GRACE出院评分对急性冠状动脉综合征患者介入术后院外远期死亡的预测价值

Predictive value of GRACE discharge score for long-term out-of-hospital death in acute coronary syndrome after percutaneous coronary intervention

目的评估全球急性冠状动脉综合征（ACS）事件注册（GRACE）出院评分对ACS介入术后患者院外远期死亡事件的预测价值。方法本研究为单中心、前瞻性、观察性研究，连续纳入自2013年1至12月于中国医学科学院阜外医院行经皮冠状动脉介入治疗（PCI）的ACS患者6431例。死亡定义为全因死亡，主要不良心脑血管事件（MACCE）定义为全因死亡、心肌梗死、缺血驱动的血运重建、支架内血栓或脑卒中的复合事件。结果共纳入5867例符合入选标准，成功置入药物洗脱支架，并使用双联抗血小板治疗且无院内事件的ACS患者进行分析。2年随访中，死亡59例（1．01％），MACCE事件608例（10．56％）。GRACE出院评分在死亡组[（94±28）分]明显高于存活组[（78±24）分，P〈0．001]。GRACE出院评分能够较好地区分出高危组和低危组，高危组死亡风险是低危组的6．73倍[风险比（HR）=6．73，95％c，3．53～12．84；P〈0．001]，但对中危组和低危组不能很好区分（HR=1．61，95％CI0．88～2．95；P=0．124）。GRACE出院评分对ACS介入术后并使用DAPT治疗的患者院外远期死亡具有预测价值[受试者工作曲线下面积（AUROC）=0．661；95％CI0．586～0．736；P〈0．001]。进一步亚组分析显示，GRACE出院评分不论在不稳定心绞痛（UAP）亚组（AUROC=0．660，95％CI0．576～0．744；P〈0．001）还是急性心肌梗死（AMI）亚组（AUROC=0．748，95％CI0．631～0．864；P=0．001），均显示对死亡的预测价值。结论GRACE出院评分对ACS已行介入治疗患者并使用DAPT治疗的院外长期死亡仍具有预测价值，并能够较好地区分出死亡的高危组和低危组患者。

Objective To evaluate the prognostic value of Global Registry of Acute Coronary Events （GRACE） discharge score for long-term out-of-hospital death in acute coronary syndrome （ACS） after drugeluting stents （DES） and with Dual-antiplatelet Therapy （DAPT）. Methods Our study was a prospective, observational, single center （Fuwai Hospital of China） study. A total of 6 431consecutive ACS patients underwent percutaneous coronary intervention （ PCI ） between January 2013 and December 2013 were involved. The primary endpoint was all-cause death and second endpoint was major adverse cardiovascular and cerebrovascular events （MACCE） as a composite of all-cause death, myocardial infarction, revascularization, stent thrombosis or stroke. Results Finally, 5 867 ACS patients who were received DES with DAPT and had no in-hospital event included in this study, and 59 （ 1.01% ） death and 608 （ 10. 36% ） MACCE were reported during 2-year follow-up after discharge. GRACE score was significantly higher among death patients than those survivalpatients （94 ± 28 vs 78 ± 24,P 〈 0. 001 ）. According to risk stratification of GRACE discharge score, as compared to the low-risk group, death risk in high-risk group was 6. 73 times （HR =6.73, 95% CI 3.53 -12. 84; P 〈 0. 001 ） higher, but could not distinguish between the moderate and low risk group （HR = 1.61, 95% CI 0. 88 -2. 95; P =0. 124）. The GRACE score showed predictive value in ACS patients after DESand with DAPT （area under the receiver operating characteristic curve （AUROC） = 0. 661 ; 95% CI 0. 586 - 0. 736, P 〈 0. 001 ）. In subgroup analysis, GRACE score also showed predictive value both in unstable angina pectoris （UAP） （ AUROC = 0. 660, 95% CI 0. 576 - 0. 744 ; P 〈 0. 001 ） and acute myocardial infarction （AMI） subgroup （ AUROC = 0. 748, 95 % CI 0. 631 - 0. 864 ; P = 0. 001 ）. Conclusion GRACE discharge score shows prognostic value for long-term out-of-hospital death in ACS patients undergoing PCI with DES and DAPT, and demonstrates good risk stratification of high and low- risk of death.