Original Article|Articles in Press

Standard modifiable cardiovascular risk factors in patients with acute coronary syndrome: A report from multicenter percutaneous coronary intervention registry

Published:February 13, 2023DOI:


      • SMuRF-less patients accounted for 6% among acute coronary syndrome patients
      • The prevalence of left main trunk or left anterior descending artery lesion was higher in SMuRF-less patients
      • SMuRF-less patients were more likely to die than those with SMuRFs
      • SMuRF-less patients were at risk of cardiac shock or cardiopulmonary arrest



      High mortality in patients with acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors [SMuRFs (e.g. diabetes, hypertension, smoking, and dyslipidemia)] has been reported. However, details regarding their acute presentation and reasons for the excess risk remain unclear.


      Patient-level data were extracted from a multicenter procedure-based registry (KiCS-PCI). We analyzed consecutive patients with ACS who underwent de novo percutaneous coronary intervention (PCI) between 2009 and 2020. The primary outcome of interest was the in-hospital mortality.


      Among the 10,523 patients with ACS, 7775 met the inclusion criteria. Patients without SMuRFs who underwent PCI [n = 529 (6.8 %)] were older [median 71 (IQR: 63–79) vs. 68 (59–76) years, p < 0.001] and more often presented with cardiogenic shock or cardiopulmonary arrest (14.6 % vs. 8.6 %, p < 0.001; 12.7 % vs. 5.3 %, p < 0.001, respectively). In patients with ST-elevation myocardial infarction (STEMI), median door-to-balloon time was significantly longer in SMuRF-less patients (90 min vs 82 min). In-hospital death was significantly higher in SMuRF-less patients [10.2 % vs. 4.1 %, p < 0.001, adjusted odds ratio, 1.81 (95%CI, 1.26–2.59); p = 0.001], whereas the rate of procedural complications showed no significant difference. When stratified by the ACS presentation pattern, the findings were consistent, although the association between SMuRF-less and the increased risk of in-hospital mortality was not statistically significant in patients with non-ST-elevation- (NSTE)-ACS.


      SMuRF-less ACS patients frequently presented with cardiopulmonary arrest and/or cardiogenic shock, leading to high in-hospital mortality. When stratified by the ACS presentation pattern, the association of SMuRF-less and the increased risk of mortality was more prominent in STEMI patients and it was not statistically significant in NSTE-ACS patients. Almost half of these patients had amendable left main trunk or left anterior descending artery disease and treating clinicians should be aware of this paradox to avoid the delay in treatment.

      Graphical abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dawber T.R.
        • Moore F.E.
        • Mann II., G.V.
        Coronary heart disease in the Framingham study.
        Int J Epidemiol. 2015; 44: 1767-1780
        • Fuchs F.D.
        • Whelton P.K.
        High blood pressure and cardiovascular disease.
        Hypertension. 2020; 75: 285-292
        • Einarson T.R.
        • Acs A.
        • Ludwig C.
        • Panton U.H.
        Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007–2017.
        Cardiovasc Diabetol. 2018; 17: 83
        • Silverman M.G.
        • Ference B.A.
        • Im K.
        • Wiviott S.D.
        • Giugliano R.P.
        • Grundy S.M.
        • et al.
        Association between lowering LDL-C and cardiovascular risk reduction among different therapeutic interventions: a systematic review and meta-analysis.
        JAMA. 2016; 316: 1289-1297
        • Csordas A.
        • Bernhard D.
        The biology behind the atherothrombotic effects of cigarette smoke.
        Nat Rev Cardiol. 2013; 10: 219-230
        • Khot U.N.
        • Khot M.B.
        • Bajzer C.T.
        • Sapp S.K.
        • Ohman E.M.
        • Nrener S.J.
        • et al.
        Prevalence of conventional risk factors in patients with coronary heart disease.
        JAMA. 2003; 290: 898-904
        • Figtree G.A.
        • Vernon S.T.
        • Hadziosmanovic N.
        • Sundström J.
        • Alfredsson J.
        • Arnott C.
        • et al.
        Mortality in STEMI patients without standard modifiable risk factors: a sex-disaggregated analysis of SWEDEHEART registry data.
        Lancet. 2021; 397: 1085-1094
        • Vernon S.T.
        • Coffey S.
        • Bhindi R.
        • Soo Hoo S.Y.
        • Nelson G.I.
        • Ward M.R.
        • et al.
        Increasing proportion of ST elevation myocardial infarction patients with coronary atherosclerosis poorly explained by standard modifiable risk factors.
        Eur J Prev Cardiol. 2017; 24: 1824-1830
        • Vernon S.T.
        • Coffey S.
        • D’Souza M.
        • Chow C.K.
        • Kilian J.
        • Hyun K.
        • et al.
        ST-segment-elevation myocardial infarction (STEMI) patients without standard modifiable cardiovascular risk factors – how common are they, and what are their outcomes?.
        J Am Heart Assoc. 2019; 8e013296
        • The Japanese Circulation Society
        The Japanese registry of all cardiac and vascular diseases. [Internet].
        (Available at:)
        Date accessed: July 31, 2022
        • Messenger J.C.
        • Ho K.K.L.
        • Young C.H.
        • Slattery L.E.
        • Draoui J.C.
        • Curtis J.P.
        • et al.
        The National Cardiovascular Data Registry (NCDR) data quality brief: the NCDR data quality program in 2012.
        J Am Coll Cardiol. 2012; 60: 1484-1488
        • Kohsaka S.
        • Miyata H.
        • Ueda I.
        • Masoudi F.A.
        • Peterson E.D.
        • Maekawa Y.
        • et al.
        An international comparison of patients undergoing percutaneous coronary intervention: a collaborative study of the National Cardiovascular Data Registry (NCDR) and Japan cardiovascular database-Keio interhospital cardiovascular studies (JCD-KiCS).
        Am Heart J. 2015; 170: 1077-1085
        • Nuding S.
        • Werdan K.
        • Prondzinsky R.
        Optimal course of treatment in acute cardiogenic shock complicating myocardial infarction.
        Expert Rev Cardiovasc Ther. 2018; 16: 99-112
        • Numasawa Y.
        • Sawano M.
        • Miyata H.
        • Ueda I.
        • Noma S.
        • Suzuki M.
        • et al.
        Outcomes after percutaneous coronary intervention of acute coronary syndrome complicated with cardiopulmonary arrest (from a japanese multicenter Registry).
        Am J Cardiol. 2017; 119: 1173-1178
        • National Cardiovascular Data Registry (NCDR) CathPCI Registry
        (Available at:)
        Date accessed: July 8, 2015
        • Moledina S.M.
        • Rashid M.
        • Nolan J.
        • Nakao K.
        • Sun L.Y.
        • Velagapudi P.
        • et al.
        Addressing disparities of care in non-ST-segment elevation myocardial infarction patients without standard modifiable risk factors: insights from a nationwide cohort study.
        Eur J Prev Cardiol. 2022; 29: 1084-1092
        • Yamamoto K.
        • Natsuaki M.
        • Morimoto T.
        • Shiomi H.
        • Takeji Y.
        • Yamaji K.
        • et al.
        Coronary artery disease without standard cardiovascular risk factors.
        Am J Cardiol. 2022; 164: 34-43
        • Ikeda N.
        • Saito E.
        • Kondo N.
        • Inoue M.
        • Ikeda S.
        • Satoh T.
        • et al.
        What has made the population of Japan healthy?.
        Lancet. 2011; 378: 1094-1105
        • Ikemura N.
        • Sawano M.
        • Ueda I.
        • Fukuda K.
        • Kohsaka S.
        Consequence of reimbursement policy alteration for urgent PCI in Japan.
        Lancet. 2018; 391: 2208-2209
        • Bugiardini R.
        • Cenko E.
        • Ricci B.
        • Vasiljevic Z.
        • Dorobantu M.
        • Kedev S.
        • et al.
        Comparison of early versus delayed oral β blockers in acute coronary syndromes and effect on outcomes.
        Am J Cardiol. 2016; 117: 760-767
        • Figtree G.A.
        • Redfors B.
        • Kozor R.
        • Vernon S.T.
        • Grieve S.M.
        • Mazhar J.
        • et al.
        Clinical outcomes in patients with ST-segment elevation MI and no standard modifiable cardiovascular risk factors.
        JACC Cardiovasc Interv. 2022; 15: 1167-1175
        • Kuno T.
        • Numasawa Y.
        • Sawano M.
        • Abe T.
        • Ueda I.
        • Kodaira M.
        • et al.
        Real-world use of intravascular ultrasound in Japan: a report from contemporary multicenter PCI registry.
        Heart Vessels. 2019; 34: 1728-1739