英国皇家布朗普顿和哈尔菲尔德医院Thomas F Lüscher团队研究了英国和瑞士人群中非ST段抬高急性冠状动脉综合征GRACE评分的性别特异性评估和再开发。2022年8月29日出版的《柳叶刀》杂志发表了这项成果。

全球急性冠状动脉事件登记（GRACE）2.0评分在以男性为主的患者人群中开发和验证。该研究旨在评估GRACE 2.0评分在非ST段抬高型急性冠状动脉综合征（NSTE-ACS）中的性别特异性表现，并制定一个改良评分（GRACE 3.0），以解释疾病特征的性别差异。

研究组评估了来自英国和瑞士的当代全国队列中420781名NSTE-ACS患者的GRACE 2.0评分。预测住院死亡率的机器学习模型由GRACE变量提供信息，并根据英格兰、威尔士和北爱尔兰386591名患者的性别分类数据开发（分为309083名[80.0%]患者的训练队列和77508名[20.0%]患者的验证队列）?。对来自瑞士的20727名患者进行了GRACE 3.0评分的外部验证。

2005年1月1日至2020年8月27日，英国400054名NSTE-ACS患者和瑞士20727名NSTE-ACS患者被纳入研究。在男性患者中，GRACE 2.0评分对住院死亡的鉴别良好（受试者操作特征曲线下面积[AUC]为0.86），而在女性患者中显著较低（0.82），组间差异显著。

GRACE 2.0评分低估了女性患者的住院死亡率风险，倾向于将其错误分层为低至中风险组，该评分不提示早期侵入性治疗。考虑到性别差异，在外部队列验证中，GRACE 3.0显示出优越的辨别力和良好的校准，男性患者AUC为0.91，女性患者AUC为0.87。GRACE 3.0将女性患者重新正确分类为高危组。

研究结果表明，GRACE 2.0评分具有有限的鉴别性能，并低估了NSTE-ACS女性患者的住院死亡率。GRACE 3.0评分在男性和女性中表现更好，减少了风险分层中的性别偏倚。

附：英文原文

Title: Sex-specific evaluation and redevelopment of the GRACE score in non-ST-segment elevation acute coronary syndromes in populations from the UK and Switzerland: a multinational analysis with external cohort validation

Author: Florian A Wenzl, Simon Kraler, Gareth Ambler, Clive Weston, Sereina A Herzog, Lorenz Rber, Olivier Muller, Giovanni G Camici, Marco Roffi, Hans Rickli, Keith A A Fox, Mark de Belder, Dragana Radovanovic, John Deanfield, Thomas F Lüscher

Issue&Volume: 2022-08-29

Abstract:

Background

The Global Registry of Acute Coronary Events (GRACE) 2.0 score was developed and validated in predominantly male patient populations. We aimed to assess its sex-specific performance in non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and to develop an improved score (GRACE 3.0) that accounts for sex differences in disease characteristics.

Methods

We evaluated the GRACE 2.0 score in 420781 consecutive patients with NSTE-ACS in contemporary nationwide cohorts from the UK and Switzerland. Machine learning models to predict in-hospital mortality were informed by the GRACE variables and developed in sex-disaggregated data from 386591 patients from England, Wales, and Northern Ireland (split into a training cohort of 309083 [80·0%] patients and a validation cohort of 77508 [20·0%] patients). External validation of the GRACE 3.0 score was done in 20727 patients from Switzerland.

Findings

Between Jan 1, 2005, and Aug 27, 2020, 400054 patients with NSTE-ACS in the UK and 20727 patients with NSTE-ACS in Switzerland were included in the study. Discrimination of in-hospital death by the GRACE 2.0 score was good in male patients (area under the receiver operating characteristic curve [AUC] 0·86, 95% CI 0·86–0·86) and notably lower in female patients (0·82, 95% CI 0·81–0·82; p<0·0001). The GRACE 2.0 score underestimated in-hospital mortality risk in female patients, favouring their incorrect stratification to the low-to-intermediate risk group, for which the score does not indicate early invasive treatment. Accounting for sex differences, GRACE 3.0 showed superior discrimination and good calibration with an AUC of 0·91 (95% CI 0·89–0·92) in male patients and 0·87 (95% CI 0·84–0·89) in female patients in an external cohort validation. GRACE 3·0 led to a clinically relevant reclassification of female patients to the high-risk group.

Interpretation

The GRACE 2.0 score has limited discriminatory performance and underestimates in-hospital mortality in female patients with NSTE-ACS. The GRACE 3.0 score performs better in men and women and reduces sex inequalities in risk stratification.

DOI: 10.1016/S0140-6736(22)01483-0

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01483-0/fulltext