Corresponding Author
Key Words: acute myocardial infarction, cancer, chronic systemic inflammatory diseases, risk factor
The concept of risk factors for coronary artery disease was advocated by several cohort studies, including the Framingham Heart Study >50 years ago.1 Since then, modifiable cardiovascular risk factors, including hypertension, diabetes, dyslipidemia, and smoking, have been the therapeutic target for primary and secondary prevention of coronary artery disease.2,3 The contemporary guidelines for coronary artery disease focus on the modification of risk factors.4, 5, 6 However, recent registry studies revealed that a substantial proportion of patients with acute myocardial infarction (AMI) did not have standard modifiable risk factors (SMuRFs) and that clinical outcomes were worse in patients without modifiable risk factors than in those with modifiable risk factors.7, 8, 9 These findings suggest that patients without modifiable risk factors might have unmodifiable risk factors such as active cancer or chronic systemic inflammatory diseases (CSIDs) and that these unmodifiable risk factors might be the cause of poor outcomes. AMI patients with cancer have apparently worse clinical outcomes, especially all-cause death, than those without cancer.10,11 Furthermore, AMI patients with CSIDs may have worse clinical outcomes after the hospital discharge.12
In this issue of JACC: Asia, Yaginuma et al13 compared major adverse cardiovascular events (MACE) and major bleeding events in patients with AMI among active cancer, CSIDs, no SMuRFs, and SMuRFs. From 4 hospital cohorts, they included 2,480 patients with AMI and divided them into the cancer, CSID, no SMuRFs, and SMuRFs groups. In-hospital MACE were most frequently observed in the no SMuRF group and least frequently in the SMuRFs group. The highest rates of in-hospital MACE in the no SMuRFs group may be explained by the highest rates of cardiogenic shock and cardiac arrest in the no SMuRFs group. In-hospital bleeding events were most frequently observed in the cancer group and least frequently in the SMuRFs group. AMI patients with active cancer, especially gastrointestinal cancer, would have bleeding events under dual antiplatelet therapy and systemic anticoagulation during percutaneous coronary intervention. After discharge, both MACE and bleeding events were most frequently observed in the cancer group and least frequently in the SMuRFs group. Patients with at least one SMuRF who did not have active cancer and CSIDs had the lowest risk of ischemic and bleeding events during hospitalization and after discharge. The unique point of this study is that they clearly separated active cancer, CSIDs, and no SMuRFs. In other words, the no SMuRFs group does not include patients with active cancer or CSIDs. Nevertheless, the clinical outcomes were consistently worse in the no SMuRFs group than in the SMuRFs group. This study suggests that no SMuRFs itself is the risk marker for clinical outcomes in patients with AMI.
If no SMuRFs is the risk marker in patients after AMI, we should carefully follow-up AMI patients without SMuRFs. However, the strategy of secondary prevention has not been established for patients with AMI but without SMuRFs. It is unclear whether these patients require the tighter control of modifiable risk factors such as LDL cholesterol levels <50 mg/dL or systolic blood pressure level <120 mm Hg to prevent adverse events after AMI. In terms of primary prevention, the incidence of coronary artery disease including AMI is apparently lower in the general population without SMuRFs than in those with SMuRFs.14 Therefore, AMI patients without SMuRFs might have any unrecognized risk factor except active cancer or CSIDs. In the long history of risk factors for cardiovascular diseases, no SMuRFs is a relatively new concept, and clinical evidence regarding no SMuRFs is still sparse. Yaginuma et al13 helped us gain a better understanding of no SMuRFs. Further research is warranted to elucidate the unrecognized risk factors behind no SMuRFs and the strategy of secondary prevention for patients with no SMuRFs.
Funding Support and Author Disclosures
The author has reported that he has no relationships relevant to the contents of this paper to disclose.
Footnotes
The author attests they are in compliance with human studies committees and animal welfare regulations of the author’s institution and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
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