Assessment Of Disease Severity And Prognostic Risk In Patients With Acute Coronary Syndrome And Diabetes Mellitus

BackgroundCoronary artery disease as well as diabetes mellitus(DM),is acknowledged as a chronic inflammatory disease.Consistent and low-level inflammation plays a crucial role in the initiation,progression,and prognosis of aforementioned diseases.High-sensitivity C-reactive protein(hs-CRP)is one of the most widely-explored biomarkers in clinical practice which can sensitively test low concentration of inflammation.Patients diagnosed with both acute coronary syndrome(ACS)and DM are regarded to be at very high risk of thrombotic events.For now,there is no convincing evidence about the role of hs-CRP in predicting complexity and severity of lesions together with long-term outcomes.In particular,we lack abundant data from large research with regard to Chinese population.Whether hs-CRP is able to guide management is yet to be investigated.ObjectivesThe present study sought to evaluate the effect of serum hs-CRP in lesion severity and long-term outcomes in patients with both DM and ACS.MethodsBetween January 2013 and December 2013,we enrolled patients with both ACS and DM who underwent percutaneous coronary intervention in Fuwai Hospital consecutively.Subjects were divided into three groups according to serum hs-CRP at baseline:low-risk(<3.00 mg/L),intermediate-risk(3.00-9.99 mg/L),and high-risk(?10mg/L)groups.Use SYNTAX score to measure the complexity and severity of lesions.Multivariable logistic regression analysis was conducted to assess the relationship between hs-CRP and SYNTAX score.The primary endpoint was all-cause death.And the secondary endpoints were MACCE(major adverse cardiovascular and cerebrovascular events).The latter one is defined as one or more occurrences of all-cause death,myocardial infarction,revascularization,or stroke.Kaplan-Meier curves and Cox regression models were performed to determine the prognostic factors.ResultsA total of 2,616 patients were eligible in the present study.Specifically,the numbers and proportions of low-risk,intermediate-risk,and high-risk groups were 1617(61.8%),614(23.5%),and 385(14.7%),respectively.From analysis of baseline characteristics,itConclusionsIn patients with ACS and DM,hs-CRP was significantly associated with complexity and severity of lesions,especially in high-risk patients.Although hs-CRP was not an independent predictor for long-term outcomes,it could aid in risk stratification by influencing SYNTAX score which could portend adverse events.BackgroundDyslipidemia plays a crucial role in acute coronary syndrome(ACS).Apolipoprotein(apo)A-I and apoB are main components of lipoprotein.The ratio of apoB/A-I is considered to be a reflection of the balance between pro-atherogenic and anti-atherogenic effects.To date,paucity data are available concerning the impact of apoB/A-I ratio in the context of ACS patients with diabetes.ObjectivesThe present research aimed to(1)investigate the association between apo ratio and the severity and complexity of lesions(2)estimate the prognostic value of apoB/A-I for the long-term outcomes in patients with both ACS and diabetes mellitus.MethodsThe present research was post-hoc analysis of a large,single-center,prospective,and observational study.Between January 2013 and December 2013,a total of 2563 ACS patients with diabetes who underwent percutaneous coronary intervention were enrolled in the analysis.Patients were divided into two groups based on apoB/apoA-1 ratio on admission:<0.63(n=1279,49.9%)and>0.63(n=1284,50.1%).Angiographic complexity and severity were determined by SYNTAX score.Use multivariable logistic regression analysis to determine the relationship between apo ratio and SYNTAX score.Kaplan-Meier curves and Cox regression model were performed to find the independent predictors of long-term outcomes.ResultsPatients with high apoB/apoA-I ratio were younger,had fewer comorbidities,but more glucose and lipid abnormalities.High apo ratio was significantly associated with more onset of acute myocardial infarction(MI)and higher rates of intermediate-high SS.Multivariable logistic regression analysis showed that apo ratio>0.63(OR 1.341,95%confidence interval 1.039-1.730,p=0.024),presence of acute MI,and low glomerular filtration rate(<60 ml/min)were independent factors of complicated lesions.Moreover,consistent results were found in the subgroups of normal concentrations of conventional lipid parameters.During a median follow-up period of 878 days,although two groups had similar survival rates,significant differences were found in peri procedural MI(1.0%versus 2.2%,p=0.019)and total events of MI(2.0%versus 3.3%,p=0.028).After adjusting confounders,multivariable Cox proportional regression model demonstrated that high apoB/apoA-I ratio remained independently predictive of MI,the risks of which were doubled during periprocedural period and in the long term.ConclusionsIn patients with ACS and diabetes,apoB/A-I is an independent predictor of both complicated lesions and long-term outcomes.The unconventional lipid index could aid in stratify complex lesions as well as high-risk population and therefore guide post operational management.BackgroundBilirubin,the end product of heme metabolism,is regarded as an endogenous antioxidant.There are cumulative studies that support the protective effect of total bilirubin against the onset of cardiovascular disease.Some also correlate mildly elevated bilirubin with improvement of insulin sensitivity.Nevertheless,a few contradictory findings in established acute coronary syndrome(ACS)make this issue inconclusive.In light of direct bilirubin(DB,also known as conjugated bilirubin),scarce evidence is available regarding its effect in either diagnosis or risk stratification of ACS.Until now,there is little research concentrating on the performance of bilirubin in complicated and high-risk ACS population.ObjectivesThe objectives of the present study are as follows:(1)To evaluate whether the level of DB on admission can indicate angiographic manifestations in ACS patients with all three-vessel stenoses.(2)To assess the relationship between DB and long-term prognosis,especially the effect of DB in the different settings of glucose metabolism(i.e.,normal glucose metabolism,pre-diabetes and diabetes).(3)To see the combinative performance of DB together with SYNTAX score ?.MethodsThe present study was a post hoc analysis of a large prospective cohort.From April 2004 to February 2011,5322 ACS patients presenting with three-vessel disease were consecutively enrolled.Identification of normal glucose regulation,pre-diabetes and diabetes according to a previous diagnosis of diabetes,hypoglycemic medications,fasting blood glucose and hemoglobin Alc.Disease severity and complexity were determined by SYNTAX score(SS)and SS ?.All patients achieved at least one follow-up and the last follow-up ended up in March 2016.The primary endpoint was all-cause mortality and the secondary endpoints were major adverse cardiovascular and cerebrovascular events(MACCE).The latter one is defined as one or more occurrences of all-cause death,myocardial infarction,revascularization,or stroke.ResultsSubjects were divided into quartiles according to baseline DB:Q1(0-1.60?mol/L),Q2(1.61-2.20?mol/L),Q3(2.21-2.80?mol/L),and Q4(>2.80?mol/L).Patients with higher DB were older,more often to be male,and had higher proportions of previous history of MI and smoking.However,relatively fewer cases of diabetes or hyperlipidemia were found following DB elevation.Multivariable logistic regression analysis showed that DB was an independent predictor of intermediate-high SS(>22).During a median follow-up time of 6.5 years,elevated DB was associated with more all-cause death(14.7%vs 14.4%vs 18.5%vs 19.3%,p<0.001).After adjusting for confounding factors,DB remained to be predictive of all-cause death in multivariable Cox regression model(Q1 vs Q4:HR 0.757,95%CI 0.613-0.934,p=0.01;Q2 vs Q4:HR 0.798,95%CI 0.644-0.988,p=0.038,Q3 vs Q4:HR 0.947,95%CI 0.775-1.157,p=0.595).Furthermore,when stratifying subjects according to glucose metabolism regulation and treatment strategies,the predictivity of DB was only profound in patients with diabetes or with conservative treatment.For those with normal glucose regulation or pre-diabetes as well as those undergoing intervention or cardiac surgery,there is no association between DB and mortality.Additionally,incorporating DB further improved the discrimination and reclassification abilities of SS? for risk prediction.ConclusionsDB is positively correlated with lesion severity in ACS patients with three-vessel disease.In the meantime,it serves as a potential biomarker for predicting long-term mortality,especially those who are concomitant with diabetes.Incorporating DB into the established scoring system could helpfully guide risk stratification and management.