【摘要】 目的 观察急性ST段抬高型心肌梗死(STEMI)患者双联抗血小板治疗(DAPT)期间BleeMACS评分及GRACE评分情况，探讨其对STEMI患者经皮冠状动脉介入治疗(PCI)后DAPT 1年内出血风险的预测价值。方法 2018年3月—2019年6月河南省人民医院诊治STEMI患者404例，均行PCI且术后应用DAPT,根据1年内是否发生出血事件分为出血组18例和非出血组386例，比较2组年龄、体质量指数、吸烟史、既往病史、Killip分级、院前心脏骤停、病变血管、院外药物使用情况、入院后实验室检查及BleeMACS评分、GRACE评分等。采用ROC曲线、净重新分类改善指数(NRI)、综合判别改善指数(IDI)、决策曲线评估BleeMACS评分及GRACE评分预测STEMI患者PCI后DAPT 1年内发生出血事件的效能。结果 404例STEMI患者PCI后DAPT 1年内发生出血事件18例(4.46%)。出血组年龄[73.80(64.44, 77.79)岁]、血肌酐水平[88.00(66.00, 103.00)μmol/L]、BleeMACS评分[21.00(15.00, 27.00)分]、GRACE评分[161.00(135.00, 187.00)分]均高于非出血组[61.50(50.91, 68.63)岁、67.00(56.00, 79.00)μmol/L、9.00(7.00, 18.00)分、139.00(120.00, 160.00)分](P<0.05),体质量指数[23.48(22.89, 24.61)kg/m~2]低于非出血组[24.49(23.60, 25.85)kg/m~2](Z=-2.212,P=0.027)。BleeMACS评分、GRACE评分预测STEMI患者PCI后DAPT 1年内发生出血事件的AUC分别为0.749(95%CI:0.633～0.866,P<0.001)、0.685(95%CI:0.555～0.814,P<0.001),灵敏度分别为72.2%、66.7%,特异度分别为81.3%、74.6%;2种评分的AUC比较差异无统计学意义(Z=0.065,P=0.435)。BleeMACS评分相较于GRACE评分预测STEMI患者PCI后DAPT 1年内发生出血事件的NRI为0.155(Z=0.640,P=0.519),IDI为0.015(Z=0.760,P=0.450)。决策曲线显示，采用BleeMACS评分在1.8%～4%及5%～12%的阈概率区间对患者进行危险分层并调整治疗方案较GRACE评分获得更多净收益。结论 BleeMACS评分和GRACE评分均可用于预测STEMI患者PCI后DAPT期间出血事件，采用BleeMACS评分预测临床获益更高。更多还原

【Abstract】 Objective To observe the BleeMACS score and GRACE score during dual antiplatelet therapy(DAPT)in patients with ST-elevation myocardial infarction (STEMI),and to investigate their values to the prediction of bleeding during one-year DAPT after percutaneous coronary intervention (PCI)in patients with STEMI.Methods Totally 404STEMI patients underwent PCI followed by DAPT in Henan Provincial People’s Hospital from March 2018to June2019,and were divided into bleeding group (n=18)and non-bleeding group (n=386)according to the occurrence of bleeding within one-year DAPT.The age,body mass index,smoking history,previous medical history,Killip classification,prehospital cardiac arrest,diseased vessel,out-of-hospital medication,postadmission laboratory examination,BleeMACS score and GRACE score were compared between two groups.ROC curve,category-free net reclassification improvement(NRI),integrated discrimination improvement(IDI)and decision curve analysis (DCA)were used to evaluate the efficiencies of BleeMACS score and GRACE score on predicting bleeding during one-year DAPT after PCI in STEMI patients.Results Among 404STEMI patients,18patients(4.46%)developed bleeding during oneyear DAPT after PCI.The patients were older in bleeding group[73.80(64.44,77.79)years]than in non-bleeding group[61.50(50.91,68.63)years](P<0.05).The level of serum creatinine,BleeMACS score and GRACE score were higher in bleeding group[88.00(66.00,103.00）μmol/L,21.00(15.00,27.00),161.00(135.00,187.00)]than those in nonbleeding group[67.00(56.00,79.00）μmol/L,9.00(7.00,18.00),139.00(120.00,160.00)](P<0.05),and the body mass index was lower in bleeding group[23.48 (22.89,24.61)kg/m~2]than that in non-bleeding group[24.49(23.60,25.85)kg/m~2](Z=-2.212,P=0.027).The AUCs of BleeMACS score and GRACE score for predicting bleeding during one-year DAPT after PCI were 0.749(95%CI:0.633-0.866,P<0.001)and 0.685(95%CI:0.555-0.814,P<0.001),with the sensitivities of 72.2%and 66.7%,and the specificities of 81.3%and 74.6%,respectively.The AUCs of two scores showed no significant differences(Z=0.065,P=0.435).Compared with GRACE score,NRI of BleeMACS score was 0.155(Z=0.640,P=0.519),and IDI was 0.015(Z=0.760,P=0.450).The DCA showed that BleeMACS score added more benefit than GRACE score in the threshold probability intervals of 1.8%to 4%and 5%to12%.Conclusion Both BleeMACS score and GRACE score can be used to predict bleeding during DAPT after PCI in STEMI patients,and BleeMACS score achieves more clinical benefit.更多还原