Use of risk stratification to identify patients with unstable angina likeliest to benefit from an invasive versus conservative management strategy.
Use of risk stratification to identify patients with unstable angina likeliest to benefit from an invasive versus conservative management strategy.
复制标题
使用风险分层来识别不稳定心绞痛患者最有可能从侵入性与保守性治疗策略中受益。
DOI：
10.1016/s0735-1097(01)01503-0
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发表时间：
2001
影响因子：
24
通讯作者：
Avorn,J
中科院分区：
文献类型：
--
作者：
Solomon,DH;Stone,PH;Glynn,RJ;Ganz,DA;Gibson,CM;Tracy,R;Avorn,J
目的：本研究旨在确定就诊时收集的患者特征是否可以确定哪些患者从立即冠状动脉造影和血运重建术中获益。背景：风险分层可以提供一种方法来确定哪些不稳定型心绞痛或非q波型心肌梗死（NQMI）患者最有可能从有创治疗策略中获益。方法：该分析基于一项随机对照试验的数据，该试验纳入了1473例不稳定型心绞痛或NQMI患者，这些患者被随机分配到早期有创或早期保守（医学）治疗策略。我们根据可能预测不良结果的临床变量的调整优势比，为每位患者构建了风险分层评分。我们根据风险评分对所有受试者进行分层，并研究每一层早期有创治疗策略的死亡率或心肌梗死（MI）率。结果最终的多变量模型包括年龄、就诊时ST段下降、就诊前合并心绞痛史和基线肌酸激酶- mb分数升高。尽管在两种治疗策略中，高风险评分较高的患者在42天和365天内的死亡率或心肌梗死发生率均有所增加（p < 0.001），但与保守治疗相比，高风险和极高风险类别患者的早期侵入性治疗与42天内的死亡率或心肌梗死发生率较低相关。在极低、低或中等风险类别的患者中，没有发现这种益处（风险类别和管理分配之间的相互作用p = 0.03）。结论风险分层可能是识别不稳定型心绞痛或NQMI患者最可能从早期有创治疗中获益的有效方法。选择性地使用早期侵入性治疗对降低高风险患者的发病率和死亡率有重大影响，但对低风险患者可能没有必要。
OBJECTIVESThis study was designed to determine whether patient characteristics collected at presentation can identify which patients benefit from immediate coronary angiography and revascularization.BACKGROUNDRisk stratification may offer a method for identifying which patients with unstable angina or non–Q-wave myocardial infarction (NQMI) are likeliest to benefit from invasive management strategies.METHODSThe analysis was based on data from a randomized controlled trial that enrolled 1,473 patients presenting with unstable angina or NQMI who were randomly assigned to an early invasive or early conservative (medical) management strategy. We constructed a risk-stratification score for each patient based on adjusted odds ratios for clinical variables likely to predict adverse outcomes. We stratified all trial subjects by their risk scores and studied the rates of death or myocardial infarction (MI) of the early invasive management strategy in each stratum.RESULTSThe final multivariate model included older age, ST segment depression on presentation, history of complicated angina before presentation, and elevation in baseline creatine kinase-MB fraction. Although patients with a higher risk score had an increased rate of death or MI within 42 days and 365 days (p < 0.001) in both management strategies, early invasive management for patients in the high and very high risk categories was associated with a lower rate of death or MI within 42 days compared with conservative management. No such benefit was seen in patients in the larger group of patients in the very low, low or moderate risk categories (p = 0.03 for the interaction between risk category and management assignment).CONCLUSIONSRisk stratification may be an effective method for identifying those patients with unstable angina or NQMI most likely to benefit from early invasive management. Selective use of early invasive management can have a substantial impact in reducing morbidity and mortality in higher risk patients, but may not be warranted in lower risk patients.