Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Department of Healthcare Quality Assessment, The University of Tokyo, Tokyo, Japan.
J Cardiol. 2023 Jun;81(6):571-576. doi: 10.1016/j.jjcc.2023.01.009. Epub 2023 Feb 8.
High mortality in patients with acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors [SMuRFs (e.g. diabetes, hypertension, smoking, and dyslipidemia)] has been reported. However, details regarding their acute presentation and reasons for the excess risk remain unclear.
Patient-level data were extracted from a multicenter procedure-based registry (KiCS-PCI). We analyzed consecutive patients with ACS who underwent de novo percutaneous coronary intervention (PCI) between 2009 and 2020. The primary outcome of interest was the in-hospital mortality.
Among the 10,523 patients with ACS, 7775 met the inclusion criteria. Patients without SMuRFs who underwent PCI [n = 529 (6.8 %)] were older [median 71 (IQR: 63-79) vs. 68 (59-76) years, p < 0.001] and more often presented with cardiogenic shock or cardiopulmonary arrest (14.6 % vs. 8.6 %, p < 0.001; 12.7 % vs. 5.3 %, p < 0.001, respectively). In patients with ST-elevation myocardial infarction (STEMI), median door-to-balloon time was significantly longer in SMuRF-less patients (90 min vs 82 min). In-hospital death was significantly higher in SMuRF-less patients [10.2 % vs. 4.1 %, p < 0.001, adjusted odds ratio, 1.81 (95%CI, 1.26-2.59); p = 0.001], whereas the rate of procedural complications showed no significant difference. When stratified by the ACS presentation pattern, the findings were consistent, although the association between SMuRF-less and the increased risk of in-hospital mortality was not statistically significant in patients with non-ST-elevation- (NSTE)-ACS.
SMuRF-less ACS patients frequently presented with cardiopulmonary arrest and/or cardiogenic shock, leading to high in-hospital mortality. When stratified by the ACS presentation pattern, the association of SMuRF-less and the increased risk of mortality was more prominent in STEMI patients and it was not statistically significant in NSTE-ACS patients. Almost half of these patients had amendable left main trunk or left anterior descending artery disease and treating clinicians should be aware of this paradox to avoid the delay in treatment.
患有急性冠状动脉综合征（ACS）且无标准可改变心血管风险因素[SMuRFs（如糖尿病、高血压、吸烟和血脂异常）]的患者死亡率较高。然而，其急性表现和高风险的原因仍不清楚。
从一个多中心基于治疗的登记处（KiCS-PCI）中提取患者水平数据。我们分析了 2009 年至 2020 年间接受经皮冠状动脉介入治疗（PCI）的连续 ACS 患者。主要观察终点为院内死亡率。
在 10523 例 ACS 患者中，符合纳入标准的有 7775 例。接受 PCI 的无 SMuRFs 的患者[n=529（6.8%）]年龄较大[中位数 71（IQR：63-79）比 68（59-76）岁，p<0.001]，更常出现心源性休克或心肺骤停（14.6%比 8.6%，p<0.001；12.7%比 5.3%，p<0.001）。ST 段抬高型心肌梗死（STEMI）患者中，SMuRF 缺乏患者的门球时间明显较长（90 分钟比 82 分钟）。SMuRF 缺乏患者的院内死亡率明显较高[10.2%比 4.1%，p<0.001，调整后的优势比 1.81（95%CI，1.26-2.59）；p=0.001]，但手术并发症发生率无显著差异。按 ACS 表现模式分层时，结果一致，尽管在非 ST 段抬高型 ACS（NSTE-ACS）患者中，SMuRF 缺乏与院内死亡率增加之间的关联无统计学意义。
SMuRF 缺乏的 ACS 患者常出现心肺骤停和/或心源性休克，导致院内死亡率较高。按 ACS 表现模式分层时，STEMI 患者 SMuRF 缺乏与死亡率增加的关联更为显著，而在 NSTE-ACS 患者中则无统计学意义。这些患者中有近一半存在可治疗的左主干或前降支病变，临床医生应意识到这一矛盾，避免治疗延误。
