RESUMO
In this work, we analyzed the prognostic significance of changes in hemoglobin during intensive care unit (ICU) stay in patients with acute coronary syndromes (ACS). We prospectively enrolled 591 patients (62 ± 14 years old, 73% male, 48% ST elevated myocardial infarction) free of blood cell transfusion or bleeding events. Changes in hemoglobin between admission and ICU discharge were obtained. The primary endpoint was death or hospitalization for MI within 6 months. Hemoglobin decreased from 13.65 ± 1.77 to 13.17 ± 1.74 g/dl, p < 0.0001 in the whole population. The end point was reached in 43 patients at a mean follow-up of 180 (range 2-180 days). A decrease in hemoglobin ≥0.9 g/dl (32% of the population) was associated with adverse clinical outcomes (HR 2.37, 95% CI (1.30-4.35), p = 0.005, respectively). In multivariate analysis, age >77 year-old (p = 0.0016), Killip class ≥2 (p = 0.009), anemia (p = 0.0064), decreased estimated glomerular filtration rate (p = 0.003), and hemoglobin decline ≥0.9 g/dl (p < 0.0001) were independently associated with outcome. Hemoglobin decline and anemia both provided additional prognostic information on top of the GRACE score, as demonstrated by a systematic improvement in model global fit, discrimination, and calibration. Hemoglobin decline is frequent during ICU stay in non-bleeding ACS patients. A decline in hemoglobin ≥0.9 g/dl identifies high-risk patients. Identification of these patients refines the prognostic value of the GRACE score.
Assuntos
Síndrome Coronariana Aguda/sangue , Anemia/sangue , Hemoglobinas/metabolismo , Hospitalização , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Anemia/diagnóstico , Anemia/mortalidade , Anemia/terapia , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Regulação para Baixo , Feminino , França , Humanos , Unidades de Terapia Intensiva , Estimativa de Kaplan-Meier , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/sangue , Infarto do Miocárdio/mortalidade , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de TempoRESUMO
AIMS: The present study was designed to build and validate a composite score based on the Global Registry of Acute Coronary Events (GRACE) score and B-type natriuretic peptide (BNP) concentrations to predict outcome in patients with acute coronary syndromes (ACS). METHODS: The GRACE risk score and BNP concentrations were obtained in a retrospective and a prospective cohort. A composite score including the GRACE score and BNP concentrations was first developed in a retrospective cohort of 248 patients with ACS and then validated in a prospective cohort of 575 patients. The primary outcome was 6-month death or myocardial infarction. RESULTS: End points were reached in 34 patients in the retrospective cohort and in 68 patients in the prospective cohort. Both higher BNP concentration and GRACE score were independently associated with outcome in the retrospective cohort (p=0.003 and p<0.0001). The composite score could be obtained as follows: GRACE+BNP/60. The use of the composite score increased the accuracy of the GRACE score, with an increase in the C statistic from 0.810 (0.727 to 0.892) to 0.822 (0.745 to 0.902) in the retrospective cohort and from 0.724 (0.657 to 0.791) to 0.750 (0.686 to 0.813) in the prospective cohort. Finally, 7% of patients in the prospective study population were reclassified from low to high risk or from high to low risk using this composite score. CONCLUSIONS: Plasma BNP levels refine the accuracy of the GRACE score. A comprehensive risk score, which includes BNP concentration and the GRACE risk score, might improve ACS risk stratification in clinical practice.
Assuntos
Síndrome Coronariana Aguda/diagnóstico , Peptídeo Natriurético Encefálico/sangue , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/mortalidade , Biomarcadores/sangue , Intervalo Livre de Doença , Humanos , Análise Multivariada , Infarto do Miocárdio/diagnóstico , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
BACKGROUND: Management of acute coronary syndromes in elderly patients is poorly defined. OBJECTIVE: To assess the impact of functional decline on all-cause mortality in elderly patients with acute coronary syndromes. METHOD: Clinical data, including the Global Registry of Acute Coronary Events score and assessment of functional status obtained by using the Katz scale, were prospectively collected on 272 patients 70 years or older hospitalized for acute coronary syndromes. All-cause mortality was assessed at 6 months, and longer term outcome data were obtained. RESULTS: Mean age of the patients was 78 years (SD, 6), and 58% were men. A total of 28% had functional decline. Six months after the index hospitalization, 38 patients had died. Another 29 patients died during a median follow-up of 611 days after the initial 6 months. Functional decline was associated with both 6-month (hazards ratio, 3.63; 95% CI, 1.91-6.88; P < .001) and long-term (hazards ratio, 2.69; 95% CI, 1.28-5.64; P = .009) outcomes. Functional decline remained associated with both 6-month and long-term outcomes in multivariate analysis and was systematically selected in the most predictive multivariate models for 6-month and long-term mortality. The multivariate model including the Global Registry of Acute Coronary Events score and functional decline was predictive of 6-month mortality, but the combination of functional decline and biological data was more predictive of long-term mortality than was a model combining functional decline and the Global Registry score. CONCLUSIONS: Functional decline in elderly patients with acute coronary syndromes is predictive of poor outcomes.