SinoSCORE对手术风险的评估作用

Set up and validation of Chinese Risk Stratification System for Coronary Artery Bypass Grafting

目的 评价中国冠状动脉旁路移植手术评分系统（SinoSCORE）对冠状动脉旁路移植手术（CABG）院内病死率和术后并发症的预测效果.方法 中国心血管外科注册登记研究收集来自全国43家心脏外科中心2007年至2008年接受CABG的9564例病人的临床资料.应用logistic回归的统计学方法建立中国冠状动脉旁路移植术风险评分系统（SinoSCORE）.本模型确定了包括年龄大于65岁、术前NYHA心功能分级、慢性肾功能衰竭史、慢性阻塞性肺疾病等11个危险因素.根据SinoSCORE评分将病人分为：低危组（≤1分）、中危组（2～5分）与高危组（≥6分）.评价SinoSCORE对CABG院内病死率和术后并发症的预测效果,应用Homser-Lemeshow（HL）拟合优度检验考察SinoSCORE的校准度,应用ROC曲线下面积（AUC）评价SinoSCORE的区分度,并与EuroSCORE进行比较.通过比较观察病死率与预测病死率95%置信区间的差异,评估SinoSCORE对不同危险组病人院内病死率的预测功能.结果 SinoSCORE对CABG手术病死率与术后主要并发症表现出较好的预测效果：手术病死率HL拟合优度检验为P=0.70,AUC=0.80,术后主要并发症：卒中为HL P=0.43,AUC=0.76;肾衰为HL P=0.70,AUC=0.72;通气时间延长（＞24 h）为HL P=0.18,AUC=0.70;多系统衰竭为HL P=0.49,AUC=0.79,效果优于EuroSCORE.在3组不同危险程度的病人中,观察病死率与预测病死率95%置信区间均有较好的重合.结论 SinoSCORE是建立在中国最新的冠脉旁路移植手术临床数据的基础上风险评分系统,预测中国病人的院内死亡与术后并发症的能力优于EuroSCORE,更加适合我国心脏外科领域临床医师应用.

Objective Our study aims to evaluate the performance of Chinese risk stratification system for coronary artery bypass grafting （CABG） in the prediction of in-hospital mortality and major postoperative complications after CABG. Methods Clinical information of 9564 consecutive CABG patients was collected in Chinese Coronary Artery Bypass Grafting Registry which recruited 43 centers over China between 2007 and 2008. Sino System for Coronary Operative Risk Evaluation （ SinoSCORE） was developed using the logistic regression model. The SinoSCORE model was designed to predict in-hospital mortality among patients undergoing coronary artery bypass surgery. The scoring system finally identified 11 risk factors including age over 65, preoperative NYHA stage, chronic renal failure, chronic obstructive pulmonary disease, etc. Cut-off point was defined for SinoSCORE model to distinguish low（ SinoSCORE： ≤ 1 ）, moderate（ SinoSCORE ：2 -5 ） and high risk groups（≥6）.AUC statistic （receiver operating characteristic curve） was used to test discrimination of SinoSCORE model and we assessed calibration of this model by the Hosmer-Lemeshow goodness-of-fit statistic. The above-mentioned results were compared with the European Risk System in Cardiac Operations （EuroSCORE）. And we also assessed the applicability of SinoSCORE model in the prediction of in-hospital mortality among the three different risk groups by comparing the 95% confidence interval （CI） between the morbidity observed with that expected. Results SinoSCORE model showed good performance （ HL P 〉 0. 05, AUC 〉 0. 70 ） in the prediction of in-hospital mortality and postoperative complications. Of our study population, calibration by Hosmer-Lemeshow （HL） test for in-hospital mortality was P=0.70, discrimination by area under ROC （AUC） was 0.80. And for major postoperative complications, the risk model SinoSCORE model still turned out good including the following： stroke （ HL P = 0. 43, AUC = 0. 76, renal failure （ HL P = 0. 70, AUC = 0. 72 ）, prolonged ventilation （ HL P = 0. 18, AUC = 0.70 ）,multiple organ failure（ HL P =0.49 ,AUC =0.79）. By comparison with EuroSCORE model, SinoSCORE model proved better prediction ability in both the discrimination and calibration based on our research crowd. And during the different danger degree of patients, mortality observations 95% CI and estimated values of 95% CI were very good overlap, which indicated that this model for the three different risk groups are applicable. Conclusion SinoSCORE model is based on the newest clinical date of Chinese patients undergoing CABG. SinoSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also postoperative complications. SinoSCORE proved better performance than the EuroSCORE model in Chinese CABG patients and is more suitable for？ application？ among？ domestic cardiac surgery？ physicians.