急性冠脉综合征住院风险评分及其对血运重建的评价

Development and validation of risk score model for acute myocardial infarction in China： prognostic value thereof for in hospital major adverse cardiac events and evaluation of revascularization

目的建立中国急性冠脉综合征（ACS）患者住院不良事件的风险评分，评价血运重建对不同风险人群的疗效。方法收集1501例中国（全球性急性冠脉事件注册研究，GRACE）研究入选患者的基线特征、诊断治疗和住院转归，通过多因素Logistic回归方法建立住院风险评分，并进行验证。以敏感度、特异度均接近70％为截点，评价血运重建对不同风险评分患者预后的影响。结果（1）6个危险因素进入风险评分模型：包括年龄、收缩压、舒张压、心功能Killip分级、入院时心脏骤停、心电图ST段偏移；（2）拟和优度检验值为0．673，c检验为0．776；（3）将入选的1301例患者分为高风险组和低风险组（风险评分〉5．5分、≤5．5分）组，血运重建明显降低ST段抬高心肌梗死患者（STEMI）[OR（95％CI）=0．32（0.11，0．94），X^2=5．39，P=0．02]和非ST段抬高ACS患者（NSTEACS）[OR（95％CI）=0.32（0．06，0．94），X^2=4．17，P=0．04]高风险组住院不良事件发生率，但是高风险组血运重建率均低于低风险组（STEMI：61．7％、78．3％，P=0．000；NSTEACS：42．0％、62．3％，P=0．000）。结论风险评分能够在入院早期定量预测ACS个体住院不良事件发生率，高风险组血运重建获益最大。

Objective To develop a simple risk score model of in-hospital major adverse cardiac events （MACE） including all-cause mortality, new or recurrent myocardial infarction （MI） ,and evaluate the efficacy about revascularization on patients with different risk. Methods The basic characteristics, diagnosis, therapy, and in-hospital outcomes of 1512 ACS patients from Global Registry of Acute Coronary Events （GRACE） study of China were collected to develop a risk score model by muhivariable stepwise logistic regression. The goodness-of-fit test and discriminative power of the final model were assessed respectively. The best cut-off value for the risk score was used to assess the impact of revascularization for ST-elevation MI （STEMI） and non-ST elevation acute coronary artery syndrome （NSTEACS） on in-hospital outcomes. Results （ 1 ） The following 6 independent risk factors accounted for about 92. 5% of the prognostic information： age ≥80 years （4 points）, SBP≤90 mm Hg （6 points）, DBP≥90 mm Hg （2 points）, Killip Ⅱ （3 points）, Killip Ⅲ or Ⅳ （9 points）, cardiac arrest during presentation （4 points）, ST-segment elevation （3 points） or depression （5 points） or combination of elevation and depression （4 points） on electrocardiogram at presentation. （2） CHIEF risk model was excellent with Hosmer-Lemeshow goodness-of-fit test of 0. 673 and c statistics of 0. 776. （3）1301 ACS patients previously enrolled in GRACE study were divided into 2 groups with the best cut-off value of 5.5 points. The impact of revascularization on the in-hospital MACE of the higher risk subsets was stronger than that of the lower risk subsets both in STEMI [ OR（95% CI） =0.32 （0. 11,0.94） ,X^2 =5.39,P =0.02] and NSTEACS [ OR（95% CI） = 0.32 （0.06,0.94） ,X^2 =4.17,P=0.04] population. However, both STEMI （61.7% vs 78.3% ,P =0. 000） and NSTEACS （42.0% vs 62.3% ,P = 0. 000） patients with the risk scores more than 5.5 points had lower revascularization rates. Conclusion The risk score provides excellent ability to predict in-hospital death or （re）MI quantitatively and accurately. The patients undergoing revascularization with risk score greater than 5.5 have lower incidence rates of endpoint.