Predictive value of the age, creatinine, and ejection fraction score in patients with myocardial infarction with nonobstructive coronary arteries

Abstract

Background: Little is known about risk stratification in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA). We investigated whether the age, creatinine, and ejection fraction (ACEF) score (age [years]/ejection fraction [%] + 1 [if creatinine >176 μmol/L]) might predict long-term outcomes after MINOCA.

Hypothesis: The ACEF score enables accurate risk prediction in patients with MINOCA.

Methods: A total of 1179 patients with MINOCA were enrolled and divided based on their ACEF score tertile levels. The primary endpoint was a composite of major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, nonfatal stroke, revascularization, and hospitalization for unstable angina or heart failure. Kaplan-Meier and Cox regression analyses were performed. Discrimination was defined as the area under the curve (AUC) using receiver operating characteristic analysis.

Results: During the median follow-up of 41.7 months, patients with MINOCA with higher ACEF score tertiles had a significantly higher incidence of MACE (6.3%, 12.5%, and 23.8%, respectively; p < .001). The adjusted risk of MACE increased with the rising ACEF score tertiles (1st tertile as reference; 2nd tertile: HR 2.70, 95% CI: 1.38-5.29, p = .004; and 3rd tertile: HR 5.35, 95% CI: 2.72-10.51, p < .001). Moreover, an elevated ACEF score was closely associated with an increased risk of MACE overall (HR 4.23, 95% CI: 3.37-5.30, p < .001) and in subgroups (all p < .05). The ACEF score also yielded a good predictive value (AUC 0.79) for MACE.

Conclusion: Elevated ACEF scores were strongly associated with a poor prognosis after MINOCA. This simple and valid risk score may facilitate risk stratification and decision making in the population with MINOCA.

Keywords: ACEF score; cardiovascular outcomes; myocardial infarction with nonobstructive coronary arteries (MINOCA); risk stratification.

FIGURE 1

Study flowchart

FIGURE 2

Cumulative incidence of MACE in patients with MINOCA stratified by the age, creatinine, and ejection fraction (ACEF) score tertiles. Low ACEF score: ACEF <0.83, Medium ACEF score: 0.83 ≤ ACEF <1.02, High ACEF score: ACEF ≥1.02

FIGURE 3

Predictive value of the risk factors and risk scores for MACE. Receiver operating characteristic curves showing the predictive value of age, creatinine, ejection fraction (EF), diabetes, ACEF score, and GRACE score for MACE in patients with MINOCA. AUC, area under the curve; GRACE, Global Registry of Acute Coronary Event; MACE, major adverse cardiovascular events; MINOCA, myocardial infarction with nonobstructive coronary arteries