Backgroud
Methods
Study design, setting, and participants
Blood sampling and laboratory testing
Outcomes and covariables
Statistical analysis
Results
Study population and baseline characteristics
Variable | All participants (n = 9429) | Deceased (n = 366) | Survival (n = 9063) | p |
---|---|---|---|---|
Demographic characteristics | ||||
Sex (Women) | 2162 (22.93) | 95 (25.96) | 1067 (22.81) | 0.160 |
Age, years | 59 [51, 66] | 66 [58, 73] | 58 [51, 65] | < 0.001 |
≥ 65 | 2623 (27.82) | 203 (55.46) | 2420 (26.70) | < 0.001 |
BMI, kg/m2 | 25.91 [23.88, 27.76] | 25.71 [23.40, 27.73] | 25.91 [23.94, 27.76] | 0.052 |
≥ 25 | 5742 (60.90) | 213 [58.20] | 5529 (61.01) | 0.280 |
Current smoking | 5363 (56.88) | 210 (57.38) | 5153 (56.86) | 0.844 |
Clinical characteristics | ||||
Clinical presentation | 0.642 | |||
ACS | 5583 (59.21) | 221 (60.38) | 5362 (59.16) | |
CCS | 3846 (40.79) | 145 (39.62) | 3701 (40.84) | |
Hypertension | 6576 (69.74) | 291 (79.51) | 6285 (69.35) | < 0.001 |
Dyslipidemia | 7121 (75.52) | 269 (73.50) | 6852 (75.60) | 0.358 |
Diabetes | 3956 (41.96) | 189 (51.64) | 3767 (41.56) | < 0.001 |
Peripheral artery disease | 252 (2.67) | 16 (4.37) | 236 (2.60) | 0.040 |
COPD | 220 (2.33) | 24 (6.56) | 196 (2.16) | < 0.001 |
Previous revascularization | 2468 (26.17) | 134 (36.61) | 2334 (25.75) | < 0.001 |
Previous MI | 1826 (19.37) | 92 (25.14) | 1734 (19.13) | 0.004 |
Previous stroke | 990 (10.50) | 51 (13.93) | 939 (10.36) | 0.029 |
Medication at admission | ||||
Aspirin | 9315 (98.79) | 359 (90.09) | 8956 (98.82) | 0.209 |
Clopidogrel | 9412 (99.82) | 365 (99.73) | 9047 (99.82) | 0.576 |
Statins | 9051 (95.99) | 351 (95.90) | 8700 (95.99) | 0.929 |
β-blockers | 8493 (90.07) | 323 (88.25) | 8170 (90.15) | 0.234 |
ACEIs/ARBs | 4929 (52.27) | 204 (55.74) | 4725 (52.14) | 0.176 |
Preprocedural laboratory tests | ||||
ALC, 109/L | 1.87 [1.51, 2.30] | 1.76 [1.45, 2.20] | 1.87 [1.51, 2.31] | < 0.001 |
Serum albumin, g/L | 42.70 [39.90, 45.90] | 41.30 [38.70, 44.60] | 42.80 [40.00, 45.90] | < 0.001 |
PNI | 52.60 [49.00, 56.15] | 50.98 [46.70, 54.65] | 52.65 [49.05, 56.25] | < 0.001 |
hs-CRP, mg/L | 1.60 [0.80, 3.59] | 2.08 [1.05, 5.25] | 1.58 [0.79, 3.54] | < 0.001 |
Fasting blood glucose, mmol/L | 5.48 [4.93, 6.63] | 5.70 [5.04, 7.08] | 5.47 [4.93, 6.62] | < 0.001 |
Glycated hemoglobin, % | 6.2 [5.8, 6.9] | 6.4 [6.0, 7.3] | 6.2 [5.8, 6.9] | 0.002 |
eGFR, ml/min/1.73m2 | 118.11 [102.63, 133.24] | 111.64 [89.10, 127.53] | 118.27 [10.300, 133.50] | < 0.001 |
≤ 60 | 92 (0.98) | 16 (4.37) | 76 (0.84) | < 0.001 |
LVEF, % | 64 [60, 67] | 62 [58, 66] | 64 [60, 67] | < 0.001 |
< 40 | 102 (1.08) | 14 (3.83) | 88 (0.97) | < 0.001 |
Angiographic characteristics | ||||
LM/TVD | 412 (4.37) | 18 (4.92) | 394 (4.35) | 0.601 |
SYNTAX score | 0.911 | |||
SYNTAX category | 0.110 | |||
≤ 22 | 8367 (88.74) | 313 (85.52) | 8054 (88.87) | |
22–32 | 893 (9.47) | 43 (11.75) | 850 (9.38) | |
≥ 33 | 169 (1.79) | 10 (2.73) | 159 (1.75) | |
DES implantation | 8950 (94.92) | 340 (92.90) | 8610 (95.00) | 0.072 |
Variable | Non-DM/H-PNI (n = 4217) | Non-DM/L-PNI (n = 1256) | DM/H-PNI (n = 3130) | DM/L-PNI (n = 826) | p |
---|---|---|---|---|---|
Demographic characteristics | |||||
Sex (Women) | 835 (19.80) | 318 (25.32) | 784 (25.05) | 225 (27.24) | < 0.001 |
Age, years | 56 [49, 63] | 62 [55, 70] | 58 [51, 65] | 64 [58, 71] | < 0.001 |
≥ 65 | 872 (20.68) | 528 (42.04) | 835 (26.68) | 388 (46.97) | < 0.001 |
BMI, kg/m2 | 25.9 [23.9, 27.8] | 25.0 [22.9, 26.8] | 26.2 [24.2, 28.3] | 25.7 [23.7, 27.7] | < 0.001 |
≥ 25 | 2555 (60.59) | 619 (49.28) | 2088 (66.71) | 480 (58.11) | < 0.001 |
Current smoking | 2497 (59.21) | 672 (53.50) | 1750 (55.91) | 444 (53.75) | < 0.001 |
Clinical characteristics | |||||
Clinical presentation | < 0.001 | ||||
ACS | 1744 (41.36) | 424 (33.76) | 1409 (45.02) | 269 (32.57) | |
CCS | 2473 (58.64) | 832 (66.24) | 1721 (54.98) | 557 (67.43) | |
Hypertension | 2793 (66.23) | 852 (67.83) | 2294 (73.29) | 637 (77.12) | < 0.001 |
Dyslipidemia | 3085 (73.16) | 861 (68.55) | 2526 (80.70) | 649 (78.57) | < 0.001 |
Peripheral artery disease | 88 (2.09) | 26 (2.07) | 105 (3.35) | 33 (4.00) | < 0.001 |
COPD | 84 (1.99) | 45 (3.58) | 63 (2.01) | 28 (3.39) | 0.001 |
Previous revascularization | 947 (22.46) | 311 (24.76) | 927 (29.62) | 283 (34.26) | < 0.001 |
Previous MI | 772 (18.31) | 229 (18.23) | 634 (20.26) | 191 (23.12) | 0.004 |
Previous stroke | 359 (8.51) | 131 (10.43) | 359 (11.47) | 141 (17.07) | < 0.001 |
Medication at admission | |||||
Aspirin | 4174 (98.98) | 1230 (97.93) | 3097 (98.95) | 814 (98.55) | 0.018 |
Clopidogrel | 4209 (99.81) | 1253 (99.76) | 3126 (99.87) | 824 (99.76) | 0.822 |
Statins | 4060 (96.28) | 1222 (97.29) | 2985 (95.37) | 784 (94.92) | 0.007 |
β-blockers | 3761 (89.19) | 1114 (88.69) | 2872 (91.76) | 746 (90.31) | < 0.001 |
ACEIs/ARBs | 2048 (48.57) | 622 (49.52) | 1772 (56.61) | 487 (58.96) | < 0.001 |
Preprocedural laboratory tests | |||||
ALC, 109/L | 2.00 [1.64, 2.38] | 1.46 [1.20, 1.71] | 2.04 [1.67, 2.49] | 1.47 [1.19, 1.74] | < 0.001 |
Serum albumin, g/L | 44.20 [41.70, 46.70] | 38.60 [37.1, 40.00] | 44.10 [41.50, 46.70] | 38.40 [36.70, 40.08] | < 0.001 |
PNI | 54.00 [51.35, 57.00] | 46.25 [44.55, 47.45] | 54.25 [51.50, 57.33] | 46.15 [44.31, 47.45] | < 0.001 |
hs-CRP, mg/L | 1.40 [0.72, 2.99] | 1.74 [0.82, 4.69] | 1.72 [0.87, 3.54] | 2.27 [0.98, 9.15] | < 0.001 |
Fasting blood glucose, mmol/L | 5.13 [4.80, 5.54] | 4.95 [4.63, 5.34] | 7.04 [5.90, 8.45] | 6.74 [5.50, 8.40] | < 0.001 |
Glycated hemoglobin, % | 5.9 [5.7, 6.2] | 6.0 [5.7, 6.2] | 7.2 [6.7, 8.2] | 7.2 [6.6, 8.2] | < 0.001 |
eGFR, ml/min/1.73m2 | 119.16 [104.99, 133.64] | 115.59 [101.22, 132.21] | 118.23 [102.19, 133.70] | 114.85 [94.54, 131.67] | < 0.001 |
≤ 60 | 21 (0.50) | 11 (0.88) | 29 (0.93) | 31 (3.75) | < 0.001 |
LVEF, % | 64 [60, 68] | 63 [60, 68] | 64 [60, 67] | 62 [58, 66] | < 0.001 |
< 40 | 35 (0.83) | 17 (1.35) | 30 (0.96) | 20 (2.42) | < 0.001 |
Angiographic characteristics | |||||
LM/TVD | 166 (3.94) | 55 (4.38) | 140 (4.47) | 51 (6.17) | 0.038 |
SYNTAX score | 9 [6, 16] | 10 [6, 17] | 10 [6, 17] | 11 [6, 19] | < 0.001 |
SYNTAX category | < 0.001 | ||||
≤ 22 | 3794 (89.97) | 1122 (89.33) | 2757 (88.08) | 694 (84.02) | |
22–32 | 359 (8.51) | 111 (8.84) | 315 (10.06) | 108 (13.08) | |
≥ 33 | 64 (1.52) | 23 (1.83) | 58 (1.85) | 24 (2.91) | |
DES implantation | 4031 (95.59) | 1185 (94.35) | 2968 (94.82) | 766 (92.74) | 0.005 |
Effect of preprocedural PNI category and diabetes status on clinical outcomes
Outcome | Events/Total | Event rate per 1000 pys | Crude HR (95% CI) | p | Adjusted HR (95% CI) | p |
---|---|---|---|---|---|---|
All-cause death | 366/9429 | 7.87 | – | – | – | – |
Non-DM/H-PNI | 122/4217 | 5.83 | Reference | – | Reference | – |
Non-DM/L-PNI | 55/1256 | 8.89 | 1.53 (1.11, 2.10) | 0.009 | 1.44 (1.05, 1.98) | 0.026 |
DM/H-PNI | 113/3130 | 7.32 | 1.26 (0.97, 1.62) | 0.080 | 1.16 (0.90, 1.51) | 0.248 |
DM/L-PNI | 76/826 | 19.16 | 3.30 (2.47, 4.39) | < 0.001 | 2.65 (1.97, 3.56) | < 0.001 |
p for trend | – | – | < 0.001 | – | < 0.001 | – |
Cardiac death | 219/9429 | 4.71 | – | – | – | – |
Non-DM/H-PNI | 69/4217 | 3.30 | Reference | – | Reference | – |
Non-DM/L-PNI | 35/1256 | 5.66 | 1.72 (1.14, 2.58) | 0.009 | 1.61 (1.07, 2.43) | 0.022 |
DM/H-PNI | 67/3130 | 4.34 | 1.32 (0.94, 1.84) | 0.107 | 1.21 (0.86, 1.69) | 0.274 |
DM/L-PNI | 48/826 | 12.10 | 3.68 (2.54, 5.31) | < 0.001 | 2.83 (1.94, 4.14) | < 0.001 |
p for trend | – | – | < 0.001 | – | < 0.001 | – |
Non-fatal MI | 551/9429 | 12.18 | – | – | – | – |
Non-DM/H-PNI | 236/4217 | 11.58 | Reference | – | Reference | – |
Non-DM/L-PNI | 65/1256 | 10.75 | 0.93 (0.71, 1.22) | 0.600 | 0.91 (0.69, 1.20) | 0.495 |
DM/H-PNI | 199/3130 | 13.28 | 1.15 (0.95, 1.39) | 0.152 | 1.08 (0.89, 1.31) | 0.423 |
DM/L-PNI | 51/826 | 13.28 | 1.14 (0.84, 1.55) | 0.386 | 1.03 (0.76, 1.40) | 0.837 |
p for trend | – | – | 0.1358 | 0.4946 | ||
Non-fatal stroke | 345/9429 | 7.54 | – | – | – | – |
Non-DM/H-PNI | 115/4217 | 5.57 | Reference | – | Reference | – |
Non-DM/L-PNI | 59/1256 | 9.74 | 1.75 (1.28, 2.39) | 0.001 | 1.68 (1.22, 2.30) | 0.001 |
DM/H-PNI | 131/3130 | 8.66 | 1.56 (1.21, 2.00) | 0.001 | 1.46 (1.14, 1.88) | 0.003 |
DM/L-PNI | 40/826 | 10.32 | 1.85 (1.29, 2.66) | 0.001 | 1.63 (1.13, 2.35) | 0.009 |
p for trend | – | – | < 0.001 | – | 0.001 | – |
Unplanned revascularization | 1371/9429 | 32.46 | – | – | – | – |
Non-DM/H-PNI | 577/4217 | 30.21 | Reference | – | Reference | – |
Non-DM/L-PNI | 154/1256 | 26.98 | 0.89 (0.75, 1.07) | 0.217 | 0.89 (0.75, 1.07) | 0.220 |
DM/H-PNI | 519/3130 | 37.50 | 1.23 (1.10, 1.39) | 0.001 | 1.21 (1.07, 1.36) | 0.002 |
DM/L-PNI | 121/826 | 33.81 | 1.11 (0.91, 1.35) | 0.308 | 1.07 (0.88, 1.31) | 0.475 |
p for trend | – | – | 0.003 | – | 0.011 | – |
MACCE | 2143/9429 | 52.36 | – | – | – | – |
Non-DM/H-PNI | 851/4217 | 45.71 | Reference | – | Reference | – |
Non-DM/L-PNI | 269/1256 | 48.66 | 1.06 (0.93, 1.22) | 0.375 | 1.04 (0.91, 1.20) | 0.543 |
DM/H-PNI | 777/3130 | 58.17 | 1.26 (1.55, 1.39) | < 0.001 | 1.21 (1.10, 1.34) | < 0.001 |
DM/L-PNI | 246/826 | 71.86 | 1.55 (1.35, 1.79) | < 0.001 | 1.42 (1.23, 1.65) | < 0.001 |
p for trend | – | – | < 0.001 | – | < 0.001 | – |
Sensitivity analysis
Added value of nutritional indexes beyond the GRACE risk score
AUC (95% CI) | p | NRI (95% CI) | p | IDI (95% CI) | p | |
---|---|---|---|---|---|---|
All participants | ||||||
GRACE | 0.688 (0.651, 0.725) | – | Reference | – | Reference | – |
GRACE+PNI categorya | 0.733 (0.698, 0.768) | <0.001 | 0.323 (0.186, 0.466) | <0.001 | 0.080 (0.023, 0.137) | 0.006 |
GRACE+dichotomous PNIb | 0.730 (0.695, 0.765) | <0.001 | 0.221 (− 0.176, 0.350) | 0.819 | 0.088 (0.032, 0.144) | 0.002 |
GRACE+continuous PNIc | 0.733 (0.698, 0.768) | <0.001 | 0.102 (− 0.041, 0.262) | 0.326 | 0.094 (0.037, 0.151) | 0.001 |
GRACE+postprocedural PNId | 0.731 (0.694, 0.768) | <0.001 | 0.202 (− 0.203, 0.340) | 0.142 | 0.075 (0.014, 0.136) | 0.015 |
GRACE+ΔPNIe | 0.694 (0.656, 0.733) | 0.119 | 0.079 (− 0.048, 0.230) | 0.449 | 1x10-4 (-0.044, 0.044) | 0.998 |
GRACE+GLIMf | 0.706 (0.670, 0.743) | 0.026 | − 0.128 (− 0.326, 0.201) | 0.318 | 0.024 (− 0.027, 0.074) | 0.363 |
Diabetic patients | ||||||
GRACE | 0.707 (0.657, 0.756) | – | Reference | – | Reference | – |
GRACE+PNI categorya | 0.763 (0.713, 0.813) | <0.001 | 0.414 (0.179, 0.628) | <0.001 | 0.089 (0.023, 0.154) | 0.008 |
GRACE+dichotomous PNIb | 0.762 (0.713, 0.811) | <0.001 | 0.346 (0.129, 0.528) | <0.001 | 0.091 (0.018, 0.164) | 0.015 |
GRACE+continuous PNIc | 0.766 (0.718, 0.815) | <0.001 | 0.228 (0.018, 0.441) | 0.019 | 0.104 (0.031, 0.178) | 0.005 |
GRACE+postprocedural PNId | 0.746 (0.692, 0.800) | 0.003 | 0.240 (− 0.236, 0.404) | 0.349 | 0.055 (-0.010, 0.120) | 0.097 |
GRACE+ΔPNIe | 0.704 (0.652, 0.755) | 0.310 | 0.147 (− 0.067, 0.375) | 0.493 | − 0.019 (− 0.073, 0.035) | 0.495 |
GRACE+GLIMf | 0.741 (0.692,0.790) | 0.009 | − 0.267 (− 0.394, 0.421) | 0.288 | 0.08 (0.005, 0.149) | 0.036 |
Nondiabetic patients | ||||||
GRACE | 0.662 (0.608, 0.716) | – | Reference | – | Reference | – |
GRACE+PNI categorya | 0.716 (0.667, 0.764) | 0.001 | 0.261 (0.118, 0.449) | 0.016 | 0.104 (0.019, 0.188) | 0.017 |
GRACE+dichotomous PNIb | 0.714 (0.665, 0.762) | 0.002 | − 0.104 (-0.161, 0.294) | 0.543 | 0.090 (0.006, 0.173) | 0.036 |
GRACE+continuous PNIc | 0.713 (0.665, 0.762) | 0.002 | − 0.007 (-0.117, 0.266) | 0.607 | 0.103 (0.020, 0.187) | 0.015 |
GRACE+postprocedural PNId | 0.725 (0.674, 0.775) | 0.002 | − 0.179 (-0.198, 0.369) | 0.416 | 0.045 (− 0.017, 0.160) | 0.112 |
GRACE+ΔPNIe | 0.675 (0.617, 0.732) | 0.133 | 0.037 (− 0.095, 0.242) | 0.562 | − 3x10-4 (-0.002, 0.002) | 0.706 |
GRACE+GLIMf | 0.678 (0.626, 0.731) | 0.243 | − 0.131 (− 0.241, 0.270) | 0.352 | 0.025 (− 0.052, 0.101) | 0.527 |