Jung varijabla u predikciji jednogodišnjeg mortaliteta i akutne srčane slabosti kod pacijenata sa akutnim koronarnim sindromom

Abstract

Uvod: Pravovremena i pouzdana stratifikacija rizika pacijenata sa akutnim ST eleviranim infarktom miokarda (STEMI) je važna zbog adekvatnog zbrinjavanja ovih bolesnika. Primarna perkutana koronarna intervencija (pPCI) je dovela do značajnog poboljšanja ishoda pacijenata sa STEMI, a time moguće i do promene prediktivne važnosti različitih faktora rizika. Jung variabla je jednostavan klinički indeks rizika koji se koristi tokom inicijalne prezentacije pacijenata. Pokazana je prediktivna vrednost Jung varijable za hospitalni mortalitet pacijenata sa STEMI lečenih fibrinolitičkom terapijom, dok uloga Jung varijable u dugoročnoj prognozi pacijenata lečenih putem pPCI nije razjašnjena. Cilj: Dokazati prediktivni značaj i odrediti najbolju vrednost Jung varijable u predviđanju jednogodišnjeg neželjenog kliničkog ishoda kod pacijenata sa STEMI lečenih pPCI, kao i dokazati njenu validnost na nezavisnoj populaciji. Metode: Sprovedena je prospektivna studija praćenja pacijenata sa STEMI lečenih pPCI tokom godinu dana; primarna studija je sprovedena u Institutu za kardiovaskularne bolesti Vojvodine (IKVBV), a validaciona u Vojnomedicinskoj akademiji (VMA). Ishodi studije: smrtni ishod, akutna srčana insuficijencija (AHF) i zbirni neželjeni ishod. Jung varijabla je računata prema formuli: sistolni krvni pritisak / (srčana frekvencija × godine života) × 100. Prediktivna vrednost Jung variable i prethodno etabliranih skorova rizika TIMI, PAMI i Zwolle je evaluiarana adekvatnim statističkim metodama. Rezultati: Od 647 pacijenata uključenih u primarnu studiju, umrlo je 70 (10.8%), dok je AHF imalo 42 (6.5%); od 418 pacijenata uključenih u validacionu studiju umrlo je 33 (7.9%), a 52 (12.4%) pacijenta je imalo AHF. U primarnoj studiji Jung variabla je bila prediktor smrtnog ishoda i zbirnog neželjenog ishoda, dok je u validacionoj studiji Jung varijabla bila nezavisni prediktor nastanka AHF (p<0.01). Za mortalitet, Jung variabla <= 2.35 je imala sensitivnost 74.3% i specifičnost 77.3%. U primarnoj studiji, C-statistike i 95% interval poverenja Jung varijable za jednogodišnji mortalitet i zbirni neželjeni ishod su bile dobre (0.784 (0.750-0.815) i 0.764 (0.729-0.796)) i poredive sa TIMI, PAMI i Zwolle skorovima (p>0.05). C-statistika za predikciju AHF i zbirnog neželjenog ishoda u validacionoj studiji je bila dobra (0.732 (0.655-0.809) i 0.721 (0.655-0.788)), ali manja u odnosu na ostale ispitivane skorove (p<0.01). Zaključak: Jung varijabla je nezavisni prediktor jednogodišnjeg smrtnog ishoda i zbirnog neželjenog ishoda pacijenata sa STEMI lečenih pPCI u IKVBV i nezavisni prediktor AHF u validacionoj studiji. Jung varijabla, TIMI, PAMI i ZWOLLE skorovi imaju dobar i porediv diskriminatorni kapacitet za sve praćene ishode u primarnoj studiji, dok je u validacionoj studiji Jung varijabla imala dobar diskriminatorni kapacitet za AHF i zbirni neželjeni ishod, ali manji u odnosu na ostale ispitivane skorove.

Alternate abstract:

Background: Accurate eary risk stratification of patients with ST-elevation myocardial infarction (STEMI) is important in the management of this patients. Primary percutaneous coronary intervention (pPCI) in patients with STEMI has improved the outcome significantly and might have changed the relative contribution of different risk factors. Jung variable is a simple clinical risk index, designed to be used at initial presentation. It is predictive of in hospital mortality in STEMI patients treated with fibrinolysis, but it's long term predictive power in patients treated with pPCI is not elucidated. Aim: To determine the prognostic accuracy and cut off value of Jung variable for one year clinical outcomes in STEMI patients treated with pPCI, and to validate it in independent STEMI patients. Methods: Two prospective studies of consecutive patients treated with pPCI were conducted; primary study in Institute of Cardiovascular diseases of Vojvodina and validation study in Military medical academy. One-year clinical outcomes (all-cause mortality, acute heart failure (AHF) and combined end point) were assessed. The Jung variable was calculated using the equation: systolic blood/ (heart rate×age)×100. The predictive value of Jung variable and previously established scores TIMI, PAMI, and Zwolle were evaluated with adequate statistical analyses. Results: Out of 647 patients 70 (10.8%) died and 42 (6.5%) had AHF in primary, while out of 418 patients 33 (7.9%) died and 52 (12.4%) had AHF in validation study. In primary study Jung variable was independent predictor of mortality and combined end point, while it was independent predictor of AHF in validation study (p<0.01). Jung variable <= 2.35 had sensitivity 74.3% and specificity 77.3% for mortality. In a primary study, C-statistic and 95% confidence intervals of Jung variable for one-year mortality and for combined end point were well (0.784 (0.750-0.815) and 0.764 (0.729-0.796), respectively) and comparable to TIMI, PAMI and Zwolle risk score (p>0.05). C-statistic for predicting one-year AHF and combined clinical endpoint in a validation study was well (0.732 (0.655-0.809) and 0.721 (0.655-0.788), respectively), but lower than other risk scores (p<0.01). Conclusion: The Jung variable was independent predictor of one year mortality and combined end point in primary study STEMI patients treated with pPCI and independent predictor of AHF in validation study. The Jung variable, TIMI, PAMI, and Zwolle risk scores performed well and comparable for all clinical outcomes in primary, while in a validation study Jung variable performed well for AHF and combined end point, but significantly lower than other risk scores.