【作者】 杨健；

【导师】 赵慧颖；

【作者基本信息】 吉林大学 ， 临床医学， 2009， 硕士

【摘要】 研究GRACE和TIMI危险积分对ST段抬高型心肌梗死患者预后的评估价值。回顾性分析112例2007年1月至2008年1月在我院心内科住院的ST段抬高型心肌梗死患者的临床资料,分别进行GRACE、TIMI危险评分,各将患者分为低危、中危、高危3组,随访患者发病30天内及出院后1年生存情况、发生主要心血管不良事件(心脏呼吸骤停、室速及室颤等严重高危心律失常、心源性休克、急性左心衰等)的情况,计算病死率和主要心血管不良事件(major adverse cardiac events,MACE)的发生率。比较两种评分方法下各组间上述指标的差异,并绘制ROC曲线,通过曲线下面积比较GRACE及TIMI危险积分对患者死亡率、主要心血管事件发生率预测的准确度。两种评分方法下,低危、中危、高危三组患者间30天及1年内病死率、MACE发生率均有显著性差异; GRACE危险积分各时间段病死率、MACE发生率对应的ROC曲线面积更大。两种评分方法均可为临床上的ST段抬高型心肌梗死患者进行危险分层;与TIMI危险积分相比,GRACE危险积分评估患者预后的准确度更高。更多还原

【Abstract】 Coronary atherosclerotic heart disease is a common disease in cardiology department. Acute myocardial infarction is usually serious, so it should be paid much attention generally by the doctors, but it is still necessary to make a risk stratification for the patients who suffer from this kind of disease. Because the GRACE/TIMI risk scores are simple and easy to do. They can give a clinical evaluation at a short time when the patient was admission (even in emergency). As a patient whose risk score was high, he (or she) should be paid more attention by the doctors. For example, he (or she)should be made a percutanneous coronary intervention as quickly as possible, more length of hospital stay, standard pharmacologic treatments, and so on. There have been much paper to prove that: the risk score has a guidance direction to the prognostic of the non ST-segment elevation myocardial infarction.It means that following the GRACE/TIMI risk scores raising, the mortality rate and MACE proportion of patient was increasing.Some studies showed that the TIMI risk score was associated with The extent of coronary artery stenosis, the range or character of pathological changes of the coronary.It means that if a patient was divided into the higher risk group,his coronay artery stenosis would be more serious, the range of pathological changes would be wider and the character would be more serious.There is no systemic study about the ST-segment elevation myocardial infarction. The area of infarction,circulate supply situation,if the patient can go to hospital in time, is the major factors that can effect the prognostic.But the area of infarction , circulate supply situation should be cleared by PCI.The electrocardiogram and elevated cardiac troponin can not reflect the serious degree of the myocardial infarction.We want to estimate the prognosis of the patient suffered from STEMI by the GRACE/TIMI risk scores, so that we can provide some reference for the doctors.Objective: Study the predictive value of GRACE/TIMI risk score to the prognostic of ST-segment elevation myocardial infarction.Methods: we studied 112 patients admitted to our cardiologic department with ST-segment elevation myocardial infarction who accept percutannous coronary intervention in January 2007 to January 2008.The diagnosis of AMI should accord with the standard drew up by European Society of Cardiology in 2000: typical clinical syndrome,the ST-segment deviation in electrocardiogram and elevated cardiac biomarkers, excluding the patients with serious organ dysfunctions(for example: serious infection, malignant tumor, the live and the kidney failure , cerebral vascular accident and so on).There are total 112 patients,75 males and 37 females.(age: 62.15±12.27). Retrospective all the patients’database, for each patient, the GRACE/TIMI were calculated. The GRACE risk score contains 8 factors: age, heart rate, systolic blood pressure, creatine, Killip’s classification, cardiac arrest at admission, increased cardiac markers, ST-segment deviation.The range of the risk score is from 0 to 372.We divided the patients into 3 groups by the GRACE risk score when they were in admission: low risk group(0-133), medium risk group (134-200) and high risk group (>200).There are 7 factors in the TIMI risk score: age≥65years,≥3 factors about coronary heart disease(hypertension, diabetes mellitus, hyperlipidemia, smoking history), The extent of coronary artery stenosis≥50% through coronary angiography confirmed, ST-segment deviation,≥2 episode rest angina pectors in 24 hours, use of aspirin in last 7 days, elevated cardiac markers.We divided the patients into 3 groups: low risk group(0-2), medium risk group (3-5) and high risk group (>5).Calculate the mortality and MACE(Cardiac respiratory arrest, ventricular tachycardia and ventricular fibrillation and other high risk of serious arrhythmia, cardiogenic shock, acute left heart failure, etc) occurs rate at 30days and 1 year. Compare the result of significant difference between the two risk scores. The best predict accuracy for mortality or MACE occurring rate at 30 days and at 1 year was evaluated by the area under ROC curve.Results: 1、This paper included 112 STEMI patients, aged 62.15±12.27 years old, heart rate 79.58±11.69 p/m, systolic blood pressure 131.9±27.8mmHg, creatinine 0.99±0.34mg/dl. 2、We divided the patients into 3 groups by the GRACE risk score,39 cases in low-risk group, 51 cases in the medium- risk group and 22 cases in high-risk group; by the TIMI risk score, 35 cases in the low-risk group, 56 cases in the medium-risk group and 21 cases in the high-risk group. 3、The mortality and MACE occurring rate within 30 days and 1 year was significantly increased with the GRACE risk score increased among the three groups, the difference was statistically significant; by the TIMI risk score, the mortality within 30 days of the high-risk group and the medium-risk group was significantly higher than the low-risk group, but there was no significant difference between the high-risk group and the medium-risk group. The MACE occurring rate within 30 days and the mortality and MACE occurring rate within 1 year was significantly increased with the TIMI risk score increased among the three groups, the difference was statistically significant. 4、Compared with the TIMI risk score, the mortality and MACE occurring rate at each time period of GRACE risk score was greater according to the area under the ROC curve, which suggests that the predictive value of the GRACE risk score was better than the TIMI risk score for the prognostic of the patient with STEMI..Conclusions: There are significant differences among the 3 groups in either GRACE risk score or TIMI risk score, it means that both the two risk scores can calculate the risk stratification for the patient with the ST-segment elevation myocardial infarction.The area under the curve of GRACE risk score is larger than that of the TIMI risk score, so we think the prective value of the GRACE risk score is better than TIMI risk score.更多还原