Risk Factors Associated With Readmission In Patients With Acute Coronary Syndrome Within 6 Months After Percutaneous Coronary Intervention

Background and objectiveAcute coronary syndrome(ACS)is a group of clinical syndromes based on the pathology of coronary atherosclerotic plaque rupture or invasion,as well as secondary complete or incomplete occlusive thrombosis.It is a common serious cardiovascular disease and a serious type of coronary heart disease.In China,there were 290 million patients with cardiovascular diseases in 2017,including 11 million patients with coronary atherosclerotic heart disease.ACS is an important cause of death of cardiovascular diseases.The total hospital mortality rate of ACS patients in China is about 5%-6%,and the incidence of recurrent myocardial infarction is 8%-11%.Rehospitalization is a common,costly and preventable event among the survivors of ACS.Although the survival rate of ACS patients has improved after hospitalization,early symptoms recurrence is still a common phenomenon with significant clinical and financial implications.Emergency or selective percutaneous coronary intervention(PCI)is the most common form of revascularization in ACS patients.The rehospitalization rate of 30 days after PCI varies from 8%to 17.9%.Most of them are related to cardiac symptoms,which significantly increases the financial burden of patients and seriously affects the quality of life of patients.Some patients need to be hospitalized many times,and repeated hospitalization leads to the increase of patients'worries and expenditures on diseases,as well as the impact on their families and the burden of care.Psychological problems such as pessimism,anxiety and depression can easily arise.These rehospitalization incidents are regarded as adverse events for patients and the health care system.However,the specific long-term readmission rate and risk factors after PCI are rarely studied and reported.Recognizing these patients with high risk of rehospitalization and their related factors,and actively taking secondary preventive measures are expected to reduce the recurrence of ACS ischemic symptoms,reduce the occurrence of psychological disorders,improve the quality of life of patients and short-term and long-term prognosis,and reduce the economic burden of patients and the country.Risk stratification or risk assessment of ACS patients is critical for clinical diagnosis,decision-making and management.At present,there are many evaluation methods for cardiovascular diseases,such as GRACE score,SYNTAX score,Euro score,Gensini score and so on.These scoring systems are widely used in clinical practice and guide clinical work.Compared with other scoring systems,the Age,Creatinine,and Ejection Fraction Score(ACEF Score)is a simple and"old"risk assessment tool.The ACEF Score with only three variables has the advantage of easy calculation,and when it is used in a small number of people with adverse events,it can avoid over-fitting many independent variables.However,there is no study on risk assessment of readmission for ACS patients after PCI.The value of ACEF score in evaluating the risk of readmission for ACS patients within 6 months after percutaneous coronary intervention is discussed while the risk factors of readmission for ACS patients are studied.MethodsClinical data of ACS patients undergoing PCI from January 1,2015 to December 30,2017 in the Department of Cardiovascular Medicine,Xijing Hospital were collected.ACS patients were diagnosed as ST elevation myocardial infarction(STEMI),non-ST elevation myocardial infarction(NSTEMI),unstable angina pectoris(UA).STEMI diagnostic criteria:dynamic changes of troponin>99th normal reference value upper limit or creatine kinase isozyme>99th normal reference value upper limit,electrocardiographic manifestations were ST-segment arch back-up elevation or new left bundle branch block,accompanied by one or more of the following conditions:persistent ischemic chest pain;echocardiography showed abnormal segmental ventricular wall activity;abnormal coronary angiography.NSTEMI diagnostic criteria:dynamic changes of troponin>99th normal reference value upper limit or creatine kinase isoenzyme>99th normal reference value upper limit,accompanied by one or more of the following conditions:persistent ischemic chest pain;electrocardiogram manifestations of new ST segment depression or T wave low flat,inverted;echocardiography showed segmental ventricular wall activity abnormalities;coronary angiography abnormalities.UA diagnostic criteria:troponin negative,ischemic chest pain,electrocardiogram showed transient ST segment depression or T wave low flat,inverted.Patients in the case group were hospitalized twice or more within 6 months after PCI for ACS from January 1,2015 to December 30,2017.The control group was hospitalized patients who had not been hospitalized again after PCI because of ACS.Inclusion criteria of case group:From January 1,2015 to December 30,2017,ACS patients were hospitalized again or more within 6 months after PCI,with complete clinical data.Inclusion criteria of control group:From January 1,2015 to December 30,2017,25patients with ACS who were not hospitalized again 6 months after PCI in our hospital were included in the control group by random number table every month.Outpatient follow-up or telephone follow-up patients had no history of hospitalization outside the hospital,and clinical data were complete.Exclusion criteria:patients in the case group were readmitted after PCI for more than 6 months;patients in the control group who did not receive PCI after first admission;lack of clinical data.The clinical data of patients and control group were retrospectively analyzed.Chi-square test,t-test or Wilcoxon rank sum test were used for univariate analysis,logistic regression model was used for multivariate analysis,and Hosmer-Lemeshow goodness-of-fit test was used to evaluate the fitting adequacy of regression model.The stepwise regression method was used to select variables for the final logistic regression model to predict the risk factors of re-hospitalization within 6 months.Chi-square test and Mann-Whitney U test were used to compare the two groups.Kruskal-Wallis test was used to draw receiver operator characteristic curve(ROC curve).Kaplan-Meier method was used to estimate the cumulative incidence of admission with different ACEF scores in 6months.Logarithmic rank test was used to compare the age,serum creatinine and ejection.The value of score in evaluating the risk of readmission in ACS patients within 6 months after PCI.According to P?0.05,the difference was statistically significant.ResultsA total of 1393 cases were selected,605 cases(43.7%)in case group and 788 cases(56.3%)in control group.Under 65 years old group:350 males and 93 females in case group,400 males and 137 females in control group.The group over 65 years old:115males and 52 females in the case group,141 males and 109 females in the control group.Thirty-seven items were selected for univariate analysis.The results showed that sex,smoking,history of myocardial infarction,history of angina pectoris,history of heart failure,history of diabetes mellitus,white blood cell count,high density lipoprotein,troponin,CK-MB,myoglobin,BNP,ST segment changes of ECG,LVEF,types of acute coronary syndrome(STEMI,NSTEMI,unstable angina pectoris),the number of coronary artery lesions,Gensini score,aspirin,tegrillo,ACEI/ARB,diuretics were correlated with the readmission of ACS patients 6 months after PCI.Multivariate regression analysis showed that male,age>65 years old,history of diabetes mellitus,white blood cell count>10×10~9/L,ST segment changes of ECG and multivessel lesions were main risk factors for readmission of ACS patients within 6 months after PCI.Risk ratio(OR)and95%confidence interval(CI)were 1.495(1.075-2.08),1.481(1.078-2.034),3.025(1.547-5.913),2.829(1.879-4.258),1.731(1-2.47),3.907(2.861-5.336),respectively.Aspirin use was an main protective factor for hospitalization of ACS patients within 6months after PCI.The risk ratio(OR)and 95%confidence interval(CI)were 0.184(0.053-0.64),respectively.After sex and age stratification,it can be concluded that the risk factors of re-hospitalization 6 months after PCI in male group?65 years old are diabetes mellitus history(OR 1.696;95%CI 1.04-2.765),myocardial infarction history(OR 2.526,95%CI 1.608-3.967),white blood cell count>10×10~9/L(OR 6.69,95%CI 2.613-17.132),ST segment changes(OR 2.944,95%CI 1.935-4.481),multivessel diseases.Change(OR4.521,95%CI 2.776-7.336);the risk factors for re-hospitalization after 6 months of PCI in men over 65 years old were ST segment changes of ECG(OR 9.763,95%CI4.772-19.973)and multivessel lesions(OR 3.482,95%CI 1.494-8.114).Risk factors for re-hospitalization after PCI in women younger than 65 years old were history of myocardial infarction(OR 4.907,95%CI 1.506-15.985),elevated low density lipoprotein(OR 5.819,95%CI 1.456-23.252),elevated triglycerides(OR 3.109,95%CI 1.173-8.243),ST segment changes(OR 3.807,95%CI 1.56-9.288),multiple vessel lesions(OR 16.98,95%CI 5.432-50.075).The risk factors for rehospitalization after PCI in women over 65years old were increased triglyceride(OR 9.165,95%CI 2.075-40.486),ST segment changes of ECG(OR 10.212,95%CI 2.751-37.91),and multiple vessel lesions(OR10.172,95%CI 2.553-40.533).Among the three groups of ACEF scores(ACEF?1,1<ACEF?1.3,ACEF>1.3),the patients in the three groups were younger,more smokers,more patients with a history of MI,higher GRACE scores,and more patients with ST segment changes in ECG.In ACEF?1 group,the number of patients taking aspirin and clopidogrel was less.In group1<ACEF?1.3,the number of patients with hypertension was higher and the number of patients taking aspirin was lower.In group 1<ACEF?1.3 and ACEF>1.3,the number of patients with diabetes was higher.The area under the curve is 0.553(0.522-0.583,P<0.01).ACEF value can predict the occurrence of re-admission events in ACS patients 6months after PCI.The cumulative incidence of re-admission events in ACS patients 6months after PCI estimated by different ACEF scores(Log-rank P<0.001).The higher the ACEF score,the higher the risk of re-admission in ACS patients 6 months after PCI.Conclusion1.The factors affecting readmission of ACS patients 6 months after PCI are complicated.It relates to gender,leucocyte count,platelet count,high density lipoprotein,troponin,Gensini score,EF less than 50%,history of myocardial infarction,heart failure,diabetes and smoking,ST segment changes of electrocardiogram,aspirin,tigrelo,ACEI/ARB,diuretics,multi-vessel disease,etc.Multivariate analysis showed that male,age>65 years old,white blood cell count>Multivariate analysis showed that male,age>65 years old,white blood cell count>10×10~9/L,multiple vessel disease,history of diabetes mellitus,ST segment change of ECG are the main risk factors,and aspirin is the main protective factor.2.Risk factors for male and female readmission after different age stratification are different.Multiple vessel lesions and ST segment changes of electrocardiogram are more correlated in male patients with ACS when they are readmitted to hospital.Hyperlipidemia,especially high triglyceride,is more correlated in women patients with ACS when they are readmitted to hospital.3.The application of ACEF scoring method in risk assessment and risk stratification of readmission of ACS patients 6 months after PCI is simple and easy,which is a convenient scoring method for evaluating readmission of ACS patients.