GRACE score incorporating high-sensitivity cardiac troponin (hs-cTn) T at presentation, a surrogate of the extent of myocardial injury.

DESIGN, SETTING, AND PARTICIPANTS: This retrospectively designed longitudinal cohort study examined 3 independent cohorts of 9803 patients with ACS enrolled from September 2009 to December 2017; 2 ACS derivation cohorts (Heidelberg ACS cohort and Newcastle STEMI cohort) and an ACS validation cohort (SPUM-ACS study). The Heidelberg ACS cohort included 2535 and the SPUM-ACS study 4288 consecutive patients presenting with a working diagnosis of ACS. The Newcastle STEMI cohort included 2980 consecutive patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Data were analyzed from March to June 2023.

EXPOSURES

In-hospital, 30-day, and 1-year mortality risk estimates derived from an updated risk score that incorporates continuous hs-cTn T at presentation (modified GRACE).

MAIN OUTCOMES AND MEASURES

The predictive value of continuous hs-cTn T and modified GRACE risk score compared with the original GRACE risk score. Study end points were all-cause mortality during hospitalization and at 30 days and 1 year after the index event.

RESULTS

Of 9450 included patients, 7313 (77.4%) were male, and the mean (SD) age at presentation was 64.2 (12.6) years. Using continuous rather than binary hs-cTn T conferred improved discrimination and reclassification compared with the original GRACE score (in-hospital mortality: area under the receiver operating characteristic curve [AUC], 0.835 vs 0.741; continuous net reclassification improvement [NRI], 0.208; 30-day mortality: AUC, 0.828 vs 0.740; NRI, 0.312; 1-year mortality: AUC, 0.785 vs 0.778; NRI, 0.078) in the derivation cohort. These findings were confirmed in the validation cohort. In the pooled population of 9450 patients, modified GRACE risk score showed superior performance compared with the original GRACE risk score in terms of reclassification and discrimination for in-hospital mortality end point (AUC, 0.878 vs 0.780; NRI, 0.097), 30-day mortality end point (AUC, 0.858 vs 0.771; NRI, 0.08), and 1-year mortality end point (AUC, 0.813 vs 0.797; NRI, 0.056).

CONCLUSIONS AND RELEVANCE

In this study, using continuous rather than binary hs-cTn T at presentation, a proxy of the extent of myocardial injury, in the GRACE risk score improved the mortality risk prediction in patients with ACS.

摘要

重要性

全球急性冠状动脉事件登记处（GRACE）风险评分是一种指南推荐的用于急性冠状动脉综合征（ACS）患者的风险分层工具，但它没有考虑心肌损伤的程度。

目的

评估在现有的 GRACE 评分基础上加入高敏肌钙蛋白 T（hs-cTnT），以评估心肌损伤程度的改良 GRACE 评分在预测中的增量价值。

设计、设置和参与者：本回顾性设计的纵向队列研究共纳入了来自 2009 年 9 月至 2017 年 12 月的 3 个独立的 ACS 队列的 9450 例患者；2 个 ACS 推导队列（海德堡 ACS 队列和纽卡斯尔 STEMI 队列）和 1 个 ACS 验证队列（SPUM-ACS 研究）。海德堡 ACS 队列纳入了 2535 例连续患者，SPUM-ACS 研究纳入了 4288 例连续接受直接经皮冠状动脉介入治疗的 ST 段抬高型心肌梗死患者。数据分析于 2023 年 3 月至 6 月进行。

暴露

使用改良的 GRACE 风险评分（包含入院时连续 hs-cTnT）评估院内、30 天和 1 年的死亡率风险。

主要结果和测量

与原始 GRACE 风险评分相比，连续 hs-cTnT 和改良 GRACE 风险评分的预测价值。研究终点为住院期间和索引事件后 30 天和 1 年的全因死亡率。

结果

在 9450 例纳入患者中，7313 例（77.4%）为男性，入院时的平均（SD）年龄为 64.2（12.6）岁。与原始 GRACE 评分相比，使用连续而非二进制 hs-cTnT 可提高对患者的鉴别和重新分类能力（院内死亡率：接受者操作特征曲线下面积[AUC]，0.835 比 0.741；连续净重新分类改善[NRI]，0.208；30 天死亡率：AUC，0.828 比 0.740；NRI，0.312；1 年死亡率：AUC，0.785 比 0.778；NRI，0.078），这一发现在验证队列中得到了证实。在 9450 例患者的总体人群中，改良 GRACE 风险评分在院内死亡率终点（AUC，0.878 比 0.780；NRI，0.097）、30 天死亡率终点（AUC，0.858 比 0.771；NRI，0.08）和 1 年死亡率终点（AUC，0.813 比 0.797；NRI，0.056）方面的再分类和判别能力均优于原始 GRACE 风险评分。