Prognostic Value Of Admission Non Myocardium Markers In Patients With ST-segment Elevation Myocardial Infarction

Risk stratification and prognosis evaluation of patients with acute myocardial infarction (AMI) has always been concerned. Risk assessment for patients with AMI should use the simple and easily accessible clinical variables before admission or on admission. Some baseline characteristics such as age, heart rate, blood pressure, Killip class have been clearly proved to be strong independent predictors of short and long term mortality. Recently, some studies have shown that high glucose levels, hyponatraemia and anemia on admission are associated with increased mortality in patients with AMI. However, previous studies have some limitations, or the sample size is too small; or the sample size is large, but the results are not consistent. Little is known about the prognostic impact of the hemoglobin A1c, hyponatraemia and anemia in Chinese patients. To address these gaps in knowledge, the present study was designed with four parts:Part1:The impact of hemoglobin A1c on the prognosis of patients with ST-segment elevation myocardial infarction.Part2:The comparison of the predictive value of hemoglobin A1c and acute glucose level for short term outcomes of patients with ST-segment elevation myocardial infarction.Part3:Prognostic significance of the mean serum sodium level in patients with ST-elevation myocardial infarctionPart4:Hemoglobin level and the short term outcomes of patients with ST-segment elevation myocardial infarction. Part1:The impact of hemoglobin A1c on the prognosis of patients with ST-segment elevation myocardial infarctionObjective:To evaluate the association of the hemoglobin A1c (HbA1c) and the short term mortality and combined end point events in patients with ST-segment elevation acute myocardial infarction (STEMI) with or without history of DM.Methods:This is an observational analysis of5471Chinese STEMI patients from a global randomized controlled trial which included patients presented within12hours of symptom onset. HbA1c analyses were performed on frozen whole-blood samples collected at baseline using an automated, high-performance liquid chromatography analyzer. The study population was stratified into quintiles by HbA1c level. The HbA1c quintiles were Q1:<5.3%, Q2:5.3-<5.6%, Q3:5.6-<5.9%, Q4:5.9-<6.5%, and Q5:≥6.5%. The incidence of all-cause mortality and combined end point events of death, re-infarction, cardiogenic shock, recurrence ischemia, and stroke within7days and30days were analyzed in HbA1c quintiles. Patients were divided by the presence or absence of known history of diabetes mellitus (DM). Each group was sub-grouped by quintiles, and the above outcomes were compared across the quintiles.Results:There was no significant difference observed in7-day mortality and combined end point events in HbA1c quintiles P=0.393and P=0.253) In patients with diabetes, J-shaped relationships between HbAlc quintiles and7-day mortality as well as combined end point events were observed (P=0.002and P=0.001). The lowest mortality and combined end point events occurred in the Q2group, the highest events occurred in the Q1group followed by the Q5group. While no significant difference was observed in above events in patients without diabetes (P=0.539and P=0.542). Similar results were seen in30-day outcomes.Multivariate logistic regression analysis showed that, HbAlc level (evaluated as continuous variables) had neutral effect on7-day and30-day mortality and combined end point events (all P>0.05). Also no increased risk of mortality or combined end point events was observed across the HbA1c quintiles (all P>0.05). In patients with diabetes, increased risks of above events were observed in the Q1group.Conclusion:In patients with diabetes, J-shaped relationships existed between increased HbA1c level and mortality as well as combined end point events. While in patients without diabetes, no significant association was observed between HbA1c and above events. After multivariate adjusted, elevated HbA1c level was not a risk factor for short term outcomes in STEMI patients. Part2:The comparison of the predictive value of hemoglobin A1c and acute glucose level for short term outcomes of patients with ST-segment elevation myocardial infarction.Objective:To compare the prognostic impact of hemoglobin A1c (HbA1c) and blood glucose level in patients with acute ST-segment elevation myocardial infarction (STEMI). The relationship between HbA1c and acute hyperglycemia was also explored.Methods:Based on the same patient database of part1, first, patients were stratified into4groups according to admission glucose and HbA1c levels:Ⅰ, normal admission glucose and HbA1c; Ⅱ, The normal admission glucose and elevated HbA1c; Ⅲ:elevated admission glucose and normal HbAlc; Ⅳ: elevated admission glucose and HbA1c. Then patients were reclassified into the above groups using mean glucose (the average of admission,6h and24h glucose values in each patient) instead of admission glucose. Seven and30-day mortality and combined end point were compared across the groups. Results:In the admission glucose and HbA1c groups, the group with elevated admission glucose and normal HbA1c (Ⅲ) had the highest mortality and combined end point events rates (all P<0.05). Multivariate analysis showed that the group Ⅲ and Ⅳ had increased7-day mortality of85%and43%; increased7-day combined end point events of67%and39%; increased30-day mortality of70%and42%;30-day combined end point events of74%and50%; respectively(all P<0.05). Similar results were obtained using mean glucose instead of admission glucose. Multivariate analysis showed that the mean glucose group III and IV had increased7-day mortality of172%and69%; increased7-day combined end point events of100%and45%; increased30-day mortality of149%and67%;30-day combined end point events of135%and65%; respectively(all P<0.05).Conclusion:Unlike acute hyperglycemia, elevated HbAlc level was not a risk factor for short term outcomes in STEMI patients. Patients with acute hyperglycemia and non-elevated HbAlc were associated with the worst prognosis. That suggests chronic glycemic control/HbA1c level may help to recognize stress-induced hvperglvcemia and identify high risk patients. Part3:Prognostic significance of the mean serum sodium level in patients with ST-elevation myocardial infarctionObjective:To evaluate the association of the serum sodium level and the short term mortality and combined end point events in patients with ST-segment elevation acute myocardial infarction (STEMI).Methods:This is an observational analysis of7510Chinese STEMI patients from a global randomized controlled trial which included patients presented within12hours of symptom onset. Serum sodium level was measured at hospital admission and6and24hours after admission, respcetively. The mean serum sodium level through the first24hours for each patient was calculated. Patients were stratified into3groups according to their mean serum sodium levels of>135mmol/l (control group),130-135mmol/l, and <130mmol/L. The incidence of all-cause mortality and combined end point of death, re-infarction, cardiogenic shock, recurrence ischemia, and stroke within7days and30days in patients with various sodium levels were analyzed.Results:Hyponatraemia was present in37.5%of the total patients and13.8%with sodium level<130mmol/l. Compared with the sodium levels>135mmol/l group,7and30-day mortality, cardiogenic shock and combined end point events increased as serum sodium level decreased (all P<0.001). Patients with sodium level<130mmol/L were associated with the highest mortality, cardiogenic shock and combined end point events rates. Multivariate regression analysis showed that, the sodium level<130mmol/L groups had increased risks of7-day mortality (OR2.11,95%CI1.70-2.62, P<0.001) and combined end point events (OR2.28,95%CI1.89-2.75, P<0.001); and30-day mortality (OR1.51,95%CI1.27-1.79, P<0.001) and combined end point events (OR1.99,95%CI1.68-2.36, P<0.001) respectively.Conclusion:Serum sodium level<130mmol/l is an independent predictor of7-day and30-day mortality and combined end point events; and could be used in the assessment of short-term risk. Part4:Hemoglobin level and the short term outcomes of patients with ST-segment elevation myocardial infarctionObjective:The prognostic value of hemoglobin level in patients with ST-elevation myocardial infarction (STEMI) has not been well defined.Methods:This is an observational analysis of7414Chinese STEMI patients from a global randomized controlled trial which included patients presented within12hours of symptom onset. Patients were divided by baseline hemoglobin level of≥12g/dl (control group),11-<12g/dl,10-<11g/dl, and <10g/dl.The incidence of all-cause mortality, bleeding events, and combined end point within7days and30days in patients with different hemoglobin levels were analyzed.Results:Anemia was present in27.9%of the STEMI patients. The proportion of male patients with anemia was25.6%, female patients with anemia was33.4%. Seven and30-day mortality, bleeding events, combined end point increased significantly as hemoglobin decreased, Compared with the hemoglobin≥12g/dl group, patients with hemoglobin11-<12g/dl,10-<11g/dl, and<10g/dl were all associated with increased mortality and combined end point (all P<0.05). After multivariate adjusted, regression analysis showed that, the hemoglobin<10g/dl groups independently associated with increased risks of7-day mortality (OR1.64,95%CI1.04-2.59, P=0.035) and combined end point events (OR1.46,95%CI 1.01-2.09, P=0.036); and30-day mortality (OR1.75,95%CI1.04-2.69, P=0.011) and combined end point events (OR1.81,95%CI1.21-2.69, P=0.004) respectively. After the addition of mean glucose, serum sodium, and hemoglobin level in the7and30-day multivariate mortality models, the overall performance of the models improved as the area under the receiver operating characteristic (ROC) curve increased slightly.Conclusion:Anemia has been shown to be present in more than one quarter of STEMI patients. Hemoglobin<10g/dl identifies patients with STEMI at a high risk of death and adverse outcome events.