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Predictive value of the novel risk score BETTER (BiomarkErs and compuTed Tomography scorE on Risk stratification) for patients with unstable angina

Prädiktiver Wert des neuen Risikoscores BETTER (BiomarkErs and compuTed Tomography scorE on Risk stratification) bei instabiler Angina pectoris

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Abstract

Background

The Braunwald classification and TIMI (Thrombolysis In Myocardial Infarction) risk score are used to stratify cardiovascular risk in patients with unstable angina (UA). However, these scores have a limited capacity in the practice of cardiology.

Objectives

This study sought to develop a new score, based on blood biomarkers and coronary computed tomographic angiography (CCTA) characteristics, for patients with UA.

Patients and methods

The study group consisted of 201 patients with confirmed UA. Follow-up time was 1 year; major adverse cardiac events (MACEs) included cardiovascular death, recurrent acute coronary syndrome (ACS), and re-admission to hospital. Blood biomarkers including high-sensitivity cardiac troponin T (Hs-cTnT), high-sensitivity C-reactive protein (Hs-CRP), myeloperoxidase (MPO) N-terminal pro-B-type natriuretic peptide (NT-proBNP), and ischemia-modified albumin (IMA) were measured. CCTA characteristics such as stenosis, plaque, epicardial fat volume (EFV), and calcification were evaluated. After analysis of relationships, the novel risk BETTER (BiomarkErs and compuTed Tomography scorE on Risk stratification) score was assessed in 201 patients.

Results

In all, 25 MACEs (12.44 %) occurred: 2 cardiac deaths (1.00 %), 13 non-fatal myocardial infarctions (6.47 %), 10 recurrent ACS and re-admission in hospital (4.96 %). Serum levels of MPO, NT-proBNP, Hs-TnT, Hs-CRP, and IMA were correlated with MACEs (r = 0.20, r = 0.40, r = 0.18, r = 0.24, p < 0.01, respectively; r = 0.12, p > 0.05). CCTA characteristics of stenosis, plaque, EFV, and calcification were significantly correlated with MACEs (r = 0.53, r = 0.57, r = 0.42, and r = 0.52, all p < 0.01 respectively) and were significantly higher in the MACEs group than in the non-MACEs group. Thus, a new risk score was created combining biomarkers and CCTA statistics into a Cox multivariable for risk prediction of 1-year MACEs: BETTER risk score = MPO•0.1 + Hs-TnT•50 + Hs-CRP•0.4 + stenosis•9 + plaque•13 + EFV•0.2.

The areas under the curve (AUC) for the prediction by Hs-cTnT, Hs-CRP, and MPO were 0.536 (95 % CI 0.409–0.662), 0.745 (95 % CI 0.641–0.850), and 0.650 (95 % CI 0.541–0.760), respectively. The AUC for the prediction of CCTA characteristics of stenosis, plaque, and EFV were 0.905 (95 % CI 0.860–0.950), 0.912 (95 % CI 0.867–0.957), and 0.835 (95 % CI 0.752–0.917), respectively. In addition, the AUC was 0.621 (95 % CI 0.492–0.750) for the Braunwald classification and 0.680 (95 % CI 0.559–0.801) for the TIMI score. The AUC for the BETTER risk score was 0.937 (95 % CI 0.902–0.972).

Conclusion

The BETTER risk score is new tool specifically developed for patients with UA. The score displays higher prediction accuracy in terms of discrimination and calibration than other currently available scores for risk stratification.

Zusammenfassung

Hintergrund

Um Patienten mit instabiler Angina pectoris (AP) nach kardiovaskulärem Risiko zu stratifizieren werden die Braunwald-Klassifikation und der TIMI(Thrombolysis In Myocardial Infarction)-Risikoscore verwendet. Doch in der Praxis sind beide nur begrenzt einsetzbar.

Ziele

Entwickelt werden sollte ein neuer, auf Serum-Biomarkern und CCTA(„koronare Angio-Computertomographie)-Parametern basierender Score für Patienten mit instabiler AP.

Patienten und Methoden

Das Studienkollektiv bestand aus 201 Patienten mit diagnostizierter instabiler AP. Die Follow-up-Zeit betrug 1 Jahr. Zu schwerwiegenden unerwünschten kardialen Ereignissen („major adverse cardiac events“, MACEs) zählten kardiovaskulär bedingter Tod, rezidivierendes akutes Koronarsyndrom („acute coronary syndrome“, ACS) und Wiederaufnahme in die Klinik. Gemessen wurden Serum-Biomarker, u. a. hoch sensitives kardiales Troponin T (Hs-cTnT), hoch sensitives C-reaktives Protein (Hs-CRP), Myeloperoxidase (MPO), N-terminales pro-B-Typ natriuretisches Peptid (NT-proBNP) und ischämiemodifiziertes Albumin (IMA) sowie CCTA-Parameter, wie Stenosen, Plaque, Volumen des epikardialen Fettgewebes (EFV) und Kalzifizierungen. Nach Analyse der Beziehungen wurde der BETTER(BiomarkErs and compuTed Tomography scorE on Risk stratification)-Score bei allen Patienten bestimmt.

Ergebnisse

Insgesamt kam es zu 25 MACEs (12,44 %): 2 kardial bedingte Todesfälle (1 %), 13 nichtletale Myokardinfarkte (6,47 %), 10 rezidivierende ACS und Wiederaufnahmen in die Klinik (4,96 %). Serumkonzentrationen von MPO, NT-proBNP, Hs-TnT, Hs-CRP und IMA wurden mit den MACEs korreliert (r = 0,20, r = 0,40, r = 0,18, r = 0,24, p < 0,01 bzw. r = 0,12, p > 0,05). Es zeigten sich signifikante Korrelationen zwischen den CCTA-Parametern Stenose, Plaque, EFV und Kalzifizierungen und MACEs (r = 0,53, r = 0,57, r = 0,42 und r = 0,52, jeweils p < 0,01), in der MACEs-Gruppe waren sie signifikant ausgeprägter als in der Gruppe ohne MACE. Unter Verwendung von Biomarkern und CCTA-Statistiken wurde in einer multivariaten Cox-Analyse ein neuer Risikoscore für die Prädiktion des MACE-Einjahresrisikos generiert, der Score BETTER MPO•0,1 + Hs-TnT•50 + Hs-CRP•0,4 + Stenose•9 + Plaque•13 + EFV•0,2.

Die Flächen unter der Kurve (AUC) für die Prädiktion mittels Hs-cTnT, Hs-CRP bzw. MPO betrugen 0,536 (95 %-KI 0,409–0,662), 0,745 (95 %-KI 0,641–0,850) bzw. 0,650 (95 %-KI 0,541–0,760), die AUC für die Prädiktion der CCTA-Parameter Stenose, Plaque und EFV 0,905 (95 %-KI 0,860–0,950), 0,912 (95 %-KI 0,867–0,957) und 0,835 (95 %-KI 0,752–0,917). Die AUC für die Braunwald-Klassifikation war 0,621 (95 %-KI 0,492–0,750), für den TIMI-Score 0,680 (95 %-KI 0,559–0,801) und für den BETTER-Risikoscore 0,937 (95 %-KI 0,902–0,972).

Fazit

Der BETTER-Risikoscore ist ein neues, speziell für IA-Patienten entwickeltes Tool. Hinsichtlich Diskrimination und Kalibrierung hat er eine höhere prädiktive Genauigkeit gezeigt als andere zzt. verfügbare Scores zur Risikostratifikation.

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Compliance with ethical guidelines

Conflict of interest. Y. Xia, Y. Xia, K. Xu, Y. Ma, D. Pan, T. Xu, L. Lu and D. Li state that there are no conflicts of interest. All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

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Authors and Affiliations

  1. Institute of Cardiovascular Disease Research, Xuzhou Medical College, 84 West Huaihai Road, 221006, Xuzhou, Jiangsu, China

    Y. Xia, D. Pan, T. Xu & D. Li MD, PhD

  2. Department of Radiology, Affiliated Hospital of Xuzhou Medical College, Xuzhou, Jiangsu, China

    K. Xu & L. Lu

  3. Department of Cardiology, Affiliated Hospital of Xuzhou Medical College, Xuzhou, Jiangsu, China

    Y. Xia & Y. Ma

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  1. Y. Xia
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Correspondence to D. Li MD, PhD.

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Yan Xia and Yong Xia contributed equally to this work.

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Xia, Y., Xia, Y., Xu, K. et al. Predictive value of the novel risk score BETTER (BiomarkErs and compuTed Tomography scorE on Risk stratification) for patients with unstable angina. Herz 40 (Suppl 1), 43–50 (2015). https://doi.org/10.1007/s00059-014-4141-y

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