Incremental Prognostic Value of the Incorporation of Clinical Data Into Coronary Anatomy Data in Acute Coronary Syndromes: SYNTAX-GRACE Score

Abstract Background: When performing coronary angiography in patients with acute coronary syndrome (ACS), the anatomical extent of coronary disease usually prevails in the prognostic reasoning. It has not yet been proven if clinical data should be accounted for in risk stratification together with anatomical data. Objective: To test the hypothesis that clinical data increment the prognostic value of anatomical data in patients with ACS. Methods: Patients admitted with objective criteria for ACS and who underwent angiography during hospitalization were included. Primary outcome was defined as in-hospital cardiovascular death, and the prognostic value of the SYNTAX Score (anatomical data) was compared to that of the SYNTAX-GRACE Score, which resulted from the incorporation of the GRACE Score into the SYNTAX score. The Integrated Discrimination Improvement (IDI) was calculated to evaluate the SYNTAX-GRACE Score ability to correctly reclassify information from the traditional SYNTAX model. Results: This study assessed 365 patients (mean age, 64 ± 14 years; 58% male). In-hospital cardiovascular mortality was 4.4%, and the SYNTAX Score was a predictor of that outcome with a C-statistic of 0.81 (95% CI: 0.70 - 0.92; p < 0.001). The GRACE Score was a predictor of in-hospital cardiac death independently of the SYNTAX Score (p < 0.001, logistic regression). After incorporation into the predictive model, the GRACE Score increased the discrimination capacity of the SYNTAX Score from 0.81 to 0.92 (95% CI: 0.87 - 0.96; p = 0.04). Conclusion: In patients with ACS, clinical data complement the prognostic value of coronary anatomy. Risk stratification should be based on the clinical-anatomical paradigm, rather than on angiographic data only.

摘要 背景：针对急性冠状动脉综合征（ACS）患者开展冠状动脉造影时，临床预后判断通常仅以冠状动脉病变的解剖累及范围为依据。目前尚不清楚是否应将临床数据与解剖学数据一同纳入风险分层评估。目的：验证临床数据可提升急性冠状动脉综合征（ACS）患者解剖学数据预后价值这一假说。方法：本研究纳入符合ACS客观诊断标准、且住院期间接受冠状动脉造影的患者。以住院期间心血管死亡为主要研究终点，对比仅基于解剖学数据的SYNTAX评分（SYNTAX Score）与整合GRACE评分（GRACE Score）后的SYNTAX-GRACE评分的预后价值。通过计算综合判别改善指数（IDI），评估SYNTAX-GRACE评分对传统SYNTAX模型的信息重分类准确性。结果：本研究共纳入365例患者，平均年龄为64±14岁，男性占比58%。住院期间心血管死亡率为4.4%；SYNTAX评分对该终点具有预测价值，C统计量为0.81（95%置信区间：0.70~0.92；p<0.001）。经logistic回归分析显示，GRACE评分可独立于SYNTAX评分预测住院期间心脏死亡事件（p<0.001）。将GRACE评分整合至预测模型后，SYNTAX评分的判别能力从0.81提升至0.92（95%置信区间：0.87~0.96；p=0.04）。结论：对于ACS患者，临床数据可补充冠状动脉解剖学特征的预后评估价值。风险分层应基于临床-解剖学联合评估模式，而非仅依赖血管造影数据。