Comparison of Mortality Outcomes in Acute Myocardial Infarction Patients With or Without Standard Modifiable Cardiovascular Risk Factors

Ching-Hui Sia; Junsuk Ko; Huili Zheng; Andrew Fu-Wah Ho; David Foo; Ling-Li Foo; Patrick Zhan-Yun Lim; Boon Wah Liew; Ping Chai; Tiong-Cheng Yeo; James W L Yip; Terrance Chua; Mark Yan-Yee Chan; Jack Wei Chieh Tan; Gemma Figtree; Heerajnarain Bulluck; Derek J Hausenloy

doi:10.3389/fcvm.2022.876465

Comparison of Mortality Outcomes in Acute Myocardial Infarction Patients With or Without Standard Modifiable Cardiovascular Risk Factors

Front Cardiovasc Med. 2022 Apr 14:9:876465. doi: 10.3389/fcvm.2022.876465. eCollection 2022.

Authors

Ching-Hui Sia^{1

2}, Junsuk Ko³, Huili Zheng⁴, Andrew Fu-Wah Ho^{5

6

7}, David Foo⁸, Ling-Li Foo⁴, Patrick Zhan-Yun Lim⁹, Boon Wah Liew¹⁰, Ping Chai^{1

2}, Tiong-Cheng Yeo^{1

2}, James W L Yip^{1

2}, Terrance Chua¹¹, Mark Yan-Yee Chan^{1

2}, Jack Wei Chieh Tan¹¹, Gemma Figtree¹², Heerajnarain Bulluck¹³, Derek J Hausenloy^{2

6

14

15

16}

Affiliations

¹ Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.
² Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
³ MD Program, Duke-NUS Medical School, Singapore, Singapore.
⁴ Health Promotion Board, National Registry of Diseases Office, Singapore, Singapore.
⁵ SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore, Singapore.
⁶ National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore.
⁷ Pre-hospital and Emergency Care Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.
⁸ Tan Tock Seng Hospital, Singapore, Singapore.
⁹ Khoo Teck Puat Hospital, Singapore, Singapore.
¹⁰ Changi General Hospital, Singapore, Singapore.
¹¹ Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore.
¹² Sydney Medical School (Northern), University of Sydney, Sydney, NSW, Australia.
¹³ Leeds Teaching Hospital NHS trust, Leeds, United Kingdom.
¹⁴ Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore, Singapore.
¹⁵ The Hatter Cardiovascular Institute, University College London, London, United Kingdom.
¹⁶ Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taichung City, Taiwan.

Abstract

Background: Acute myocardial infarction (AMI) cases have decreased in part due to the advent of targeted therapies for standard modifiable cardiovascular disease risk factors (SMuRF). Recent studies have reported that ST-elevation myocardial infarction (STEMI) patients without SMuRF (termed "SMuRF-less") may be increasing in prevalence and have worse outcomes than "SMuRF-positive" patients. As these studies have been limited to STEMI and comprised mainly Caucasian cohorts, we investigated the changes in the prevalence and mortality of both SMuRF-less STEMI and non-STEMI (NSTEMI) patients in a multiethnic Asian population.

Methods: We evaluated 23,922 STEMI and 62,631 NSTEMI patients from a national multiethnic registry. Short-term cardiovascular and all-cause mortalities in SMuRF-less patients were compared to SMuRF-positive patients.

Results: The proportions of SMuRF-less STEMI but not of NSTEMI have increased over the years. In hospitals, all-cause and cardiovascular mortality and 1-year cardiovascular mortality were significantly higher in SMuRF-less STEMI after adjustment for age, creatinine, and hemoglobin. However, this difference did not remain after adjusting for anterior infarction, cardiopulmonary resuscitation (CPR), and Killip class. There were no differences in mortality in SMuRF-less NSTEMI. In contrast to Chinese and Malay patients, SMuRF-less patients of South Asian descent had a two-fold higher risk of in-hospital all-cause mortality even after adjusting for features of increased disease severity.

Conclusion: SMuRF-less patients had an increased risk of mortality with STEMI, suggesting that there may be unidentified nonstandard risk factors predisposing SMuRF-less patients to a worse prognosis. This group of patients may benefit from more intensive secondary prevention strategies to improve clinical outcomes.

Keywords: NSTEMI; SMuRF; STEMI; acute myocardial infarction; mortality; standard modifiable cardiovascular disease risk factors.