Serum Albumin and Bleeding Events After Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction (from the HAGAKURE-ACS Registry)

Association between albumin changes and prognosis in older patients with acute myocardial infarction

Background and aims

Acute myocardial infarction (AMI) is the leading cause of death in the world. Therefore, early identification of the prognosis of older patients with AMI are particularly urgent, and better to improve treatment. This study aimed to explore the association between albumin changes and prognosis in older patients with AMI.

Methods

Outcomes included all-cause death during hospitalization, cardiac death, gastrointestinal hemorrhage, nonfatal myocardial infarction, acute heart failure, and severe arrhythmia. Multivariable-adjusted Cox regression analysis and curve fitting were used to assess the relationship between albumin changes and prognosis in patients with AMI.

Results

Our study included 288 older patients with AMI. A S-shaped association between the albumin changes and mortality of patients with AMI was found. For all-cause death, we found two inflection points were - 3.27 and 0.92 g/L. On the left side of -3.27 g/L, the OR was 0.41 (OR: 0.41, 95%CI: 0.32-0.64, p < 0.05). On the right side of 0.92 g/L, the OR was 0.58 (OR: 0.58, 95%CI: 0.34-0.86, p < 0.05). The OR was 2.12 between -3.27 and 0.92 g/L (OR: 2.12, 95%CI: 1.16-6.24, p < 0.05). For cardiac death, two inflection points were - 3.19 and 1.17 g/L. On the left side of -3.19 g/L, the OR was 0.45 (OR: 0.45, 95%CI: 0.28-0.79, p < 0.05). On the right side of 1.17 g/L, the OR was 0.63 (OR: 0.63, 95%CI: 0.38-0.86, p < 0.05). The OR was 4.53 between -3.19 and 1.17 g/L (OR: 4.53, 95%CI: 0.90-12.52, p > 0.05). After adjusting for all potential covariates, albumin changes were negatively associated with gastrointestinal hemorrhage (OR: 0.87; 95%CI: 0.81-0.94, p < 0.001). After adjusting for all potential covariates, albumin changes were negatively associated with acute heart failure (OR: 0.86; 95%CI: 0.75-0.99, p = 0.046).

Conclusion

Out findings showed that a S-shaped association between the albumin changes and mortality of older AMI patients, with the inflection of roughly -3.27 g/L and 0.92/L. And changes in albumin levels are negatively correlated with gastrointestinal bleeding and acute heart failure. These findings were helpful for the clinical treatment.

Prognostic Value of Four Objective Nutritional Indices in Predicting Long-Term Prognosis in Elderly Patients with Atrial Fibrillation: A Retrospective Cohort Study

Background

Several objective and comprehensive nutritional assessment methods have been used for predicting adverse outcomes in elderly patients with various diseases. However, their predictive value for long-term adverse outcomes in elderly patients with atrial fibrillation (AF) is unclear. This study aimed to explore the prognostic significance of the four nutritional indices, namely Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT), and High-Sensitivity Modified Glasgow Prognostic Score (HS-mGPS), in evaluating the long-term prognosis in elderly patients with AF.

Methods

This retrospective study was conducted at a single center and included a total of 261 elderly patients with AF from December 2015 to December 2021. Patients were divided into all-cause death and survival groups based on the follow-up results. Kaplan-Meier analysis and COX regression were conducted to explore the relationship between all-cause mortality and nutritional scores. In addition, Receiver Operating Characteristic (ROC) curves were used to compare the predictive value of the four nutritional screening tools for the endpoint event.

Results

During the follow-up period, 119 cases (45.59%) of all-cause mortality were recorded. The cumulative incidence of all-cause death was significantly higher in participants with a lower PNI, lower GNRI, higher CONUT, and higher HS-mGPS levels. And the low PNI (HR 1.325, 95% CI 1.032-2.857, P=0.025) and the high HS-mGPS (HR 2.166, 95% CI 1.281-4.326, P=0.023) groups were independently and significantly associated with increased risk of all-cause death analyzed by multivariate COX regression. Additionally, PNI showed the best area under the curve value (AUC: 0.696, 95% CI 0.632-0.760 P < 0.001) for the prediction of all-cause mortality compared with the other nutritional indices.

Conclusion

Among the four nutritional risk screening tools, PNI might be a simple and useful indicator in predicting the long-term prognosis of elderly patients with AF.

Importance of reassessment to identify trajectories of chronic transition of clinical indicators in post-myocardial infarction management

Despite advances in multidisciplinary acute care for myocardial infarction (MI), the clinical need to manage heart failure and elevated mortality risks in the remote phase of MI remains unmet. Various prognostic models have been established using clinical indicators obtained during the acute phase of MI; however, most of these indicators also show chronic changes in the post-MI phase. Although relevant guidelines recommend follow-up assessments of some clinical indicators in the chronic phase, systematic reassessment has not yet been fully established and implemented in a real-world clinical setting. Therefore, clinical evidence of the impact of such chronic transitions on the post-MI prognosis is lacking. We speculate that post-MI reassessment of key clinical indicators and the impact of their chronic transition patterns on long-term prognoses can improve the quality of post-MI risk stratification and help identify residual risk factors. Several recent studies have investigated the impact of the chronic transition of some clinical indicators, such as serum albumin level, mitral regurgitation, and left-ventricular dysfunction, on post-MI prognosis. Interestingly, even in MI survivors with these indicators within their respective normal ranges in the acute phase of MI, chronic transition to an abnormal range was associated with worsening cardiovascular outcomes. On the basis of these recent insights, we discuss the clinical significance of post-MI reassessment to identify the trajectories of several clinical indicators and elucidate the potential residual risk factors affecting adverse outcomes in MI survivors.

Comparative Analysis of Therapeutic Efficacy and Adverse Reactions among Various Thrombolytic Agents

Thrombosis is a major health concern that contributes to the development of several cardiovascular diseases and a significant number of fatalities worldwide. While stent surgery is the current recommended treatment according to the guidelines, percutaneous coronary intervention (PCI) is the optimal approach for acute myocardial infarction (AMI). However, in remote areas with limited resources, PCI procedures may not be feasible, leading to a delay in treatment and irreversible outcomes. In such cases, preoperative thrombolysis becomes the primary choice for managing AMI in remote settings. The market for thrombolytic drugs is continuously evolving, and identifying a safe and effective thrombolytic agent for treating AMI is crucial. This study evaluated Urokinase, Alteplase, and Recombinant Human TNK Tissue-type Plasminogen Activator for Injection (rhTNK) as representatives of first-, second-, and third-generation thrombolytic drugs, respectively. The research included in vitro thrombolysis experiments, exposure of human cardiomyocytes, zebrafish tail vein injections, and vascular endothelial transgenic zebrafish models. The findings revealed that rhTNK is the most effective thrombolytic drug with the least adverse effects and lowest bleeding rate, highlighting its potential as the preferred treatment option for AMI. The order of thrombolytic effectiveness was Urokinase < Alteplase < rhTNK, with adverse effects on cardiomyocytes post-thrombolytic therapy ranking similarly as Urokinase < Alteplase < rhTNK, while the bleeding rate after thrombolysis followed the order of Urokinase > Alteplase > rhTNK.

Prognostic value of the prognostic nutritional index for patients with acute myocardial infarction undergoing percutaneous coronary intervention with variable glucose metabolism statuses: a retrospective cohort study

BACKGROUND

The prognostic nutritional index (PNI) and different glucose metabolisms have been separately reported to be correlated with long-term prognosis in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). However, PNI application in patients with an impaired glucose metabolism has not been well validated, especially in pre-diabetic patients. This study evaluated whether PNI influences a long-term risk of mortality along different glucose metabolism statuses.

METHODS

A total of 17,697 patients with AMI and a history of PCI were enrolled in this retrospective observational cohort study from January 2007 to December 2020. Three subgroups with different glucose metabolism statuses, including normal glucose regulation (NGR), pre-diabetes mellitus (pre-DM), and diabetes mellitus (DM), were divided into three groups according to the tertiles of PNI, respectively.

RESULTS

All-cause mortality occurred in 2613 (14.8%) patients within a median of 4.1 years of follow-up. Upon analyzing the Kaplan-Meier plots for the NGR, pre-DM, and DM groups, the incidence of all-cause or cardiovascular mortality in the low PNI (PNI-L, ≤ 42.7) subgroup was significantly higher than that in the median PNI (PNI-M, > 42.7 and ≤ 48.2) and high PNI (PNI-H, > 48.2) subgroups (all, P < 0.001). After adjusting for confounding factors, the hazard ratio (HR) for all-cause mortality in the PNI-L group significantly increased compared to that in the PNI-H subgroups of the NGR group (HR, 1.35; 95% CI 1.14-1.66; P < 0.001), pre-DM group (HR, 1.29; 95% CI 1.02-1.62; P < 0.001), and DM group (HR, 1.36; 95% CI 1.13-1.63; P < 0.001). Given that there was evidence of interactions between PNI and different glucose statuses (P for interaction < 0.001), patients were divided into nine subgroups, and we found that DM patients with PNI-L statuses had the highest risk of all-cause mortality compared to NGR patients with PNI-H statuses (HR, 1.69; 95% CI 1.42-2.01; P < 0.001).

CONCLUSION

Lower PNI is a significant and independent risk factor for all-cause mortality in AMI patients undergoing PCI with different glucose metabolism statuses, and this risk further increases with DM compared to NGR or pre-DM statuses.

Does Albumin Predict the Risk of Mortality in Patients with Cardiogenic Shock?

This study investigates the prognostic impact of albumin levels in patients with cardiogenic shock (CS). Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. Limited data regarding the prognostic value of albumin in patients with CS is available. All consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from the day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. The prognostic impact of albumin was tested for 30-day all-cause mortality. Moreover, the prognostic performance of albumin decline during ICU treatment was examined. Statistical analyses included univariable t-test, Spearman's correlation, Kaplan-Meier analyses, multivariable mixed analysis of variance (ANOVA), C-Statistics, and Cox proportional regression analyses. In total, 230 CS patients were included, with an overall all-cause mortality at 30 days of 54%. The median albumin on day 1 was 30.0 g/L. Albumin on day 1 was able to discriminate between 30-day survivors and non-survivors (area under the curve (AUC) 0.607; 0.535-0.680; p = 0.005). CS patients with albumin < 30.0 g/L were associated with an increased risk of 30-day all-cause mortality (63% vs. 46%; log-rank p = 0.016; HR = 1.517; 95% CI 1.063-2.164; p = 0.021), which was demonstrated even after multivariable adjustment. Moreover, a decrease of albumin levels by ≥20% from day 1 to day 3 was accompanied by a higher risk of 30-days all-cause mortality (56% vs. 39%; log-rank p = 0.036; HR = 1.645; 95% CI 1.014-2.669; p = 0.044). Especially when combined with lactate, creatinine, and cardiac troponin I, reliable discrimination of 30-day all-cause mortality was observed, including albumin in CS risk stratification models (AUC = 0.745; 95% CI 0.677-0.814; p = 0.001). In conclusion, low baseline albumin levels as well as a decay of albumin levels during the course of ICU treatment, deteriorate prognostic outcomes in CS patients. The additional assessment of albumin levels may further improve risk stratification in CS patients.

Low serum albumin: A neglected predictor in patients with cardiovascular disease

Albumin, the most abundant circulating protein in blood, is an essential protein which binds and transports various drugs and substances, maintains the oncotic pressure of blood and influences the physiological function of the circulatory system. Albumin also has anti-inflammatory, antioxidant, and antithrombotic properties. Evidence supports albumin's role as a strong predictor of cardiovascular (CV) risk in several patient groups. Its protective role extends to those with coronary artery disease, heart failure, hypertension, atrial fibrillation, peripheral artery disease or ischemic stroke, as well as those undergoing revascularization procedures or with aortic stenosis undergoing transcatheter aortic valve replacement, and patients with congenital heart disease and/or endocarditis. Hypoalbuminemia is a strong prognosticator of increased all-cause and CV mortality according to several cohort studies and meta-analyses in hospitalized and non-hospitalized patients with or without comorbidities. Normalization of albumin levels before discharge lowers mortality risk, compared with hypoalbuminemia before discharge. Modified forms of albumin, such as ischemia modified albumin, also has prognostic value in patients with coronary or peripheral artery disease. When albumin is combined with other risk factors, such as uric acid or C-reactive protein, the prognostic value is enhanced. Although albumin supplementation may be a plausible approach, its efficacy has not been established and in patients with hypoalbuminemia, priority is focused on diagnosing and managing the underlying condition. The CV effects of hypoalbuminemia and relevant issues are considered in this review. Large cohort studies and meta-analyses are tabulated and the physiologic effects of albumin and the deleterious effects of low albumin are pictorially illustrated.