Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors

Shiyovich, Arthur; Ovdat, Tal; Klempfner, Robert; Beigel, Roy; Halabi, Majdi; Shiran, Avinoam; Skalsky, Keren; Porter, Avital; Orvin, Katia; Kornowski, Ran; Eisen, Alon

doi:10.1016/j.jjcc.2021.10.019

Cited by 6 publications

(6 citation statements)

References 38 publications

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“…However, some previous studies reported that the inverse association of the number of SMuRFs with mortality risk persisted even after multivariate adjustment, which might be related to inadequate control of residual confounding [ 10 , 29 ]. Most recently, the SWEDEHEART study, a large prospective cohort enrolled 62,048 patients with first STEMI in Sweden, found that the association became neutral after adjusting for pharmacotherapy prescription at discharge (statin, ACEI/ARB, and β-blocker) [ 7 ].…”

Section: Discussionmentioning

confidence: 99%

Number of standard modifiable risk factors and mortality in patients with first-presentation ST-segment elevation myocardial infarction: insights from China Acute Myocardial Infarction registry

Gao

Yang

et al. 2022

BMC Med

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Background Recent publications reported a paradoxical finding that there was an inverse association between the number of standard modifiable risk factors (SMuRFs; smoking, hypertension, diabetes, and hyperlipidemia) and mortality in patients with myocardial infarction. However, the current evidence is only limited to those highly developed countries with advanced medical management systems. Methods The China Acute Myocardial Infarction registry is a prospective observational study including patients with acute myocardial infarction from three-level hospitals across 31 administrative regions throughout mainland China. A total of 16,228 patients with first-presentation ST-elevation myocardial infarction (STEMI) admitted to hospitals from January 2013 to September 2014 were enrolled in the current analysis. Cox proportional hazard models adjusting for baseline characteristics, clinical profiles at presentation, and in-hospital treatments were used to assess the association of the number of SMuRFs with all-cause mortality at 30 days after STEMI presentation. Results A total of 1918 (11.8%), 11,503 (70.9%), and 2807 (17.3%) patients had 0, 1–2, and 3–4 SMuRFs at presentation, respectively. Patients with fewer SMuRFs were older and more likely to be females, experienced longer pre-hospital delays, and were less likely to receive primary percutaneous coronary intervention and evidence-based medications. Compared with those without any SMuRF, patients with 1–2 SMuRFs and 3–4 SMuRFs were associated with an HR of 0.74 (95% CI, 0.63–0.87) and 0.63 (0.51–0.77) for all-cause mortality up to 30 days in the unadjusted model (Ptrend < 0.0001). However, after multivariate adjustment, the number of SMuRFs was positively associated with increased mortality risk (HR for 1–2 SMuRFs, 1.15 [0.95–1.39]; HR for 3–4 SMuRFs, 1.31 [1.02–1.68]; Ptrend = 0.03), and the association was only significant among patients admitted to hospitals beyond 12 h from onset (HR for 1–2 SMuRFs, 1.39 [1.03–1.87]; HR for 3–4 SMuRFs, 2.06 [1.41–3.01]) but not their counterparts (Pinteraction = 0.01). Conclusions The increased crude mortality risk among patients without SMuRFs is explained by confounding factors related to their poor risk profiles (old age, longer pre-hospital delays, and poor clinical management). After multivariate adjustment, a higher risk-factor burden was associated with poor prognosis among patients with STEMI.

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Section: Discussionmentioning

confidence: 99%

Number of standard modifiable risk factors and mortality in patients with first-presentation ST-segment elevation myocardial infarction: insights from China Acute Myocardial Infarction registry

Gao

Yang

et al. 2022

BMC Med

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“…Patients with ACS without SMuRFs represent heterogeneous class of patients, and these patients have worse long-term clinical prognosis than those with at least one SmuRF ( 5 , 7 ). Recent evidence has demonstrated that patients with CAD without SMuRFs had similar rates of plaque progression as those with traditional risk factors ( 22 ).…”

Section: Discussionmentioning

confidence: 99%

“…The key influences of diabetes mellitus, hypertension, hypercholesterolemia and smoking [known as the standard modifiable cardiovascular risk factors (SmuRFs)] on subsequent cardiovascular events has been well-illustrated (2). However, an increasing proportion of patients with ACS have no SmuRFs (3)(4)(5)(6)(7)(8)(9). Compared with patients with at least one risk factor, patients with ACS without SMuRFs remain at increased risk of death and recurrent cardiovascular events in contemporary secondary prevention strategies (5,7).…”

Section: Introductionmentioning

confidence: 99%

“…However, an increasing proportion of patients with ACS have no SmuRFs (3)(4)(5)(6)(7)(8)(9). Compared with patients with at least one risk factor, patients with ACS without SMuRFs remain at increased risk of death and recurrent cardiovascular events in contemporary secondary prevention strategies (5,7). Therefore, it is important to further enhance risk stratification methods to identify patients with ACS without SMuRFs who have a higher risk for adverse events in so that appropriate treatment can be provided.…”

Section: Introductionmentioning

confidence: 99%

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Prognostic performance of multiple biomarkers in patients with acute coronary syndrome without standard cardiovascular risk factors

Wang

Cong

Zhang

et al. 2022

Front. Cardiovasc. Med.

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Background and aimsAcute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors (SMuRFs) represents a special case of ACS. Multiple biomarkers have been shown to improve risk stratification in patients with ACS. However, the utility of biomarkers for prognostic stratification in patients with ACS without SMuRFs remains uncertain. The aim of the present study was to evaluate the prognostic value of various biomarkers in patents with ACS without SMuRFs.MethodsData of consecutive patients with ACS without SMuRFs who underwent coronary angiography in Tianjin Chest Hospital between January 2014 and December 2017 were retrospectively collected. The primary outcome was the occurrence of major adverse cardiovascular event (MACE), defined as a composite of cardiovascular death, myocardial infarction and stroke. Seven candidate biomarkers analyses were analyzed using models adjusted for established risk factors.ResultsDuring a median 5-year follow-up, 81 of the 621 patients experienced a MACE. After adjustment for important covariates, elevated fibrinogen, D-dimer, N-terminal proB-type natriuretic peptide (NT-proBNP), and lipoprotein (a) [Lp(a)] were found to be individually associated with MACE. However, only D-dimer, NT-proBNP and Lp(a) significantly improved risk reclassification for MACE (all P < 0.05). The multimarker analysis showed that there was a clear increase in the risk of MACE with an increasing number of elevated biomarkers and a higher multimarker score. The adjusted hazard ratio- for MACE (95% confidential intervals) for patients with 4 elevated biomarkers was 6.008 (1.9650–18.367) relative to those without any elevated biomarker-. Adding- the 4 biomarkers or the multimarker score to the basic model significantly improved the C-statistic value, the net reclassification index and the integrated discrimination index (all P < 0.05).ConclusionFibrinogen, D-dimer, NT-proBNP and Lp(a) provided valuable prognostic information for MACE when applied to patients with ACS without SMuRFs. The multimarker strategy, which combined multiple biomarkers reflecting different pathophysiological process with traditional risk factors improved the cardiovascular risk stratification.

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“… 3 , 4 , 5 , 6 However, up to 20% of patients with acute coronary syndrome have no SMuRFs, and paradoxically such patients have worse outcomes when compared with those who have at least 1 SMuRF. 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 Furthermore, a recent study by Chunawala et al 19 found a temporal trend of increase in the incidence of 28‐day mortality following AMI for patients without SMuRFs, whereas it declined for those with ≥1 SMuRFs. This underscores the importance of identifying additional modifiable cardiovascular risk factors.…”

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confidence: 98%

Association of Lipoprotein (a) and Standard Modifiable Cardiovascular Risk Factors With Incident Myocardial Infarction: The Mass General Brigham Lp(a) Registry

Shiyovich,

Berman,

Besser

et al. 2024

JAHA

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Background Lipoprotein (a) [Lp(a)] is a robust predictor of coronary heart disease outcomes, with targeted therapies currently under investigation. We aimed to evaluate the association of high Lp(a) with standard modifiable risk factors (SMuRFs) for incident first acute myocardial infarction (AMI). Methods and Results This retrospective study used the Mass General Brigham Lp(a) Registry, which included patients aged ≥18 years with an Lp(a) measurement between 2000 and 2019. Exclusion criteria were severe kidney dysfunction, malignant neoplasm, and prior known atherosclerotic cardiovascular disease. Diabetes, dyslipidemia, hypertension, and smoking were considered SMuRFs. High Lp(a) was defined as >90th percentile, and low Lp(a) was defined as <50th percentile. The primary outcome was fatal or nonfatal AMI. A combination of natural language processing algorithms, International Classification of Diseases ( ICD ) codes, and laboratory data was used to identify the outcome and covariates. A total of 6238 patients met the eligibility criteria. The median age was 54 (interquartile range, 43–65) years, and 45% were women. Overall, 23.7% had no SMuRFs, and 17.8% had ≥3 SMuRFs. Over a median follow‐up of 8.8 (interquartile range, 4.2–12.8) years, the incidence of AMI increased gradually, with higher number of SMuRFs among patients with high (log‐rank P =0.031) and low Lp(a) (log‐rank P <0.001). Across all SMuRF subgroups, the incidence of AMI was significantly higher for patients with high Lp(a) versus low Lp(a). The risk of high Lp(a) was similar to having 2 SMuRFs. Following adjustment for confounders and number of SMuRFs, high Lp(a) remained significantly associated with the primary outcome (hazard ratio, 2.9 [95% CI, 2.0–4.3]; P <0.001). Conclusions Among patients with no prior atherosclerotic cardiovascular disease, high Lp(a) is associated with significantly higher risk for first AMI regardless of the number of SMuRFs.

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Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors

Cited by 6 publications

References 38 publications

Number of standard modifiable risk factors and mortality in patients with first-presentation ST-segment elevation myocardial infarction: insights from China Acute Myocardial Infarction registry

Number of standard modifiable risk factors and mortality in patients with first-presentation ST-segment elevation myocardial infarction: insights from China Acute Myocardial Infarction registry

Prognostic performance of multiple biomarkers in patients with acute coronary syndrome without standard cardiovascular risk factors

Association of Lipoprotein (a) and Standard Modifiable Cardiovascular Risk Factors With Incident Myocardial Infarction: The Mass General Brigham Lp(a) Registry

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