Baseline plasma lipid levels in patients with acute coronary syndrome: Association with 20-year mortality. The ABC-5a* Study on Heart Disease

Revisiting the lipid paradox in ST-elevation myocardial infarction in the Chinese population: findings from the CCC-ACS project

AIMS

Previous observations revealed a negative association between low-density lipoprotein cholesterol (LDL-C) and clinical outcomes following myocardial infarction, i.e., the lower level the higher mortality, which was referred to as lipid paradox. We sought to re-evaluate this association in ST-elevation myocardial infarction (STEMI) in contemporary practice.

METHODS AND RESULTS

We examined the association between admission LDL-C and in-hospital mortality among 44 563 STEMI patients enrolled from 2014 to 2019 in a nationwide registry in China. A total of 43 covariates, which were temporally classified into the following three domains were used for adjustment: (i) pre-admission characteristics; (ii) percutaneous coronary intervention (PCI)-related variables; and (iii) other in-hospital medications. In-hospital mortality was 2.01% (897/44 563). When no covariate adjustment was performed, an inversely 'J-shaped' curve was observed between admission LDL-C levels and in-hospital mortality by restricted cubic spline in logistic regression, with a threshold value of <75 mg/dL that associated with increased risk for in-hospital mortality. However, a gradual attenuation for this association was noted when step-wise adjustments were performed, with the threshold values for LDL-C decreasing from 75 mg/dL to 70 mg/dL after accounting for pre-admission characteristics, further to 65 mg/dL after accounting for PCI-related variables, and finally to no statistical association after further adjustment for other in-hospital medications.

CONCLUSIONS

In a nationwide registry in China, our findings do not support the lipid paradox in terms of in-hospital mortality in STEMI patients in contemporary practice. Previous findings in this scenario are possibly due to inadequate control for confounders.

Predicting One-Year Deaths and Major Adverse Vascular Events with the Controlling Nutritional Status Score in Elderly Patients with Non-ST-Elevated Myocardial Infarction Undergoing Percutaneous Coronary Intervention

The prognostic value of malnutrition in elderly patients with non-ST-elevated myocardial infarction (NSTEMI) is not fully understood. Nutritional characteristics were evaluated by novel Controlling Nutritional status (CONUT), the prognostic nutritional index (PNI) and the geriatric nutritional risk index (GNRI) scores. The impact of these scores on major outcomes in 253 NSTEMI patients over 60 years and older were assessed. Compared to those with good nutritional status; malnourished patients had more major adverse cardiac and cerebrovascular events (MACCEs) at 1-year follow up. Multivariable cox regression analysis revealed that CONUT (hazard ratio = 1.372; p < 0.01) was independent predictor of MACCEs, whereas PNI (p = 0.44) and GNRI (p = 0.52) were not. The discriminating power of the CONUT (AUC: 0.79) was adequate and significantly superior to both the PNI (AUC: 0.68) and the GNRI (AUC: 0.60), with a p-value for both < 0.01. Patients with elevated CONUT exhibited the highest event rate for all-cause mortality and MACCEs in survival analysis (p < 0.01). We conclude that malnutrition is strongly associated with adverse outcomes in older patients with NSTEMI. In fact, the CONUT score adequately predicts one-year MACCEs among elderly NSTEMI patients who achieve complete revascularization after coronary intervention.