心率减速力与GRACE评分对急性心肌梗死患者心脏不良事件的预测价值

Prediction value of deceleration capacity of rate and GRACE risk score on major adverse cardiac events in patients with acute myocardial infarction

目的探讨心率减速力（DC）与GRACE评分对急性心肌梗死患者心脏不良事件的预测价值。方法前瞻性连续人组2012年8月至2013年8月在解放军总医院心血管内科住院明确诊断为急性心肌梗死且心电图为窦性心律的患者157例，其中男121例，女36例，对受检者在急性心肌梗死1周内行24h动态心电图检查并分析得出DC值，计算患者GRACE危险评分，分别根据DC与GRACE评分将患者分为高、中、低危组（以DC值分别为12、71和74例，以GRACE评分分别为33、41和83例），对人组患者平均随访1年或以上，记录患者随访期间心脏不良事件发生情况和生存状况。分别以DC、GRACE评分危险分层作为检验变量，以患者随访期间心脏不良事件和生存状况作为状态变量，绘制受试者工作特征（ROC）曲线，比较其评估价值。根据DC值危险分层进行Kaplan—Meier生存分析，并在GRACE评分基础上进一步做亚组分析。结果157例患者的平均年龄（58．9±12．7）岁，平均随访（20．54±2．85）个月。Kaplan-Meier生存分析显示，随访期内的DC值≤2．5患者的病死率明显高于DC值〉2．5的患者（P〈0．01）。预测死亡方面，根据DC危险分层ROC曲线下面积为0．898（95％C10．840～0．940，P〈0．01），其敏感度为84．6％，特异度为84．0％；根据GRACE评分危险分层ROC曲线下面积为0．786（95％c，0．714～0．847，P〈0．01），其敏感度为84．6％，特异度为74．3％。在预测心脏不良事件方面，根据DC危险分层ROC曲线下面积为0．747（95％c，0．672～0．813，P〈0．01），其敏感度为90．0％，特异度为67．7％；根据GRACE评分危险危险分层ROC曲线下面积为0．708（95％C10．652—0．769，P〈0．01），其敏感度为63．3％，特异度为75．6％。亚组分析显示，在GRACE评分低中危患者组中，再进行DC危险分层，应用Kaplan—Meier生存分析，根据DC值危险分层高危组在随访期内患者的病死率高于中危和低危组，3组比较差异有统计学意义（P〈0．01）。结论DC危险分层对急性心肌梗死猝死高危患者筛选与预测有较强的实用价值，亚组分析显示，DC分层在GRACE评分低中危组患者中也表现出对心原性死亡的良好的预测价值。

Objective To investigate the prediction value of deceleration capacity of rate （DC） and GRACE risk score for cardiovascular events in AMI patients. Methods Consecutive AMI patients with sinus rhythm hospitalized in our department during August 2012 to August 2013 were included in this prospective study. 24-hour ECG Holter monitoring was performed within 1 week, and the DC value was analyzed, GRACE risk score was acquired with the application of GRACE risk score calculator. Patients were followed up for more than 1 year and major adverse cardiac events （MACE） were obtained. Analysised the Kaplan Meier survival according to DC and GRACE score risk stratification respectively. Results A total of 157 patients were enrolled in the study （average age：（58.9 ± 12. 7）years old）. The average follow- up was （20. 54 ± 2. 85 ） months. Mortality during follow-up was significantly higher in patients with DC 〉 2. 5 compared to patients with DC 〈 2. 5 （ P 〈 0. 01 ）. In terms of early warning cardiac death, the area under ROC curve of DC risk stratification was 0. 898 （95 % CI O. 840 -0. 940, P 〈 0. 01 ）, the sensitivity was 84. 6%, and the specificity was 84. 0%. The area under ROC curve of GRACE risk stratification was 0. 786（95 % CI 0. 714 -0. 847,P 〈 0. 01 ） , the sensitivity was 84.6% , and the specificity was 74. 3 %. In terms of early warning cardiac adverse events, the ROC curve of DC was 0. 747 （ 95% C10. 672 - 0. 813, P 〈 0. 01 ） , with the 90. 0% sensitivity and 67.7% specificity. The GRACE risk stratification was 0. 708 （95% CI 0. 652 -0. 769, P 〈 0. 01 ）, with the 63.3% sensitivity and 75.6% specificity. Subgroup analysis showed that mortality during follow-up was significantly higher in high risk patients than those with intermediate and low risk patients according to DC risk stratification in intermediate and low risk patients by GRACE risk stratification （P 〈0. 01 ）. Conclusion DC could predict cardiac death and MACE in patients with AMI. DC risk stratification is superior to GRACE risk score on outcome assessment in this AMI patient cohort.