A Synergistic Effect of Lp(a) and GRACE Score on Cardiovascular Risk in Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention: A Cohort Study From China

Adjustment of the GRACE score by the stress hyperglycemia ratio improves the prediction of long-term major adverse cardiac events in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A multicenter retrospective study

AIMS

The predictive value of the stress hyperglycemia ratio (SHR) for long-term prognosis in acute coronary syndrome (ACS) is inconsistent. Whether the SHR provides additional prognostic value in addition to the GRACE score in ACS patients undergoing percutaneous coronary intervention (PCI) remains unknown.

METHODS

A development-validation method was adopted to develop an algorithm to adjust the GRACE score using the SHR in ACS patients undergoing PCI from 11 hospitals.

RESULTS

During a median follow-up of 31.33 months, the occurrence of major adverse cardiac events (MACEs), defined as a composite of all-cause mortality and nonfatal myocardial infarction, was more frequent in the patients with a higher level of SHR. The SHR independently predicted long-term MACEs (hazard ratio 3.3479; 95% CI 1.4103-7.9475; P = 0.0062). Adjustment of the GRACE risk by addition of the SHR increased the C-statistic from 0.706 (95% CI: 0.599-0.813) to 0.727 (95% CI: 0.616-0.837) (P < 0.01), with a continuous net reclassification improvement of 30.5% and an integrated discrimination improvement of 0.042 (P < 0.01) in the derivation cohort; and addition of the SHR showed superior discrimination and good calibration in the validation cohort.

CONCLUSIONS

The SHR is an independent predictor of long-term MACEs in ACS patients undergoing PCI and markedly improves the performance of the GRACE score.

Lipoprotein (a) and Cardiovascular Disease: A Missing Link for Premature Atherosclerotic Heart Disease and/or Residual Risk

ABSTRACT

Lipoprotein(a) or lipoprotein "little a" is an under-recognized causal risk factor for cardiovascular (CV) disease (CVD), including coronary atherosclerosis, aortic valvular stenosis, ischemic stroke, heart failure and peripheral arterial disease. Elevated plasma Lp(a) (≥50 mg/dL or ≥100 nmol/L) is commonly encountered in almost 1 in 5 individuals and confers a higher CV risk compared to those with normal Lp(a) levels, although such normal levels have not been generally agreed upon. Elevated Lp(a) is considered a cause of premature and accelerated atherosclerotic CVD. Thus, in patients with a positive family or personal history of premature coronary artery disease (CAD), Lp(a) should be measured. However, elevated Lp(a) may confer increased risk for incident CAD even in the absence of a family history of CAD, and even in those who have guideline-lowered LDL-cholesterol (<70 mg/dl) and continue to have a persisting CV residual risk. Thus, measurement of Lp(a) will have a significant clinical impact on the assessment of atherosclerotic CVD risk, and will assume a more important role in managing patients with CVD with the advent and clinical application of specific Lp(a)-lowering therapies. Conventional therapeutic approaches like lifestyle modification and statin therapy remain ineffective at lowering Lp(a). Newer treatment modalities, such as gene silencing via RNA interference with use of antisense oligonucleotide(s) or small interfering RNA molecules targeting Lp(a) seem very promising. These issues are herein reviewed, accumulated data are scrutinized, meta-analyses and current guidelines are tabulated and Lp(a)-related CVDs and newer therapeutic modalities are pictorially illustrated.