Homocysteine enhances the predictive value of the GRACE risk score in patients with ST-elevation myocardial infarction

Clinical implication of homocysteine in premature acute coronary syndrome female patients: Its distribution and association with clinical characteristics and major adverse cardiovascular events risk

Homocysteine (Hcy) is a risk factor for the presence of atherosclerotic vascular disease and hypercoagulability states, which is associated with increased risk of cardiovascular events in cardiovascular disease patients. Whereas the role of Hcy in premature acute coronary syndrome (ACS) female patients is still obscure. Hence, we aimed to explore the relationship of Hcy with clinical features, and more importantly, to probe its predictive value for major adverse cardiovascular events (MACE) risk in premature ACS female patients.By retrospectively reviewing the medical charts of 1441 premature ACS female patients, we collected patients' Hcy level (at diagnosis) and other clinical data. According to the follow-up records, the accumulating MACE occurrence was calculated.Hcy presented with a skewed distribution with median value 11.3 μmol/L (range: 4.4-64.0 μmol/L, inter quartile: 9.2-14.1 μmol/L). Hcy was associated with older age, heavy body mass index, dysregulated liver/renal/cardiac indexes, hypertension history, and old myocardial infarction history. The 1-year, 3-year, 5-year MACE incidence was 2.9%, 10.7%, and 12.6%, respectively. Interestingly, Hcy was increased in 1-year MACE patients compared with 1-year non-MACE patients, in 3-year MACE patients compared with 3-year non-MACE patients, in 5-year MACE patients compared with 5-year non-MACE patients, and it had a good value for predicting 1-year/3-year/5-year MACE risk. Furthermore, Hcy was also correlated with increased accumulating MACE occurrence.Hcy associates with increased age and body mass index, dysregulated liver, renal, and cardiac indexes; more interestingly, it predicts increased MACE risk in premature ACS female patients.

Homocysteine and long-term recurrent infarction following an acute coronary syndrome

BACKGROUND

There are no well-established predictors of recurrent ischemic coronary events after an acute coronary syndrome (ACS). Higher levels of homocysteine have been reported to be associated with an increased atherosclerotic burden. The primary endpoint was to assess the relationship between homocysteine at discharge and very long-term recurrent myocardial infarction (MI).

METHODS

1306 consecutive patients with ACS were evaluated (862 with non-ST-segment elevation ACS [NSTEACS] and 444 with ST-segment elevation myocardial infarction [STEMI]) discharged from October 2000 to June 2003 in a single teaching-center. The relationship between homocysteine at discharge and recurrent MI was evaluated through bivariate negative binomial regression accounting for mortality as a competitive event.

RESULTS

The mean age was 66.8 ± 12.4 years, 69.1% were men, and 32.2% showed prior diabetes mellitus. Most of the patients were admitted for an NSTEACS (66.0%). The median (interquartile range) GRACE risk score, Charlson comorbidity index, and homocysteine were 144 (122-175) points, 1 (1-2) points, and 11.9 (9.3-15.6) μmol/L, respectively. In-hospital revascularization was performed in 26.3% of patients. At a median follow-up of 9.7 (4.5-15.1) years, 709 (54.3%) deaths were registered and 779 recurrent MI in 478 (36.6%) patients. The rates of recurrent MI were higher in patients in the upper homocysteine quartiles (p < 0.001). After a multivariate adjustment, homocysteine along its continuum remained almost linearly associated with a higher risk of recurrent MI (p = 0.001) and all-cause mortality (p < 0.001).

CONCLUSIONS

In patients with ACS, higher homocysteine levels identified those at a higher risk of recurrent MI at very long-term follow-up.

Prognostic value of the combination of GRACE risk score and mean platelet volume to lymphocyte count ratio in patients with ST-segment elevation myocardial infarction after percutaneous coronary intervention

The Global Registry of Acute Coronary Events (GRACE) risk score and the mean platelet volume to lymphocyte count ratio (MPVLR) can be used independently to predict adverse outcomes in patients with acute coronary syndromes. However, the level of MPVLR in relation to the GRACE score, and whether a combination of these methods can better predict the clinical adverse outcome of patients with ST-segment elevation myocardial infarction (STEMI), have not been previously examined. Therefore, the aim of the present study was to investigate whether the combination of GRACE risk score and MPVLR is a good predictor of a 30-day major adverse cardiovascular events (MACE) in patients with STEMI. A total of 464 patients with STEMI undergoing percutaneous coronary intervention (PCI) were enrolled, and divided into four groups based on the optimal cut-off values for GRACE score and MPVLR. GRACE score and MPVLR levels were separately recorded during admission. Spearman's rank correlation analysis showed a positive correlation between GRACE score and MPVLR (ρ=0.304; P<0.001). Both GRACE score [hazard ratio (HR), 1.706; 95% CI, 1.435-3.058; P<0.001] and MPVLR level (HR, 1.668; 95% CI, 1.202-2.170; P<0.001) were found to be independent predictors of a 30-day MACE. Additionally, the high MPVLR + high GRACE score group of patients had an HR of 2.455 (95% CI, 1.736-3.188) for a 30-day MACE, when using the low MPVLR + low GRACE score group as a reference. Based on the area under the curve, MPVLR combined with GRACE scores achieved an improved performance in differentiating angiographic no-reflow during a 30-day MACE, compared with individual MPVLR and GRACE scores. Therefore, the present results suggested that the GRACE score may be positively correlated with MPVLR and that their combination accurately predicted the occurrence of short-term MACE in patients with STEMI after PCI.

Biomarkers enhance the long-term predictive ability of the KAMIR risk score in Chinese patients with ST-elevation myocardial infarction

Background:

The Global Registry of Acute Coronary Events (GRACE) score is recommended by current ST-elevation myocardial infarction (STEMI) guidelines. But it has inherent defects. The present study aimed to investigate the more compatible risk stratification for Chinese patients with STEMI and to determine whether the addition of biomarkers to the Korea Acute Myocardial Infarction Registry (KAMIR) score could enhance its predictive value for long-term outcomes.

Methods:

A total of 1093 consecutive STEMI patients were included and followed up 48.2 months. Homocysteine, hypersensitive C-reactive protein (hs-CRP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were detected. The KAMIR score and the GRACE score were calculated. The performance between the KAMIR and the GRACE was compared. The predictive power of the KAMIR alone and combined with biomarkers were assessed by the receiver-operating characteristic (ROC) curve.

Results:

The KAMIR demonstrated a better risk stratification and predictive ability than the GRACE (death: AUC = 0.802 vs. 0.721, P < 0.001; major adverse cardiovascular events (MACE): AUC = 0.683 vs. 0.656, P < 0.001). It showed that the biomarkers could independently predict death [homocysteine: HR = 1.019 (1.015–1.024), P < 0.001; hs-CRP: HR = 1.052 (1.000–1.104), P = 0.018; NT-pro BNP: HR = 1.142 (1.004–1.280), P = 0.021] and MACE [homocysteine: HR = 1.019 (1.015–1.024), P < 0.001; hs-CRP: HR = 1.012 (1.003–1.021), P = 0.020; NT-pro BNP: HR = 1.136 (1.104–1.168), P = 0.006]. When they were used in combination with the KAMIR, the area under the ROC curve (AUC) significantly increased for death [homocysteine: AUC = 0.802 vs. 0.890, Z = 5.982, P < 0.001; hs-CRP: AUC = 0.802 vs. 0.873, Z = 3.721, P < 0.001; NT-pro BNP: AUC = 0.802 vs. 0.871, Z = 2.187, P = 0.047; homocysteine, hs-CRP and NT-pro BNP: AUC = 0.802 vs. 0.940, Z = 6.177, P < 0.001] and MACE [homocysteine: AUC = 0.683 vs. 0.771, Z = 6.818, P < 0.001; hs-CRP: AUC = 0.683 vs. 0.712, Z = 2.022, P = 0.031; NT-pro BNP: AUC = 0.683 vs. 0.720, Z = 2.974, P = 0.003; homocysteine, hs-CRP and NT-pro BNP: AUC = 0.683 vs. 0.789, Z = 6.900, P < 0.001].

Conclusion:

The KAMIR is better than the GRACE in risk stratification and prognosis prediction in Chinese STEMI patients. A combination of above-mentioned biomarkers can develop a more predominant prediction for long-term outcomes.