Association of NPAC score with survival after acute myocardial infarction
Graphical abstract
Introduction
Cardiovascular diseases pose a significant disease burden worldwide and are associated with considerable years of life lost, particularly in low- and middle-income countries [1,2]. Given similar care settings and implementation of international guidelines, the long-term mortality following the first episode of acute myocardial infarction (AMI) was more than three-fold higher in developing countries as compared to European countries [3].
Infarction of the myocardium is characterized by a fluctuation in plasma leukocyte levels as part of the acute phase response [4]. Inflammation is key to its pathogenesis, placing an onus on the discovery and subsequent implementation of inflammatory biomarkers for risk stratification in clinical settings [5]. Following AMI, the absolute neutrophil count rises while the circulating lymphocyte number decreases, leading to an elevation in the plasma neutrophil-to-lymphocyte ratio (NLR) [6]. Activated neutrophils invade the infarcted region and release various mediators that perpetuate the inflammatory process [4,7]. This causes an increase in infarct size and consequently worsens the extent of myocardial ischemia [6], tissue injury and plaque damage [8]. By contrast, the ensuing reduction in plasma lymphocyte count following AMI occurs secondarily to enhanced apoptosis [9], and is probably associated with poorer prognosis in acute ST-elevation MI (STEMI) [10]. To date, a significant body of research has focused on STEMI given the high mortality and the extensive areas of myocardial involvement. However, it is recognized that a subset of non-STEMI patients remain at a high risk of mortality. Yet, risk stratification in NSTEMI can be challenging. A number of risk scores have demonstrated proven utility, but clinicians may be reluctant to use these during clinical practice at bedside because of the time-consuming nature to calculate them [11]. Moreover, recent research has devised increasingly complex scores incorporating different novel biomarkers [12], which may not be readily available in all centers.
With a greater understanding of the mechanistic roles of both neutrophils and lymphocytes in AMI patients, NLR has recently emerged as a cost-effective biomarker for clinical outcomes in several cardiovascular diseases. NLR is a readily accessible biomarker for ongoing inflammation [13]. However, the discriminatory power of neutrophil-to-lymphocyte counts alone for mortality remains sub-optimal [14], leading to the search of its combination with other hematological markers for risk stratification. While increasing the number of variables into a composite scoring system maximizes its predictability, it compromises the simplicity for clinical use.
Our study aim was to determine independent parameters including clinical risk factors and hematological parameters for short-term mortality in incident cases of acute myocardial infarction. A small set of significant parameters were identified for model simplicity. We developed a scoring system based on adjusted odds ratio for easy clinical use. A deep learning model was also developed as a gatekeeper to provide more accurate survival classification to facilitate clinical decision-making.
Section snippets
Study design, population and case identification
This retrospective single center observational study was conducted on consecutive admissions due to a first episode of acute myocardial infarction using the electronic health records registry database of the Prince of Wales Hospital, Hong Kong, between January 2013 and December 2017 (derivation cohort). The center is a university-affiliated teaching hospital with 173,114 discharges and registered in-hospital deaths per year collectively, and the sole trauma center in the territory where 7.3
Baseline characteristics
From 2013 through 2017, 2249 unique cases with principal diagnosis of first episode of acute myocardial infarction were identified. Of these, 122 patients (5.4%) had incomplete laboratory data, and were therefore removed from subsequent analysis. A total of 2127 patients were finally included in this study. The mean age (standard deviation) was 71.08 ± 14.04 years. The majority was male (65.5%). Of note, the proportion of elders (≥65 years) was over-represented in the female group as compared
Discussion
In this large cohort study, we developed and validated a rapid and easy-to- use risk stratification tool for acute myocardial infarction. The timing for percutaneous coronary intervention in the non-STEMI population is important [17]. As such, we developed the four-variable NPAC scoring system for short-term mortality risk stratification in patients experiencing their first episode of AMI, regardless of ST-elevation. The NPAC scoring system consists of age, history of PVD, serum creatinine and
Financial support
Gary Tse was supported by the Croucher Foundation, Hong Kong.
Author contributions
Christien KH Li: Study conception, manuscript drafting, data-analysis and data collection.
Jeffery Ho: Data collection and data analysis.
Zhongzhi Xu: Data-analysis, deep learning model and critical appraisal.
Ishan Lakhani: Data collection and data analysis.
Ying Zhi Liu: Deep learning model and data collection.
George Bazoukis: Critical appraisal and data analysis.
Tong Liu: Critical appraisal and data collection.
Wing Tak Wong: Critical appraisal and data collection.
Shuk Han Cheng: Data collection.
Declaration of competing interest
The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript.
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These authors contributed equally to this work.