Impact of admission serum acid uric levels on in-hospital outcomes in patients with acute coronary syndrome

Abstract Background Hyperuricemia has been associated with high mortality rates in patients with acute myocardial infarction. The role and the prognostic relevance of increased serum uric acid (SUA) in patients with acute coronary syndrome (ACS) are still under debate Aim We sought to assess the association between elevated admission levels of SUA and in-hospital adverse outcomes in a real-world patient population with ACS and to investigate the potential incremental prognostic value of SUA added to GRACE score Methods 1088 consecutive patients admitted with a diagnosis of ACS to the Coronary Care Unit of two Hospitals were enrolled. Medical history, clinical characteristic, biochemical and electrocardiographic findings, angiographic data, treatments administered during hospitalization were all collected on an electronic database. All patients' data were entered prospectively in the database of the two hospitals and retrospectively analysed. Results The mean age was 68 years (IQR 60–78). Less than one-third of the total population was female (24%). Diabetes mellitus was present in 308 (28%) patients. The proportion of patients with STEMI and NSTEMI/UA was quite similar: 504 (46%) patients had a diagnosis of STEMI and 584 (54%) patients had a diagnosis of NSTEMI/UA. The GRACE score was 133 (IQR 112–156). In-hospital mortality rate was 2.3% in the overall population. Two variables were associated with a significantly increased risk of in-hospital death at the multivariate analysis: SUA (OR 1.72 95% CI 1.33–2.22, p<0.0001) and GRACE score (OR 1.04 95% CI 1.02–1.06, p<0.0001). To investigate the potential incremental prognostic value of SUA added to GRACE score for in-hospital death, we analyzed the results of adding hyperuricemia as categorical variable to the original GRACE risk model (GRACE-SUA score). The areas under the ROC curve (AUC) for GRACE score and for SUA were 0.91 (95% CI 0.89–0.93, p<0.0001) and 0.79 (95% CI 0.76–0.81, p<0.0001) respectively. The AUC was larger for predicting in-hospital mortality with the GRACE-SUA score (0.94; 95% CI 0.93–0.95; p<0.0001). The addition of hyperuricemia to the GRACE score led to reclassifying 18 of 211 (8.5%) patients without in-hospital deaths from high to low risk. No patients with o without events were incorrectly reclassified. The net-reclassification index (NRI) of the GRACE-SUA score was 1.7% (z value of 4.3; p<0.001). Conclusions High admission levels of SUA are positively and independently associated with in-hospital adverse outcomes and mortality in a contemporary and unselected population of ACS patients. The inclusion of SUA to GRACE risk score seems to lead to a more accurate prediction of in-hospital mortality and to improve risk classification in this study population. Funding Acknowledgement Type of funding source: None

Download Full-text

Impact of Admission Blood Glucose Added on GRACE Risk Score for All-Cause In-Hospital Mortality in Patients with Acute Coronary Syndrome

Bangladesh Heart Journal ◽

10.3329/bhj.v33i2.39304 ◽

2018 ◽

Vol 33 (2) ◽

pp. 94-99

Author(s):

Md Mesbahul Islam ◽

Mohsin Ahmed ◽

Mohammad Ali ◽

Abdul Wadud Chowdhury ◽

Khandakar Abu Rubayat

Keyword(s):

Acute Coronary Syndrome ◽

Blood Glucose ◽

Hospital Mortality ◽

Blood Sugar ◽

Risk Score ◽

Hospital Death ◽

Predictive Values ◽

Coronary Syndrome ◽

Grace Risk Score ◽

Grace Score

Background: Abnormal glucose metabolism is a predictor of worse outcome after acute coronary syndrome (ACS). However, this parameter is not included in risk prediction scores, including GRACE risk score. We sought to evaluate whether the inclusion of blood glucose at admission in a model with GRACE risk score improves risk stratification. Objectives: To assess whether inclusion of admission blood glucose in a model with GRACE risk score improves risk stratification of ACS patients admitted in a tertiary hospital of Bangladesh. Methods: This cross sectional comparative study was carried out in the department of cardiology, Dhaka Medical College Hospital (DMCH), Dhaka between May 2016 to April 2017. Data were collected from ACS patients admitted at CCU, DMCH who fulfilled inclusion and exclusion criteria. GRACE score was calculated for each patient. The predictive value of death by GRACE score was compared with the predictive value of combined GRACE score + admission blood sugar. Comparison between these results in two groups were done by unpaired t-test, analysis was conducted SPSS-22.0 for windows software. The significance of the results was determined in 95.0% confidence interval and a value of p <0.05 was considered to be statistically significant. Results: A total of 249 cases of ACS patients were selected. Most of the patients belonged to 5th and 6th decades 25.3% vs 37.3% and the mean age was 55.7±11.7 years. Most of the patients were male. High GRACE risk score (≥155) and elevated admission blood sugar (≥11) was found significantly higher in-hospital death whereas only high GRACE risk score (≥155) and normal admission blood sugar (<11) was found non significant regarding in-hospital death. Test of validity showed sensitivity of GRACE risk score regarding in-hospital death was 85.29%, specificity 57.7%, accuracy 61.4%, positive and negative predictive values were 24.2% and 96.1% respectively. The sensitivity of GRACE risk score + admission blood sugar regarding in-hospital death was 85.29%, specificity 62.33%, accuracy 65.46%, positive and negative predictive values were 26.36% and 96.4% respectively. Receiver-operator characteristic (ROC) were constructed using GRACE score and GRACE score + admission blood sugar of the patients with in-hospital death, which showed the sensitivity and specificity of GRACE score for predicting in-hospital death were found to be 79.4% and 58.1%, respectively. Whereas after adding admission blood sugar value to GRACE score both the sensitivity and specificity increased to 82.4% and 58.6% respectively in this new model. Logistic regression analysis of in-hospital mortality with independent risk factors showed GRACE score (≥155) + admission blood sugar (≥11.0 mmol/l) was more significantly associated with in-hospital mortality (P =0.001, OR = 6.675, 95% CI 2.366-13.610). Conclusion: In patients with the whole spectrum of acute coronary syndrome admission blood glucose can add prognostic information to the established risk factors with the GRACE risk score. Bangladesh Heart Journal 2018; 33(2) : 94-99

Download Full-text

Exploring Triaging and Short-Term Outcomes of Early Invasive Strategy in Non-ST Segment Elevation Acute Coronary Syndrome: A Report from Japanese Multicenter Registry

Journal of Clinical Medicine ◽

10.3390/jcm9041106 ◽

2020 ◽

Vol 9 (4) ◽

pp. 1106

Author(s):

Nobuhiro Ikemura ◽

Yasuyuki Shiraishi ◽

Mitsuaki Sawano ◽

Ikuko Ueda ◽

Yohei Numasawa ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Hospital Mortality ◽

Risk Score ◽

Mortality Risk ◽

Adverse Outcomes ◽

Invasive Strategy ◽

Coronary Syndrome ◽

Increased Risk ◽

Elevation Acute Coronary Syndrome ◽

Early Invasive Strategy

This observational study aimed to examine the extent of early invasive strategy (EIS) utilization in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) according to the National Cardiovascular Data Registry (NCDR) CathPCI risk score, and its association with clinical outcomes. Using a prospective multicenter Japanese registry, 2968 patients with NSTE-ACS undergoing percutaneous coronary intervention within 72 hours of hospital arrival were analyzed. Multivariable logistic regression analyses were performed to determine predictors of EIS utilization. Additionally, adverse outcomes were compared between patients treated with and without EIS. Overall, 82.1% of the cohort (n = 2436) were treated with EIS, and the median NCDR CathPCI risk score was 22 (interquartile range: 14–32) with an expected 0.3–0.6% in-hospital mortality. Advanced age, peripheral artery disease, chronic kidney disease or patients without elevation of cardiac biomarkers were less likely to be treated with EIS. EIS utilization was not associated with a risk of in-hospital mortality; yet, it was associated with an increased risk of acute kidney injury (AKI) (adjusted odds ratio: 1.42; 95% confidence interval: 1.02–2.01) regardless of patients’ in-hospital mortality risk. Broader use of EIS utilization comes at the cost of increased AKI development risk; thus, the pre-procedural risk-benefit profile of EIS should be reassessed appropriately in patients with lower mortality risk.

Download Full-text

Clinical Application of Grace Risk Score in Patients with Acute Coronary Syndrome

Annals of King Edward Medical University ◽

10.21649/akemu.v23i2.1585 ◽

2017 ◽

Vol 23 (2) ◽

Author(s):

Samar Firdous ◽

Uzma Malik

Keyword(s):

Acute Coronary Syndrome ◽

Hospital Mortality ◽

Clinical Application ◽

Risk Score ◽

Adverse Outcomes ◽

Cardiac Biomarkers ◽

Hospital Death ◽

Coronary Syndrome ◽

Grace Risk Score ◽

The Mean

Objectives: To determine clinical application of GRACE risk score in patients with acute coronary syndrome (ACS).Patients and Methods: It was an observational analytical study conducted in the Cardiology ward of Mayo hospital, Lahore from April to July 2015. Patients with Acute STEMI, NSTEMI or Unstable angina (UA) were selected on the basis of typical chest pain, ECG changes or cardiac biomarkers .For all eligible cases, at presentation GRS was calculated using online calculator. Also, GRACE risk categories and predicted in-hospital mortality were determined. Patients with previous episodes of STEMI/ NSTEMI, old Left Bundle Branch Block (LBBB), stable angina pectoris, acute pericarditis, myocarditis, acute rheumatic fever or pulmonary embolism were excluded. Data was analyzed on SPSS 20 and the R project for statistical computing. Individual components of GRS were compared among discharged and expired cases using t-test. A p-value of <0.05 was considered significant.Results: A total of 165 patients with STEMI and ACS were included. The mean GRS among males andfemales was 137.4 ± 39 and 151.5 ± 50.6. The observed in-hospital mortality was 12.12% with 60% patients of STEMI. Among expired cases, 90% patients had high GRS, predominantly from STEMI group. Important determinants of adverse outcome were advanced age, tachycardia, low systolic blood pressure and presence of cardiac failure.Conclusion: STEMI was the major acute cardiac event. The mean GRS of expired patients was significantly higher than discharged group. GRS accurately identified low risk cases with low probability of in-hospital death. GRS over estimate probability of in-hospital death among STEMI high risk cases that had higher scores and discharged uneventfully. Grace Risk Score is a reliable predictor of risk category and adverse outcomes and its use by clinicians should be strongly recommended.

Download Full-text

Hospital mortality in acute coronary syndrome: adjustment of GRACE score by D-dimer enables a more accurate prediction in a prospective cohort study

BMC Cardiovascular Disorders ◽

10.1186/s12872-019-1239-4 ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Tongtong Yu ◽

Yundi Jiao ◽

Jia Song ◽

Dongxu He ◽

Jiake Wu ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Hospital Mortality ◽

Coronary Intervention ◽

Added Value ◽

Hospital Death ◽

Prognostic Performance ◽

Coronary Syndrome ◽

Coronary Events ◽

Grace Score ◽

D Dimer

Abstract Backgroud To assess the value of D-dimer and its combination with The Global Registry of Acute Coronary Events (GRACE) score in predicting in-hospital mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Methods In 5923 ACS patients undergoing PCI, the role of D-dimer and the added value of D-dimer to GRACE score for predicting in-hospital mortality were tested. Results After multivariable adjustment, D-dimer could significantly predict in-hospital mortality. Also, it could significantly improve the prognostic performance of GRACE score (C-statistic: z = 2.269, p = 0.023; IDI: 0.016, p = 0.032; NRI: 0.291, p = 0.035). Conclusion In patients with ACS undergoing PCI, D-dimer was an independent predictor of in-hospital death. It could also improve the prognostic performance of GRACE score.

Download Full-text

Predictors of Hospital Mortality in Patients with Acute Coronary Syndrome Complicated by Cardiogenic Shock

Sensors ◽

10.3390/s21030969 ◽

2021 ◽

Vol 21 (3) ◽

pp. 969

Author(s):

Gábor Tamás Szabó ◽

András Ágoston ◽

Gábor Csató ◽

Ildikó Rácz ◽

Tamás Bárány ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Hospital Admission ◽

Left Ventricular ◽

Hospital Death ◽

Lv Function ◽

Successful Resuscitation ◽

Coronary Syndrome ◽

Increased Risk

As demonstrated by earlier studies, pre-hospital triage with trans-telephonic electrocardiogram (TTECG) and direct referral for catheter therapy shows great value in the management of out-of-hospital chest pain emergencies. It does not only improve in-hospital mortality in ST-segment elevation myocardial infarction, but it has also been identified as an independent predictor of higher in-hospital survival rate. Since TTECG-facilitated triage shortens both transport time and percutaneous coronary intervention (PCI)-related procedural time intervals, it was hypothesized that even high-risk patients with acute coronary syndrome (ACS) and cardiogenic shock (CS) might also benefit from TTECG-based triage. Here, we decided to examine our database for new triage- and left ventricular (LV) function-related parameters that can influence in-hospital mortality in ACS complicated by CS. ACS patients were divided into two groups, namely, (1) hospital death patients (n = 77), and (2) hospital survivors (control, n = 210). Interestingly, TTECG-based consultation and triage of CS and ACS patients were confirmed as significant independent predictors of lower hospital mortality risk (odds ratio (OR) 0.40, confidence interval (CI) 0.21–0.76, p = 0.0049). Regarding LV function and blood chemistry, a good myocardial reperfusion after PCI (high area at risk (AAR) blush score/AAR LV segment number; OR 0.85, CI 0.78–0.98, p = 0.0178) and high glomerular filtration rate (GFR) value at the time of hospital admission (OR 0.97, CI 0.96–0.99, p = 0.0042) were the most crucial independent predictors of a decreased risk of in-hospital mortality in this model. At the same time, a prolonged time interval between symptom onset and hospital admission, successful resuscitation, and higher peak creatine kinase activity were the most important independent predictors for an increased risk of in-hospital mortality. In ACS patients with CS, (1) an early TTECG-based teleconsultation and triage, as well as (2) good myocardial perfusion after PCI and a high GFR value at the time of hospital admission, appear as major independent predictors of a lower in-hospital mortality rate.

Download Full-text

Circulating Levels of Dephosphorylated-Uncarboxylated Matrix Gla Protein in Patients with Acute Coronary Syndrome

Molecules ◽

10.3390/molecules26041108 ◽

2021 ◽

Vol 26 (4) ◽

pp. 1108

Author(s):

Admira Bilalic ◽

Tina Ticinovic Kurir ◽

Marko Kumric ◽

Josip A. Borovac ◽

Andrija Matetic ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

High Risk ◽

Hospital Mortality ◽

Vascular Calcification ◽

Matrix Gla Protein ◽

St Elevation Myocardial Infarction ◽

Coronary Syndrome ◽

Increased Risk ◽

St Elevation

Vascular calcification contributes to the pathogenesis of coronary artery disease while matrix Gla protein (MGP) was recently identified as a potent inhibitor of vascular calcification. MGP fractions, such as dephosphorylated-uncarboxylated MGP (dp-ucMGP), lack post-translational modifications and are less efficient in vascular calcification inhibition. We sought to compare dp-ucMGP levels between patients with acute coronary syndrome (ACS), stratified by ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) status. Physical examination and clinical data, along with plasma dp-ucMGP levels, were obtained from 90 consecutive ACS patients. We observed that levels of dp-ucMGP were significantly higher in patients with NSTEMI compared to STEMI patients (1063.4 ± 518.6 vs. 742.7 ± 166.6 pmol/L, p < 0.001). NSTEMI status and positive family history of cardiovascular diseases were only independent predictors of the highest tertile of dp-ucMGP levels. Among those with NSTEMI, patients at a high risk of in-hospital mortality (adjudicated by GRACE score) had significantly higher levels of dp-ucMGP compared to non-high-risk patients (1417.8 ± 956.8 vs. 984.6 ± 335.0 pmol/L, p = 0.030). Altogether, our findings suggest that higher dp-ucMGP levels likely reflect higher calcification burden in ACS patients and might aid in the identification of NSTEMI patients at increased risk of in-hospital mortality. Furthermore, observed dp-ucMGP levels might reflect differences in atherosclerotic plaque pathobiology between patients with STEMI and NSTEMI.

Download Full-text

P3825Long-term prognostic value of growth differentiation factor-15 in acute coronary syndrome

European Heart Journal ◽

10.1093/eurheartj/ehz745.0667 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

O M Peiro Ibanez ◽

J Ordonez ◽

A Garcia ◽

G Bonet ◽

V Quintern ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Acute Coronary Syndrome ◽

Prognostic Value ◽

Clinical Model ◽

Growth Differentiation Factor 15 ◽

Coronary Syndrome ◽

St Elevation ◽

Incremental Prognostic Value

Abstract Introduction Biomarkers plays a critical role in diagnostic, prognostication, and decision-making in cardiovascular medicine. Growth differentiation factor-15 (GDF-15) has been reported as a potential biomarker in acute coronary syndrome (ACS). However, there is limited data on the long-term prognostic value after an ACS. Purpose To study the long-term prognostic value of GDF-15 in ACS. Methods We included patients with ACS who underwent coronary angiography. During angiography an arterial blood sample was collected. Plasma GDF-15 were measured and clinical data and long-term events were obtained. As previously reported, risk categories were defined as low risk (<1200ng/L), intermediate (1200–1800ng/L) and high risk (>1800ng/L). Incremental prognostic value of GDF-15 for all-cause death was assessed on top of a clinical model (GRACE score, LVEF<40% and age). Results A total of 358 patients were included; 157 as a low risk, 85 as an intermediate and 116 as a high risk. The median (IQR) age was 65 (56–74) years and 27.4% were female. Of all patients, 61.5% were admitted with non-ST-elevation myocardial infarction, 24.0% with ST-elevation myocardial infarction and 14.5% with unstable angina. Higher values of GDF-15 were consistently associated with an increased prevalence of cardiovascular risk factors. During 6 years of follow-up 54 patients died. Of those patients, 7 (4.5%) had values of GDF-15 below 1200ng/L, 6 (7.1%) between 1200–1800ng/L and 41 (35.3%) above 1800ng/L. After adjustment for a multivariate Cox regression model, GDF-15 >1800ng/L were independently associated with all-cause death (HR 4.5; 95% CI 1.8–11.6; p=0.002) and the composite of major adverse cardiovascular events (MACE) which were identified as all-cause death, nonfatal MI and heart failure (HR 2.5; 95% CI 1.4–4.4; p=0.001). For long-term all-cause death a significant increase of the c-statistic was seen after addition of GDF-15 to the clinical model 0.871 (95% CI 0.817–0.924; p=0.019) as well as net reclassification improvement (0.769; 95% CI 0.487–1.051; p<0.001) and integrated discrimination improvement (0.117; 95% CI 0.062–0.172; p<0.001). Of 18 events of heart failure, 17 occurred in patients with GDF>1800ng/L. A multivariate competing risk model showed a significant association between GDF-15>1800ng/L and incidence of heart failure (adjusted HR 30.8; 95% CI 4.1–231.5; p=0.001) but non-significant association were found for myocardial infarction. KM figures and all-cause death ROC curve Conclusions In the setting of ACS GDF-15 can predict long-term all-cause death, MACE and heart failure and provides incremental prognostic value beyond traditional risks factors in the long-term all-cause death.

Download Full-text

Prognostic impact of alkaline phosphatase for in-hospital mortality in patients with acute coronary syndrome: a prospective cohort study in China

BMJ Open ◽

10.1136/bmjopen-2018-025648 ◽

2019 ◽

Vol 9 (8) ◽

pp. e025648

Author(s):

Tongtong Yu ◽

Yundi Jiao ◽

Jia Song ◽

Dongxu He ◽

Jiake Wu ◽

...

Keyword(s):

Alkaline Phosphatase ◽

Acute Coronary Syndrome ◽

Cohort Study ◽

Hospital Mortality ◽

Continuous Variable ◽

Prognostic Performance ◽

Coronary Syndrome ◽

C Statistic ◽

Grace Score ◽

Multivariable Adjustment

ObjectivesAlkaline phosphatase (ALP) can promote vascular calcification, but the association between ALP and in-hospital mortality in patients with acute coronary syndrome (ACS) is not well defined.DesignA prospective cohort study.Setting and participantsA total of 6368 patients with ACS undergoing percutaneous coronary intervention (PCI) from 1 January 2010 to 31 December 2017 were analysed.Main outcome measuresIn-hospital mortality was used in this study.ResultsALP was analysed both as a continuous variable and according to three categories. After multivariable adjustment, in-hospital mortality was significantly higher in Tertile 3 group (ALP＞85 U/L) (OR: 2.399, 95% CI 1.080 to 5.333, p=0.032), compared with other two groups (Tertile 1: ＜66 U/L; Tertile 2: 66–85 U/L). When ALP was evaluated as a continuous variable, after multivariable adjustment, the ALP level was associated with an increased risk of in-hospital mortality (OR: 1.011, 95% CI 1.002 to 1.020, p=0.014). C-statistic of ALP for predicting in-hospital mortality was 0.630 (95% CI 0.618 to 0.642, p=0.001). The cut-off value was 72 U/L with a sensitivity of 0.764 and a speciﬁcity of 0.468. However, ALP could not significantly improve the prognostic performance of Global Registry of Acute Coronary Events (GRACE) score (GRACE score+ALP vs GRACE score: C-statistic: z=0.485, p=0.628; integrated discrimination improvement: 0.014, p=0.056; net reclassification improvement: 0.020, p=0.630).ConclusionsIn patients with ACS undergoing PCI, ALP was an independent predictor of in-hospital mortality. But it could not improve the prognostic performance of GRACE score.

Download Full-text