Tesis

Modifikasi skor GRACE terhadap Kejadian MajorAdverse Cardiovascular Events pada Pasien Infark MiokardAkut di RS Cipto Mangunkusumo = Modification of the GRACE Score for Predicting Major Adverse Cardiovascular Events in Patients with Acute Myocardial Infarction at Cipto Mangunkusumo Hospital.

Latar Belakang: Skor GRACE (Global Registry of Acute Coronary Events)direkomendasikan sebagai alat stratifikasi risiko pada infark miokard akut (IMA) untukmemprediksi kejadian kardiovaskular mayor (major adverse cardiovascularevents/MACE) selama masa perawatan, namun belum memasukkan evaluasi fungsiventrikel kanan. Parameter fungsi ventrikel kanan seperti Right Ventricular GlobalLongitudinal Strain (RV GLS), Tricuspid S’ peak velocity (TVS’), serta rasio TricuspidAnnular Plane Systolic Excursion terhadap systolic Pulmonary Artery Pressure(TAPSE/sPAP) telah menunjukkan nilai prognostik jangka panjang terhadap kejadianMACE, meskipun data mengenai kemampuan prediksi jangka pendeknya masih terbatas.Tujuan: Menilai kemampuan diskriminatif RV GLS, TVS’, dan rasio TAPSE/sPAP, sertakombinasinya dengan skor GRACE, terhadap kejadian MACE selama rawat inap padapasien IMA di di Rumah Sakit Cipto Mangunkusumo (RSCM) Jakarta.Metode: Penelitian ini merupakan studi kohort prospektif yang melibatkan pasien IMAyang dirawat di RSCM pada periode September hingga Desember 2025, dengan metodepengambilan sampel secara konsekutif. Data yang dikumpulkan mencakup karakteristikklinis pasien, skor GRACE saat admisi, serta pemeriksaan ekokardiografi dalam 36 jampertama perawatan, diikuti dengan pemantauan kejadian MACE hingga akhir masa rawatinap. Analisis statistik dilakukan menggunakan kurva ROC untuk menilai area under thecurve (AUC) dan menentukan nilai cut-off optimal, serta regresi logistik biner padakombinasi skor GRACE dengan parameter strain.Hasil: Dari 88 pasien IMA, 43,2% mengalami MACE, terutama gagal jantung akut(86,84%). Dominasi kasus adalahh IMA-EST (63,63%) dan dengan distribusi kategoririsiko dari skor GRACE yang lebih merata dibandingkan dengan kasus IMA-EST. Pada ujitunggal, RV GLS menunjukkan AUC tertinggi 0,899 (IK 95%: 0,829 – 0.970; p 0.000) dancut-off-16,45% (sensitivitas 92,1% dan spesifisitas 78%), diikuti rasio TAPSE/sPAP 0,883(IK 95%: 0,799 – 0,968; p 0.000) dan cut-off 0,585 mm/Hg (sensitivitas 81,6% danspesifisitas 92%), dan TVS’ memiliki performa diskriminasi kurang baik dengan AUC0,694 (IK 95%: 0,581 – 0,808; p 0.002) dan cut-off 9,05 cm/s (sensitivitas 47.4% danspesifisitas 94%). Kombinasi dengan tingkat diskriminasi tertinggi adalah skor GRACEdengan RV GLS, TVS’, dan rasio TAPSE/sPAP AUC 0,928 (IK 95%: 0,877 – 0,980; p0,000; sensitivitas 92,1%; spesifisitas 82%).Simpulan: RV GLS dan rasio TAPSE/sPAP memiliki tingkat diskriminasi baik dalammemprediksi MACE selama perawatan. Modifikasi skor GRACE terbaik, didapatkan padakombinasi skor GRACE dengan RV GLS, TVS’, dan rasio TAPSE/sPAP.
Kata kunci: infark miokard akut, skor GRACE, RV GLS, TAPSE/sPAP, TVS’


Background: The Global Registry of Acute Coronary Events (GRACE) score isrecommended as a risk stratification tool in acute myocardial infarction (AMI) to predictin-hospital major adverse cardiovascular events (MACE). However, it does notincorporate assessment of right ventricular (RV) function. RV functional parameters,including Right Ventricular Global Longitudinal Strain (RV GLS), tricuspid annularsystolic peak velocity (TVS’), and the ratio of Tricuspid Annular Plane Systolic Excursionto systolic Pulmonary Artery Pressure (TAPSE/sPAP), have demonstrated long-termprognostic value for MACE, although data regarding their short-term predictiveperformance remain limited.Objective: To evaluate the discriminative ability of RV GLS, TVS’, and the TAPSE/sPAPratio, as well as their combination with the GRACE score, for predicting in-hospital MACEin patients with AMI at Cipto Mangunkusumo Hospital (RSCM), Jakarta.Methods: This was a prospective cohort study involving consecutive patients with AMIadmitted to RSCM between September and December 2025. Collected data includedpatient clinical characteristics, GRACE score at admission, and echocardiographicassessment within the first 36 hours of hospitalization. Patients were followed untildischarge to identify the occurrence of MACE. Statistical analysis included receiveroperating characteristic (ROC) curve analysis to determine the area under the curve(AUC) and optimal cut-off values, as well as binary logistic regression for combinations ofthe GRACE score with RV functional parameters.Results: Among 88 patients with AMI, 43.2% experienced MACE, predominantly acuteheart failure (86.8%). ST-segment elevation myocardial infarction (STEMI) was the mostcommon presentation (63.6%), with a relatively balanced distribution of GRACE riskcategories compared with non-ST-segment elevation myocardial infarction. Onunivariable analysis, RV GLS demonstrated the highest discriminative performance withan AUC of 0.899 (95% CI: 0.829–0.970; p < 0.001) and an optimal cut-off of −16.45%(sensitivity 92.1%, specificity 78%). This was followed by the TAPSE/sPAP ratio with anAUC of 0.883 (95% CI: 0.799–0.968; p < 0.001) and a cut-off of 0.585 mm/mmHg(sensitivity 81.6%, specificity 92%). TVS’ showed lower discriminative ability, with anAUC of 0.694 (95% CI: 0.581–0.808; p = 0.002) and a cut-off of 9.05 cm/s (sensitivity47.4%, specificity 94%). The highest discriminative performance was achieved by thecombined model of the GRACE score with RV GLS, TVS’, and TAPSE/sPAP, yielding anAUC of 0.928 (95% CI: 0.877–0.980; p < 0.001), with a sensitivity of 92.1% and specificityof 82%.Conclusions: RV GLS and the TAPSE/sPAP ratio demonstrated good discriminativeability for predicting in-hospital MACE in patients with AMI. The optimal modification ofthe GRACE score was achieved by combining it with RV GLS, TVS’, and the TAPSE/sPAPratio, resulting in improved predictive performance for in-hospital MACE.
Key words: acute myocard infarction, GRACE score, RV GLS, TAPSE/sPAP, TVS’