Impact of nutritional status on prognosis in acute myocardial infarction patients undergoing percutaneous coronary intervention

Background Malnutrition affects the prognosis of cardiovascular disease. Acute myocardial infarction (AMI) has been a major cause of death around the world. Thus, we investigated the impact of malnutrition as defined by Geriatric Nutritional Risk Index (GNRI) on mortality in AMI patients. Methods In 268 consecutive AMI patients who underwent percutaneous coronary intervention (PCI), associations between all-cause death and baseline characteristics including malnutrition (GNRI < 92.0) and Global Registry of Acute Coronary Events (GRACE) risk score were assessed. Results Thirty-three patients died after PCI. Mortality was higher in the 51 malnourished patients than in the 217 non-malnourished patients, both within 1 month after PCI (p < 0.001) and beyond 1 month after PCI (p = 0.017). Multivariate Cox proportional hazards regression modelling using age, left ventricular ejection fraction and GRACE risk score showed malnutrition correlated significantly with all-cause death within 1 month after PCI (hazard ratio [HR] 7.04; 95% confidence interval [CI] 2.30–21.51; p < 0.001) and beyond 1 month after PCI (HR 3.10; 95% CI 1.70–8.96; p = 0.037). There were no significant differences in area under the receiver-operating characteristic (ROC) curve between GRACE risk score and GNRI for predicting all-cause death within 1 month after PCI (0.90 vs. 0.81; p = 0.074) or beyond 1 month after PCI (0.69 vs. 0.71; p = 0.87). Calibration plots comparing actual and predicted mortality confirmed that GNRI (p = 0.006) was more predictive of outcome than GRACE risk score (p = 0.85) beyond 1 month after PCI. Furthermore, comparison of p-value for interaction of malnutrition and GRACE risk score for all-cause death within 1 month after PCI, beyond 1 month after PCI, and the full follow-up period after PCI were p = 0.62, p = 0.64 and p = 0.38, respectively. Conclusions GNRI may have a potential for predicting the mortality in AMI patients especially in beyond 1 month after PCI, separate from GRACE risk score. Assessment of nutritional status may help stratify the risk of AMI mortality.

Cysteine‐Rich Angiogenic Inducer 61 Improves Prognostic Accuracy of GRACE (Global Registry of Acute Coronary Events) 2.0 Risk Score in Patients With Acute Coronary Syndromes

Background It remains unclear whether the novel biomarker cysteine‐rich angiogenic inducer 61 (CCN1) adds incremental prognostic value to the GRACE 2.0 (Global Registry of Acute Coronary Events) risk score and biomarkers high‐sensitivity Troponin T, hsCRP (high‐sensitivity C‐reactive protein), and NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) in patients with acute coronary syndromes. Methods and Results Patients referred for coronary angiography with a primary diagnosis of acute coronary syndromes were enrolled in the Special Program University Medicine – Acute Coronary Syndromes and Inflammation cohort. The primary/secondary end points were 30‐day/1‐year all‐cause mortality and the composite of all‐cause mortality or myocardial infarction as used in the GRACE risk score. Associations between biomarkers and outcome were assessed using log‐transformed biomarker values and the GRACE risk score (versions 1.0 and 2.0). The incremental value of CCN1 beyond a reference model was assessed using Harrell’s C‐statistics calculated from a Cox proportional‐hazard model. The P value of the C‐statistics was derived from a likelihood ratio test. Among 2168 patients recruited, 1732 could be analyzed. CCN1 was the strongest single predictor of all‐cause mortality at 30 days (hazard ratio [HR], 1.77 [1.31, 2.40]) and 1 year (HR, 1.81 [1.47, 2.22]). Adding CCN1 alone to the GRACE 2.0 risk score improved C‐statistics for prognostic accuracy of all‐cause mortality at 30 days (0.87–0.88) and 1 year (0.81–0.82) and when combined with high‐sensitivity Troponin T, hsCRP, NT‐proBNP for 30 days (0.87–0.91), and for 1‐year follow‐up (0.81–0.84). CCN1 also increased the prognostic value for the composite of all‐cause mortality or myocardial infarction. Conclusions CCN1 predicts adverse outcomes in patients with acute coronary syndromes adding incremental information to the GRACE risk score, suggesting distinct underlying molecular mechanisms. Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT01000701.

The risk-treatment paradox in acute coronary syndrome patients: insights from the FORCE-ACS registry

Background Acute coronary syndrome (ACS) patients at high risk might benefit most from guideline-recommended interventions. However, it is well recognized that the delivery of guideline-directed care is inversely related to the estimated mortality risk, the so called risk-treatment paradox. Purpose To assess the existence of the risk-treatment paradox in a contemporary cohort of ACS patients and its possible association with one-year mortality. Methods The study population consisted patients enrolled in the FORCE-ACS registry who survived their initial admission. All ACS patients were stratified into low, intermediate or high mortality risk based on the Global Registry of Acute Coronary Events (GRACE) risk score. Optimal guideline-recommended care was defined as undergoing coronary angiography during initial hospital admission and receiving all outpatient medications with a class I guideline recommendation (i.e. aspirin, P2Y12-inhibitor, beta-blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and cholesterol-lowering drug). Aspirin and/or a P2Y12-inhibitor on top of an oral anticoagulant was also considered as optimal guideline-recommended care. The cumulative incidence of one-year mortality between optimal and suboptimal managed patients, within each GRACE risk score stratum, was estimated. Results In total, 2,524 patients who were enrolled between January 2015 and June 2018 were included. Based on the GRACE risk score, 46.9% of patients were classified as low-risk, 37.6% as intermediate-risk and 15.5% as high-risk. Overall, 49.8% of patients received optimal guideline-recommended care. Among the different risk strata, 54.9% of the low-risk, 49.1% of the intermediate-risk and 36.1% of the high-risk patients received optimal guideline-recommended care (Table 1). DAPT or DAT treatment (95.3% overall) did not differ between the risk categories. Beta-blockers were prescribed less frequently (69.6% overall), butprescription rates did not differ between the risk categories. ACE-inhibitors/ARBs were prescribed in 74.1% of all patients, but less often in high risk patients. Cholesterol lowering-drugs were prescribed in almost all patients (94.9% overall), but less frequently in high risk patients. Overall, 93.9% of patients underwent coronary angiography (CAG), high-risk patients had a statistically significant lower likelihood of undergoing CAG. In all risk categories, optimal guideline-recommended care was associated with a lower one-year mortality as compared to sub-optimal treatment (5.7% vs. 15.6% in high-risk) (Fig. 1). Conclusion Patients at higher estimated mortality risk, based on the GRACE-risk score, are less likely to receive guideline-recommended care. Although, the absolute benefit from guideline-recommended care appears to be greater in high-risk patients. Receiving guideline-recommended care was associated with a statistically significant better prognosis in intermediate- and high-risk patients. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMW Netherlands TopZorgSt. Antonius Research funds Figure 1. All-cause mortality

Serum lactic acid level predicts poor myocardial perfusion and in-hospital outcomes in patients undergoing primary percutaneous coronary intervention

Background Elevated serum lactic acid level is associated with poor outcomes in patients with critical diseases like shock. However, the clinical implication of this biomarker in patients with acute myocardial infarction remains unclear. Purpose We aimed to explore the predictive power of serum lactic acid level on admission for in-hospital outcomes in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (pPCI). Methods Consecutive patients undergoing pPCI with available data on serum lactid acid level were evaluated for eligbility in this retrospective cohort study. The primary outcome was all-cause death during hospitalization. Enzymatic infarct size and major adverse cardiovascular events (MACE, defined as a combination of all-cause death, recurrent myocardial infarction, and unplanned repeated revascularization) were considered secondary outcomes. Independent preditors of in-hospital death were determined by multiple logisic regression analysis. Odds ratio (OR) with 95% confidence interval (CI) was used to demonstrate the association. The predictive power of serum latictic acid level for in-hospital death was evaluated through receiver operator characteristic curve, which generated C-statictic. A combination model was further constructed by adding serum latictic acid level to the Global Registry of Acute Coronary Events (GRACE) risk score (LA-GRACE risk score). The linear dependence between serum lactic acids level and othe clinical variables was analysed using Spearman rank correlation. Results Of the 302 patients enrolled in the current analysis, 15 (5.0%) died during hospitalization. Serum lactic acid level (OR=1.657, 95% CI: 1.115 to 2.463, p=0.012)and left ventricular ejection fraction (OR=0.858, 95% CI: 0.767 to 0.959, p=0.007) were the only two independent predictors of in-hospital death. The C-statistic of serum lactic acid level for predicting in-hospital death was 0.886 (95% CI: 0.793 to 0.979). The LA-GRACE risk score improved the C-statistic of the GRACE score from 0.898 to 0.911 (p=0.294), with continuous net reclassification improvement of 0.567 (p=0.023) and integrated discrimination improvement of 0.206 (p=0.003). High serum lactic acid level was also asscoiated with larger enzymatic infarct size (p=0.002) and MACE (p=0.004). Further, it significantly correlated with white blood cell counts (r=0.264, p&lt;0.001), serum creatinine level (r=0.189, p=0.001), and systolic blood pressure (r=−0.122, p=0.034). Conclusion Serum lactic acid level on admission is asscoiated with poor myocardial perfusion and in-hospital outcomes in patients with acute myocardial infarction undergoing pPCI. It may contribute to better risk stratification in these populations. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the National Program on Key Basic Research Project of China (Grant No: 2019YFC0840601 and 2014CBA02003), National Natural Science Foundation of China (Grant No: 81870267, 81970295, 81521001, 81670318 and 81570314), Grant of Shanghai Shenkang on Key Clinical Research Project (Grant No: SHDC2020CR2015A and SHDC12019104), Grant of Shanghai Science and Technology Committee (Grant No: 19MC1910300, 18411950200 and 20JC1410800), Key Medical and Health Projects of Xiamen Province (No: 3502Z20204004), Grant of Shanghai Municipal Commission of Health and Family Planning (Grant No: 2017YQ057), Grant of Zhongshan Hospital Affiliated to Fudan University (Grant No: 2018ZSLC01), VG Funding of Clinical Trials (2017-CCA-VG-036) and Merck Funding (Xinxin-merck-fund-051). ROC of lactic acid and GRACE score

The value of GRACE risk score for predicting mortality in heart failure patients admitted with non-ST elevation acute coronary syndrome

Background Acute coronary syndrome (ACS) in heart failure (HF) patients has not been well studied yet. Purpose The main aims of this study were to compare the characteristics and outcomes of Non-ST elevation ACS (NSTACS) in patients with and without prior HF, and to assess the GRACE risk score performance for risk stratification in both groups. Methods All consecutive patients (n=5661) admitted due to a NSTACS from November'2003 to November'2017 in two Spanish hospitals were retrospectively analysed. Patients were divided according to prior HF. As GRACE score predicts mortality in 6 months, logistic regression models were used to predict mortality in both groups. The different aspects of model performance were studied, including calibration and discrimination. Results Killip class, GRACE and CRUSADE scores were higher in HF-patients compared to patients without prior HF. Also, HF-patients had more complications (major bleeding, worsening HF, acute kidney injury) and higher mortality. Discrimination capacity of GRACE score to predict mortality at 6 months was slightly higher in non-HF patients (AUC 83.9% [81.6–86.2]) than in HF-patients [AUC 77.0% [70.1–83.8]) (Figure 1). The risk score calibration was acceptable for both groups [Brier scores were 0.139 (c-AUC 0,77) for HF-patients, and 0.046 (c-AUC 0.839) for non-HF patients]. Finally, HF-patients with lower GRACE scores had a higher predicted mortality than non-HF patients (Table 1). Conclusions We showed the potential utility of GRACE risk score in HF-patients admitted with NSTACS, expanding the indication of GRACE risk score for HF-patients as well. In fact, GRACE risk score not only keeps its accuracy, but it is even more robust in HF-patients than in non-HF patients. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Table 1

Early vs late new-onset atrial fibrillation in STEMI patients: pathophysiological mechanisms and relationship with in-hospital outcomes

Background New-onset atrial fibrillation (NOAF) represents the most common supraventricular arrhythmia in the setting of ST-elevation myocardial infarction (STEMI), with up to 21% patients affected. The occurrence of NOAF has clinical relevance as previous studies showed that atrial fibrillation (AF), whether pre-existent to the admission or newly developed during STEMI hospitalization, is associated with worse short- and long-term prognosis. More recently, two distinct phenotypes of NOAF have been described, such as early NOAF (EAF) for AF occurring within 24 h from STEMI, and late NOAF (LAF) for AF onset beyond 24h. The mechanisms underlying EAF or LAF are poorly described. Objective To investigate atrial branches occlusion and EAF or LAF onset in STEMI patients undergoing primary percutaneous coronary intervention. Methods Retrospective cohort study including 155 STEMI patients. Patients were divided into 3 groups: sinus rhythm (SR), EAF or LAF. Clinical characteristics, angiographic features including occlusion of atrial branches, namely ramus ostia cavae superioris (ROCS), atrio-ventricular node artery (AVNA), right intermediate atrial artery (RIAA) and left intermediate atrial artery (LIAA), were assessed (Figure 1). We also investigated in-hospital adverse events (AEs) and death. Results Mean age was 63.8±11.9 years; 78.7% of men. NOAF was detected in 22 (14.2%) patients: 10 (6.4%) EAF and 12 LAF (7.7%). Compared to EAF, LAF patients were older (p=0.013), with higher GRACE risk score (p=0.014) and Killip class (p=0.015), depressed ejection fraction (p=0.007), elevated filling pressures (p=0.029), higher c-reactive protein (p=0.014) and more TIMI flow &lt;3 (p=0.015). Compared to SR, EAF was associated with higher prevalence of occluded ROCS (p=0.010), AVNA (p=0.005) and RIAA (p&lt;0.001) (Figure 2). Moreover, EAF patients had more frequently ≥2 diseased atrial branches than SR (19.5%, p&lt;0.001) and LAF (25%, p&lt;0.030) patients. In LAF patients, a higher incidence of AEs (p=0.019 vs SR; p=0.029 vs EAF) and death (p=0.004 vs SR) was found. Conclusions The occlusion of atrial branches is associated with early but not late NOAF following STEMI. LAF patients had worse in-hospital AEs and mortality. FUNDunding Acknowledgement Type of funding sources: None. Anatomy of atrial branches Involvement of atrial branches

The role of triglyceride glucose index in predicting in-hospital adverse cardiovascular outcomes in patients with acute coronary syndrome

Previous studies have shown the association of triglyceride glucose (TyG) index with metabolic syndrome (MetS), cardiovascular disease (CVD) and long-term adverse cardiovascular outcomes. However, to best our knowledge, the relation between the TyG index and in-hospital adverse cardiovascular outcomes in acute coronary syndrome (ACS) has not yet been reported. Hence, in this study, we aimed to evaluate the role of the TyG index in predicting in-hospital adverse cardiovascular outcomes in ACS and to compare its performance with the Global Acute Coronary 3Department of XXX, University of XXX, XXX Training and Research Hospital, City, Country Events Register (GRACE) risk score. 170 patients diagnosed with ACS and underwent coronary angiography were analyzed retrospectively. The 4Department of XXX, Faculty of XXX, City, Country TyG index was calculated using the following formula: ln [fasting triglycerides (mg/dL)×fasting blood glucose (mg/dL)/2]. Receiver operating characteristics (ROC) curve analysis was used to evaluate the performance of the TyG index and GRACE risk score in predicting in-hospital adverse cardiovascular outcomes. A binary logistic regression model was applied to determine the independent predictors for in-hospital adverse cardiovascular outcomes. At the initial analysis, patients with adverse cardiovascular outcomes had higher TyG index and GRACE risk score (p=0.011, p<0.001). In ROC curve analysis, the GRACE score performed better in predicting in-hospital adverse cardiovascular outcomes compared to TyG index (AUC:0.716, p<0.001; AUC:0.588, p=0.054 respectively). In binary logistic regression analysis, left ventricular ejection fraction (LVEF), multi-vessel disease and GRACE risk score were independent predictors for in-hospital adverse cardiovascular outcomes (OR: 0.840, 95% CI: 0.791-0.891, p<0.001; OR: 3.581, 95% CI:1.382-9.282, p=0.009; OR= 1.017, 95% CI: 1.001-1.034, p=0.04 respectively). Our study findings revealed that the TyG index was scant in predicting in-hospital adverse cardiovascular outcomes compared to GRACE risk score. The independent predictors for in-hospital adverse cardiovascular outcomes were LVEF, multivessel disease and GRACE risk score.

Admission Hyperglycemia is Associated with Global Registry of Acute Coronary Events Score and Complications Following Acute Myocardial Infarction During 1-Year Follow-Up

We explored the effect of admission hyperglycemia (AH) on the Global Registry of Acute Coronary Events (GRACE) risk score and major adverse cardiovascular and cerebrovascular event (MACCE) incidence during 1-year follow-up in acute myocardial infarction (AMI) patients. In this retrospective observational study enrolling 1098 AMI patients, hyperglycemia was defined as blood glucose level ≥180 mg/dl at admission. Overall, 158 and 84 patients of 272 diabetic and 826 non-diabetic patients were diagnosed with AH, respectively. Glucose levels at admission were closely associated with the GRACE score in patients with/without diabetes. MACCEs occurred in 222 patients; patients with AH showed significantly higher MACCE incidence (28.1%). Multivariate Cox logistic regression analysis indicated that AH was an independent risk factor for 1-year MACCEs. Subgroup analysis demonstrated that hyperglycemia increases MACCE risk in non-diabetic patients but not in diabetic patients. The admission glucose level combined with GRACE risk score showed a certain predictive value for MACCE incidence according to ROC analysis (OR = 0.798, p < .001). AH was strongly associated with a higher GRACE risk score in ST-segment elevation myocardial infarction patients. Thus, AH was an independent risk factor and had a high predictive value for MACCE during 1-year follow-up after AMI.

Prognostic utility of leukocyte parameters for prediction of in-hospital mortality among patients with acute myocardial infarction

Among the tools presented today for predicting the risk of death from acute myocardial infarction (AMI) the most popular one is GRACE risk score. Along with it, due to the improvement of the prognostic value of the score, a number of parameters are displayed, the main features of which are the availability and ease of interpretation on early stages of hospitalization. The most promising among those are leukocyte parameters. While most studies evaluate the long-term prognosis of AMI, our work focused on potential precursors of in-hospital events. Among 228 patients diagnosed with AMI, 18 died at the hospital. They had a significantly higher GRACE and Gensini scores (p < 0.001). Also, patients of this group had s higher levels of leukocytes, granulocytes, lymphocytes and the neutrophil to lymphocyte ratio (NLR) (p < 0,05). According to the regression analysis, the NLR index along with GRACE was strongly connected to in-hospital mortality (OR = 1,364, 95 % CI 1,119-1,664, p = 0.002). To determine the prognostic value of these indicators, ROC analysis was performed. When evaluating the sensitivity (Se) and specificity (Sp) of parameters, the following results were obtained: GRACE score (Se = 80.0 %, Sp = 77.8 %, AUC 0.854), NLR (Se = 73.3 %, Sp = 73, 4 %, AUC 0.758), GRACE + NLR (Se = 80.0 %, Sp = 84.1 %, AUC 0.91). Thus, the combination of the GRACE risk score and NLR is more effective for predicting in-hospital mortality among patients with AMI.