Hyperuricemia as a prognostic factor after acute coronary syndrome
Introduction
Different authors have suspected an association between elevated serum uric acid (SUA) levels and cardiovascular disease since the late nineteenth century [1,2]. A number of studies have shown that SUA concentration is significantly associated with cardiovascular conditions [[3], [4], [5], [6], [7]]. At the same time, elevated SUA levels are linked to various cardiovascular risk factors, including hypertension [8], dyslipidemia [9], diabetes [10], obesity [11], metabolic syndrome, kidney failure [12] and specific target organ damage, making it difficult to determine whether uric acid is a cause or a consequence of these conditions [13,14].
Many epidemiological studies have shown through multivariate analyses that hyperuricemia is an independent risk factor for the development of cardiovascular disease and/or vascular morbidity and mortality, particularly in patients with hypertension or congestive heart failure [15,16]. A recent systematic review showed that hyperuricemia may slightly increase the risk of CAD events, independently of traditional cardiovascular risk factors [17]. Nevertheless, not all population-based epidemiological studies support this hypothesis [18], and other authors have suggested that hyperuricemia is a risk marker rather than an independent risk factor [19,20]. Medical societies have not recognized elevated SUA as a cardiovascular risk factor [14].
The association between elevated SUA and poor clinical outcomes in people with stable CAD and heart failure is well documented [17,21], but less is known about SUA as a potential predictor of outcomes after acute myocardial infarction, particularly in high-risk patients [22,23]. Over the past few years, several studies have explored the value of on-admission SUA to predict outcomes in patients with acute coronary syndromes (ACS) [5,23]. A recent meta-analysis showed that hyperuricemia was associated with a 46% increased risk of adverse clinical events after any percutaneous coronary intervention (PCI) [24]. There is less evidence on how hyperuricemia impacts the long-term prognosis after ACS.
Acute myocardial infarction remains one of the most prevalent causes of death worldwide, with the highest mortality rates within the first month of an event [25]. Clinical decision-making requires an accurate assessment of cardiovascular risk, which has a significant influence on choosing between different management strategies that vary in terms of benefits, risks, and costs [26]. SUA may be a powerful tool to help stratify risk for cardiovascular disease [16], and risk stratification systems for patients with acute myocardial infarction, like the Global Registry of Acute Coronary Events (GRACE) [27], could benefit from including SUA, particularly as this marker is readily and reliably obtainable at a low cost [28].
Despite extensive research, the role of SUA as a potential risk predictor for outcomes in people with ACS remains controversial. Therefore, the present study aims to assess the prognostic value of hyperuricemia in ACS patients for medium/long-term clinical outcomes after hospital discharge and to evaluate the reclassification of the GRACE risk score.
Section snippets
Patients and methods
This is a prospective cohort study in a tertiary university hospital with a 24 h a day, seven days per week primary percutaneous coronary intervention service. We initiated a continuous registry of all non-scheduled admissions in the Cardiology Unit in December 2008 [29], and we included all consecutive patients admitted for an ACS between December 2008 and December 2013. ACS diagnosis was defined as [1] typical clinical symptoms of chest pain [2]; electrocardiographic changes indicative of
Results
The study population included 1323 patients, 204 of whom were excluded due to lack of SUA determination during hospital stay. Thus, the study cohort consisted of 1119 participants (74% men, n = 830) with a mean age of 68 (SD 13) years. Baseline characteristics are presented in Table 1. The prevalence of hyperuricemia was 34.4%; participants with high SUA levels were slightly older; had higher prevalence of hypertension, previous heart failure and kidney failure; and were more likely to be
Discussion
The prevalence of hyperuricemia was 34.4% in our ACS participants, and a SUA level above the normal range was independently associated with both total and cardiovascular mortality as well as major cardiovascular events in medium/long-term follow-up. The association of hyperuricemia with mortality remained significant in patients without kidney failure, but not in participants without diabetes. Moreover, the addition of hyperuricemia information to the GRACE risk score seemed to improve
Conflict of interest
The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript.
Financial support
This study was supported by grants from Instituto de Salud Carlos III RD12/0042/0068 and from CIBER Cardiovascular: CIBER CV CB16/11/00420 FEDER and CB16/11/00226. These organizations had no involvement in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript.
Author contributions
AC, VBM and AL contributed to the design and implementation of the research, AC, VBM and AL contributed to acquisition of data, AC and AL performed the statistical analysis and drafted the manuscript. All authors discussed the results and contributed to the final manuscript.
Acknowledgements
We would like to thank all members of the cardiology department for their participation in this registry.
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