在观察区域识别疑似非ST段抬高型急性冠状动脉综合征（NSTE-ACS）的患者：评估GRACE 1.0评分和生物标志物组合以进行风险分层和优化管理。
Identification of patients with suspected NSTE-ACS in the observe zone: evaluating GRACE 1.0 score and a biomarker panel for risk stratification and management optimization.
作者信息
Yildirim Mustafa, Reich Christoph, Salbach Christian, Biener Moritz, Mueller-Hennessen Matthias, Sörensen Nils Arne, Haller Paul Michael, Blankenberg Stefan, Neumann Johannes Tobias, Twerenbold Raphael, Frey Norbert, Giannitsis Evangelos
机构信息
Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
出版信息
Clin Res Cardiol. 2025 Jun;114(6):783-795. doi: 10.1007/s00392-025-02642-3. Epub 2025 Apr 14.
BACKGROUND
Current guidelines recommend additional diagnostic work-up for patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) triaged in the observe zone using accelerated diagnostic protocols. This study assessed the effectiveness of combining the Global Registry of Acute Coronary Events (GRACE) 1.0 score with additional non-cardio-specific biomarkers for risk stratification in the observe zone.
METHODS
A total of 6789 patients with suspected NSTE-ACS were enrolled over 24 months, with 961 (21.8%) assigned to the observe zone. A classification and regression tree (CART) analysis dichotomized risk using the GRACE-score and additional biomarkers beyond high-sensitivity cardiac troponin including C-reactive protein < 10 mg/dL, N-terminal pro-B-type natriuretic peptide < 300 ng/L, D-dimers < 5 mg/L, estimated glomerular filtration rate > 30 mL/min/1.73m, Copeptin < 10 pmol/L, and hemoglobin > 10 g/dL. The primary endpoint was 1-year all-cause mortality, validated using the Biomarkers in Acute Cardiac Care (BACC) cohort.
RESULTS
A low GRACE 1.0 score < 109 points was found in 37.6% of observe zone patients, showing a negative predictive value of 98.6% and sensitivity of 89.8% for death. Adding biomarker information reduced predicted 1-year-mortality from 1.38% with the GRACE-score alone to 0.46% when none of the biomarkers were above cutoff (prevalent in 22.7%). The proportion of protocol-eligible patients increased from 22.7 to 37.6%, with no events within 30 days. Findings were confirmed in the BACC cohort.
CONCLUSION
A low GRACE 1.0 score combined with ≤ 1 elevated biomarker significantly improves mortality prediction in the observe zone, helping identify low-risk patients for further out-of-hospital diagnostic work-up, potentially decongesting crowded emergency departments. Registration URL: https://www.
CLINICALTRIALS
gov ; Unique identifier: NCT05774431.
背景
当前指南建议，对于在观察区使用加速诊断方案进行分诊的疑似非ST段抬高型急性冠状动脉综合征（NSTE-ACS）患者，应进行额外的诊断检查。本研究评估了将全球急性冠状动脉事件注册研究（GRACE）1.0评分与其他非心脏特异性生物标志物相结合用于观察区分层的有效性。
方法
在24个月内共纳入6789例疑似NSTE-ACS患者，其中961例（21.8%）被分配至观察区。采用分类回归树（CART）分析，使用GRACE评分和高敏心肌肌钙蛋白以外的其他生物标志物进行风险二分法划分，这些生物标志物包括C反应蛋白<10mg/dL、N末端B型脑钠肽原<300ng/L、D-二聚体<5mg/L、估计肾小球滤过率>30mL/min/1.73m²、 copeptin<10pmol/L和血红蛋白>10g/dL。主要终点为1年全因死亡率，使用急性心脏护理生物标志物（BACC）队列进行验证。
结果
观察区37.6%的患者GRACE 1.0评分<109分，其死亡阴性预测值为98.6%，敏感性为89.8%。添加生物标志物信息后，预测的1年死亡率从仅使用GRACE评分时的1.38%降至没有生物标志物高于临界值时的0.46%（占22.7%）。符合方案的患者比例从22.7%增至37.6%，30天内无事件发生。这些结果在BACC队列中得到了证实。
结论
低GRACE 1.0评分与≤1种升高的生物标志物相结合，可显著改善观察区的死亡率预测，有助于识别低风险患者进行进一步的院外诊断检查，可能缓解拥挤的急诊科压力。注册网址：https://www.CLINICALTRIALS.gov；唯一标识符：NCT\(05\)774431。
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