AUTHOR=Kong Gwyneth , Chew Nicholas W. S. , Ng Cheng Han , Chin Yip Han , Lim Oliver Z. H. , Ambhore Anand , Ng Gavin , Kong William , Poh Kian-Keong , Foo Roger , Yip James , Yeo Tiong-Cheng , Low Adrian Fatt-Hoe , Lee Chi-Hang , Chan Mark Yan-Yee , Tan Huay-Cheem , Loh Poay-Huan 

TITLE=Prognostic Outcomes in Acute Myocardial Infarction Patients Without Standard Modifiable Risk Factors: A Multiethnic Study of 8,680 Asian Patients

JOURNAL=Frontiers in Cardiovascular Medicine

VOLUME=Volume 9 - 2022

YEAR=2022

URL=https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2022.869168

DOI=10.3389/fcvm.2022.869168

ISSN=2297-055X

ABSTRACT=BACKGROUND
An increasing proportion of acute myocardial infarction (AMI) patients are presenting without standard modifiable cardiovascular risk factors (SMuRFs) of hypertension, hypercholesterolemia, diabetes and smoking,  but with an unexpectedly increased mortality. This study examined the SMuRF-less patients presenting with AMI in a multi-ethnic Asian population.
METHODS
We recruited patients presenting with AMI from 2011 to 2021, and compared the prevalence, clinical characteristics, and outcomes of SMuRF-less and SMuRF patients. Multivariable analysis was used to compare the outcomes of 30-day cardiovascular mortality, all-cause mortality, readmission, cardiogenic shock, stroke and heart failure. Kaplan-Meier curves were constructed for 30-day cardiovascular mortality, with stratification by ethnicity, gender and AMI type, and 10-year all-cause mortality. 
RESULTS
SMuRF-less patients, who made up 8.6% of 8680 patients, were significantly younger with fewer comorbidities including stroke and chronic kidney disease, but higher rates of ventricular arrhythmias and inotropic or invasive ventilation requirement. Multivariable analysis showed higher rates of cardiovascular mortality (HR 1.48, 95% CI 1.09–1.86, p=0.048), cardiogenic shock (RR: 1.31, 95% CI 1.09–1.52, p=0.015) and stroke (RR: 2.51, 95% CI 1.67–3.34, p=0.030) amongst SMuRF-less patients. 30-day cardiovascular mortality was raised in the SMuRF-less group, with similar trends in men, STEMI patients, and the three Asian ethnicities. All-cause mortality remain increased in the SMuRF-less group for up to 5 years.
CONCLUSION 
There is a significant proportion of AMI patients without standard risk factors in Asia, who have worse short-term mortality. This calls for greater focus on the management of this unexpectedly high-risk subgroup of patients.