Risk prediction after myocardial infarction is often complex in older patients. The Global Registry of Acute Coronary Events (GRACE) model includes clinical parameters and age, but not frailty. We hypothesised that frailty would enhance the prognostic properties of GRACE. We performed a prospective observational cohort study in two independent cardiology units: the Royal Infirmary of Edinburgh, UK (primary cohort) and the South Yorkshire Cardiothoracic Centre, Sheffield, UK (external validation). The study sample included 198 patients ≥65 years old hospitalised with type 1 myocardial infarction (primary cohort) and 96 patients ≥65 years old undergoing cardiac catheterisation for myocardial infarction (external validation). Frailty was assessed using the Clinical Frailty Scale (CFS). The GRACE 2.0 estimated risk of 12-month mortality, Charlson comorbidity index and Karnofsky disability scale were also determined for each patient. Forty (20%) patients were frail (CFS ≥5). These individuals had greater comorbidity, functional impairment and a higher risk of death at 12 months (49% vs. 9% in non-frail patients, p < 0.001). The hazard of 12-month all-cause mortality nearly doubled per point increase in CFS after adjustment for age, sex and comorbidity (Hazard Ratio [HR] 1.90, 95% CI 1.47–2.44, p < 0.001). The CFS had good discrimination for mortality by Receiver Operating Characteristic (ROC) curve analysis (Area Under the Curve [AUC] 0.81, 95% CI 0.72–0.89) and enhanced the GRACE estimate (AUC 0.86 vs. 0.80 without CFS, p = 0.04). At existing GRACE thresholds, the CFS resulted in a Net Reclassification Improvement (NRI) of 0.44 (95% CI 0.28–0.60, p < 0.001), largely through reductions in risk estimates amongst non-frail patients. Similar findings were observed in the external validation cohort (NRI 0.46, 95% CI 0.23–0.69, p < 0.001). The GRACE score overestimated mortality risk after myocardial infarction in these cohorts of older patients. The CFS is a simple guided frailty tool that may enhance prediction in this setting. These findings merit evaluation in larger cohorts of unselected patients. Clinicaltrials.gov; NCT02302014 (November 26th 2014, retrospectively registered).

中文翻译：

---

GRACE评分对老年急性心肌梗死患者的衰弱评估及风险预测


对于老年患者来说，心肌梗死后的风险预测通常很复杂。全球急性冠脉事件登记 (GRACE) 模型包括临床参数和年龄，但不包括虚弱程度。我们假设虚弱会增强 GRACE 的预后特性。我们在两个独立的心脏病学单位进行了一项前瞻性观察队列研究：英国爱丁堡皇家医院（主要队列）和英国谢菲尔德南约克郡心胸中心（外部验证）。研究样本包括 198 名 ≥65 岁因 1 型心肌梗塞住院的患者（主要队列）和 96 名 ≥65 岁因心肌梗塞接受心导管插入术的患者（外部验证）。使用临床衰弱量表（CFS）评估衰弱程度。还确定了每位患者的 GRACE 2.0 12 个月死亡率估计风险、查尔森合并症指数和卡诺夫斯基残疾量表。四十名 (20%) 患者身体虚弱 (CFS ≥5)。这些人有更严重的合并症、功能障碍和 12 个月时更高的死亡风险（非虚弱患者为 49% vs. 9%，p < 0.001）。调整年龄、性别和合并症后，CFS 每增加一点，12 个月全因死亡率的风险几乎增加一倍（风险比 [HR] 1.90，95% CI 1.47–2.44，p < 0.001）。通过接受者操作特征 (ROC) 曲线分析（曲线下面积 [AUC] 0.81，95% CI 0.72–0.89），CFS 对死亡率具有良好的辨别力，并增强了 GRACE 估计（AUC 0.86 对比无 CFS 的 0.80，p = 0.04 ）。在现有 GRACE 阈值下，CFS 的净重分类改善 (NRI) 为 0.44（95% CI 0.28–0.60，p < 0.001），这主要是通过降低非体弱患者的风险估计来实现的。 在外部验证队列中也观察到类似的结果（NRI 0.46，95% CI 0.23–0.69，p < 0.001）。 GRACE 评分高估了这些老年患者心肌梗死后的死亡风险。 CFS 是一种简单的引导衰弱工具，可以增强这种情况下的预测。这些发现值得在更大的未经选择的患者群体中进行评估。临床试验.gov； NCT02302014（2014年11月26日，追溯注册）。