Methods

From July 2012 to March 2014, consecutive patients who were hospitalized at our institution because of ACS, who underwent urgent CA after diagnosis, were enrolled in our study.

Initially 1,049 patients were admitted for analysis. Thirty-three patients were excluded from the study for the following reasons: 6 patients were excluded because of unavailability of laboratory data, 2 patients had histories of malignancy, 18 patients had histories of coronary artery bypass grafting, 5 patients had severe renal failure, and 2 patients had acute or chronic infection or inflammation. Therefore, a total of 1,016 patients were included in the study.

Exclusion criteria consisted of hematologic disorders, active infectious or inflammatory diseases, rheumatologic diseases, severe renal or liver disease, and malignancy. Because the SXscore has been used only for patients with native coronary artery lesions, patients with histories of coronary artery bypass grafting were also excluded.

STEACS was diagnosed when patients had symptoms of acute myocardial infarction lasting ≥30 minutes and accompanied by >1-mm (0.1-mV) ST-segment elevation in ≥2 contiguous leads and later confirmed by creatine kinase (CK) and CK-MB increases and/or troponin increase. NSTEACS was diagnosed when characteristic chest pain lasted ≥20 minutes with or without associated ST-segment depression ≥0.1 mV and/or T-wave inversion in 2 contiguous leads on the electrocardiogram or no electrocardiographic abnormalities and presence or absence of increased levels of troponin. Hypercholesterolemia was defined as total serum cholesterol >200 mg/dl or the use of lipid-lowering medication.

All patients were assessed with transthoracic echocardiography (Vivid 3; GE Vingmed Ultrasound AS, Horten, Norway) within 48 hours after admission at the hospital. The left ventricular ejection fraction (LVEF) was calculated using Simpson’s method.

The study protocol was approved by the local ethics committee, and written informed consent was obtained from all subjects.

In all patients, venous blood samples were drawn immediately upon hospital admission. The total numbers of white blood cells (WBCs), platelets, and lymphocytes were determined by the Coulter LH Series (Beckman Coulter, Inc., Hialeah, Florida). Cardiac enzymes (CK, CK-MB, and troponin T), glucose, creatinine, lipid profiles, and high-sensitivity C-reactive protein (hs-CRP) were also measured in all patients. The PLR was calculated as the ratio of the platelet count to the lymphocyte count.

All patients were orally pretreated with aspirin 300 mg, clopidogrel 600 mg, and intravenous heparin 5,000 U at the time of diagnosis before CA. Baseline CA was performed through the femoral artery by standard Judkins technique with 6Fr catheters (Expo; Boston Scientific Corporation, Natick, Massachusetts) using the GE Innova 3100 (GE Healthcare, Milwaukee, Wisconsin) and the Siemens Axiom Sensis XP (Siemens Healthcare, Munich, Germany). Multivessel disease was defined as the presence of a stenosis >50% in ≥2 major epicardial coronary arteries. The SXscores of all patients were calculated by 2 independent experienced interventional cardiologists who were blinded to the identities and clinical information of the patients from baseline diagnostic CA. Each lesion with ≥50% diameter stenosis in vessels ≥1.5 mm in diameter was scored using version 2.1 of the on-line calculator at www.syntaxscore.com . A low SXscore was defined as ≤22, an intermediate score as 23 to 32, and a high score as ≥33. Patients with SXscores ≥23 were considered to have moderate to severe coronary artery disease according to this definition. Thus, the patients were divided into 2 groups, those with low SXscores (≤22) and those with intermediate to high SXscores (≥23).

All analyses were performed using SPSS for Windows version 18.0 (SPSS, Chicago, Illinois). All data are presented as mean ± SD or as medians and interquartile ranges. Continuous variables were checked for normal distribution using the Kolmogorov-Smirnov test, and those that did not satisfy the criteria were log transformed to obtain a normal distribution. Comparisons of parametric values between the 2 groups were performed by means of independent-samples Student’s t tests. Comparisons of nonparametric values between the 2 groups were performed by Mann-Whitney U tests. Categorical variables were compared by the chi-square test. Pearson’s correlations were used to analyze the correlation between PLR and SXscore. Receiver-operating characteristic analyses were used to detect the cut-off value of PLR in the prediction of intermediate to high SXscore. To determine the independent predictors of intermediate to high SXscore, parameters (age, female gender, body mass index, smoking, diabetes, the LVEF, hemoglobin, creatinine, glucose, PLR, CK-MB, WBC count, hs-CRP, and uric acid) that were found to be significant in the univariate analysis were evaluated by stepwise forward logistic regression analysis. Multivariate logistic regression analysis was used to identify independent predictors of in-hospital mortality (variables included were age, gender, smoking, diabetes mellitus, LVEF, hemoglobin, creatinine, glucose, PLR, SXscore, peak CK-MB, uric acid, and multivessel disease) in the whole of study population. Two-sided p values <0.05 were considered significant.

Results

A total of 1,016 patients with ACS who underwent urgent CA were enrolled in the study. The mean age was 61.4 ± 12.9 years, and 286 of the patients (28.1%) were women. While 678 patients (66.7%) had low SXscores (≤22), 338 patients (33.3%) had intermediate to high SXscores (≥23).

Differences in the baseline clinical and angiographic characteristics in patients with low and intermediate to high SXscores are listed in Table 1 . Previous medications, including antithrombotic treatment (aspirin and/or clopidogrel), β blockers, renin-angiotensin-aldosterone system antagonists, and statins, were similar between groups. Baseline clinical and angiographic characteristics of patients according to SXscores are presented in Table 1 . The patients in the intermediate to high SXscore group (SXscore ≥23) were significantly older, with a higher prevalence of female gender and diabetes but a lower frequency of smoking and lower body mass indexes compared with those in the low SXscore group. LVEFs were also significantly lower in patients with intermediate to high SXscores (≥23). The left main coronary artery and the left anterior descending coronary artery were more commonly the culprit vessels in patients with intermediate to high SXscores, whereas the left circumflex coronary artery and the right coronary artery were more commonly the culprit vessels in those with low SXscores. Multivessel disease and chronic total occlusions were more often present in patients with intermediate to high SXscore. The rate of patients who underwent coronary artery bypass grafting was significantly higher in patients with intermediate to high SXscores. In contrast, the rate of stent implantation in the culprit vessel was significantly higher in patients with low SXscores. Fifty-five patients died during hospitalization. The rate of in-hospital mortality was higher in patients with intermediate to high SXscores compared with those with low SXscores (12.4% and 1.9%, respectively, p <0.001; Table 1 ).

Baseline laboratory characteristics of the patients are listed in Table 2 . According to the admission laboratory results, patients in the intermediate to high SXscore group had significantly higher creatinine, glucose, uric acid, hs-CRP, WBC, and platelet levels but lower lymphocyte and hemoglobin levels than those in the low SXscore group. Patients with intermediate to high SXscores had significantly higher PLRs compared with those with low SXscores ( Figure 1 ). Additionally, patients in the intermediate to high SXscore group had significantly higher serum peak CK, CK-MB, and troponin T levels than those in the low SXscore group.

Comparison of PLRs between groups.

Univariate and multivariate logistic regression analyses of the association between intermediate to high SXscore and multiple variables are listed in Table 3 . On univariate analysis, the PLR showed a strong association with intermediate to high SXscore (p <0.001). The other univariate predictors of intermediate to high SXscore were age, female gender, body mass index, diabetes, smoking, LVEF, hemoglobin, WBC count, creatinine, glucose, uric acid, CK-MB, and hs-CRP. The univariate screen identified significant predictors that were assessed by multivariate analysis. In multivariate analysis, the independent predictors of intermediate to high SXscore were PLR (odds ratio [OR] 1.018, 95% confidence interval [CI] 1.013 to 1.023, p <0.001) together with the LVEF (OR 0.935, 95% CI 0.910 to 0.960, p <0.001) and age (OR 1.029, 95% CI 1.029 to 1.054, p = 0.02).

Table 3

Independent predictors of intermediate-high syntax score in patients with acute coronary syndromes

Variable	Univariate Analysis		Mulivariate Analysis
	Odds Ratio, 95% CI	p Value	Odds Ratio, 95% CI	p Value
Age	1.020 (1.017–1.023)	<0.001	1.029 (1.004–1.054)	0.020
Female gender	1.698 (1.279–2.254)	<0.001	1.075 (0.586–1.973)	0.815
Body mass index	0.935 (0.900–0.972)	0.001	0.982 (0.928–1.041)	0.545
Smoking	2.254 (1.713–2.967)	<0.001	0.847 (0.464–1.544)	0.588
Hypertension	0.786 (0.604–1.1023)	0.073
Diabetes mellitus	1.666 (1.269–2.192)	<0.001	1.577 (0.862–2.890)	0.139
Left ventricular ejection fraction	0.922 (0.909–0.936)	<0.001	0.935 (0.910–0.960)	<0.001
Hemoglobin	0.771 (0.717–0.830)	<0.001	0.981 (0.839–1.148)	0.814
Creatinine	2.168 (1.407–3.340)	<0.001	1.570 (0.771–3.198)	0.214
Glucose	1.004 (1.003–1.006)	<0.001	1.000 (0.997–1.004)	0.917
Platelet-to-lymphocyte ratio	1.004 (1.002–1.006)	<0.001	1.018 (1.013–1.023)	<0.001
Creatine kinase-myocardial band	1.002 (1.001–1.003)	0.005	1.001 (0.998–1.004)	0.721
White blood cell	1.046 (1.008–1.084)	0.016	0.991 (0.923–1.063)	0.792
High sensitivity C-reactive protein	1.088 (1.046–1.131)	<0.001	0.980 (0.922–1.041)	0.506
Triglyceride	0.999 (0.998–1.001)	0.365
Uric acid	1.123 (1.037–1.215)	0.004	0.969 (0.823–1.140)	0.702

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