İleri et al. Int J Clin Cardiol 2016, 3:087 Volume 3 | Issue 2 International Journal of ISSN: 2378-2951 Clinical Cardiology Research Article: Open Access Validation and Simplification of a Scoring Model Derived for Prediction of Poor Coronary Collateral Circulation in Acute Non-St Elevation Myocardial Infarction Mehmet İleri1*, Koray Gürsel1, Funda Başyiğit1, Pınar Türker Bayır1, Deniz Şahin1, Ümit Güray1, Özgül Uçar1, Burak Acer2 and Yahya Büyükaşık3 1Department of Cardiology, Ankara Numune Education and Research Hospital, Ankara, Turkey 2Department of Cardiology, Türkiye Yüksek İhtisas Education and Research Hospital, Ankara, Turkey 3Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey *Corresponding author: Mehmet İleri, Department of Cardiology, Ankara Numune Education and Research Hospital, Ankara, Turkey, Tel: +90 505 485 9803, E-mail: [email protected] myocardial infarction (NSTEMI), abrupt vessel occlusion results in Abstract myocardial necrosis in the jeopardized area. Angiographic collaterals Introduction and objective: The aim of this study was to provide to myocardial tissue distal to an acutely occluded coronary vessel validation and simplification of the scoring model derived for can reduce infarct size and risk for post-infarct complications as prediction of poor coronary collateral circulation (CCC) in acute well as infarct related mortality. These prognostic implications of non-ST elevation myocardial infarction (NSTEMI) in a population- collateral function, makes it necessary to have a better understanding based prospective cohort. of the factors promoting collateral development in acute setting of Patient and methods: The validation cohort consisted of 136 myocardial infarction. We recently developed a risk scoring model for consecutive patients with NSTEMI admitted to coronary care predicting poor collateralization in patients with NSTEMI at hospital units of three referral hospitals within 24 hours of symptom onset admission [1]. The derivation cohort included 224 consecutive and scheduled to undergo coronary angiography within 48 hours of hospitalization. Coronary collateral development was graded patients with NSTEMI admitted to coronary care unit within 24 hours according to the Cohen-Rentrop method. Presence of diabetes of symptom onset and scheduled to undergo coronary angiography mellitus (DM), ≥ 7.85 X103/ µL WBC and ≥ 6.25 X103/ µL neutrophil within 48 hours of hospitalization. The simplicity of the score and count were assigned with 2 points; high NLR (≥ 4.5) with 1 point and relatively limited number of variables included make it an attractive older age (≥ 70 years old) with -1 point as defined in the derivation choice. Details on development of the model can be found in our cohort. These individual points were then added together to provide previous article [1]. The aim of this study was to provide validation of a total risk score for every patient. this score in a population-based prospective cohort. Results: In our validation cohort, the global score was well predictive for poor CCC (AUC [95% confidence interval]: 0.859 Patients and Methods [0.797-0.922], p < 0.001). Eliminations of age, NLR or both did th not impair predictivity of the score. The simplified score including This was a prospective study conducted from 15 April 2015 th only WBC, neutrophil and DM had 45/51 (88.2%) positive and to 25 September 2015 at Ankara Numune Training and Research 40/45 (88.9%) negative predictivities for total scores of ≥ 4 (2 or Hospital (ANTRH), Türkiye Yüksek Ihtisas Training and Research 3 risk factors) and 0 (no risk factor), respectively. The model was Hospital (TYITRH) and Ankara Umut Hospital (AUH). ANTRH informative in 96 of 136 (70.5%) patients. and AYITRH were tertiary care referral centers whereas AUH was Conclusion: This study represents successful validation and a secondary care non-governmental hospital. The validation cohort simplification of a scoring model derived for prediction of PCC in consisted of 136 consecutive patients with NSTEMI admitted to patients with acute NSTEMI in a prospective cohort. coronary care units of these three hospitals (72 from ANTRH, 30 from AYITRH and 34 from AUH) within 24 hours of symptom Keywords onset and scheduled to undergo coronary angiography within 48 Coronary collateral circulation, Risk scoring, Validation hours of hospitalization. Patients who did not have a significant stenosis (≥ 70%) in at least one of the major epicardial coronary Introduction arteries in coronary angiograms were excluded. Left main coronary artery narrowing of ≥ 50% was considered as significant. Non ST Determinants of coronary collateral circulation (CCC) in human elevation myocardial infarction was diagnosed in the presence of heart are still incompletely identified. In acute non-ST elevation two following criteria: (1) an accelerating pattern of or prolonged Citation: İleri M, Gürsel K, Başyiğit F, Bayır PT, Şahin D, et al. (2016) Validation and Simplification of a Scoring Model Derived for Prediction of Poor Coronary Collateral Circulation in Acute Non-St Elevation Myocardial Infarction. Int J Clin Cardiol 3:087 ClinMed Received: April 15, 2016: Accepted: September 17, 2016: Published: September 20, 2016 International Library Copyright: © 2016 İleri M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Table 1: Baseline clinical and laboratory findings in validation cohort. The ethical committee of our hospital approved the study protocol. Clinical and laboratory findings All (n = 136) Quantitative coronary angiography was performed in all patients Age, years 65.9 ± 9.5 within 48 hours after admission in multiple orthogonal projections Age ≥ 70 years (n,%) 51 (37.5) using the Judkins technique by two experienced independent Female (n,%) 55 (40.4) interventional cardiologists. Coronary collateral grading was carried 2 Body mass index (kg/m ) (median, range) 31.9 (17.2 - 50.9) out by two experienced cardiologists who are not informed of the Diabetes mellitus (n, %) 69 (50.7) clinical characteristics and biochemical results of the study patients. Hypertension (n, %) 67 (49.2) Collateral development was graded according to the Cohen-Rentrop Hypercholesterolemia (n, %) 91 (66.9) method [2]: grade 0 (no filling of any collateral vessels), grade 1 Current smoking (n, %) 77 (56.6) (filling of side branches of the artery to be perfused by collateral History of angina pectoris (n, %) vessels without visualization of the epicardial segment), grade 2 Left ventricular ejection fraction (%) 50.7 ± 11 (partial filling of the epicardial segment by collateral vessels), grade 3 Peak troponin I (ng/mL) 13.5 ± 14.3 complete filling of the epicardial artery by collateral vessels). Patients Serum creatinine (mg/dl) 1.08 ± 0.6 were then divided into two groups according to their collateral grades, Uric acid (mg/dl) 5.59 ± 1.59 with the first group having poorly developed CCC (grade 0 and 1) and Gamma-glutamyl transferase (U/L) 37.4 ± 20.1 the second group having well-developed CCC (grade 2 and 3). Previous medications Blood samples at hospital admission were drawn in the Aspirin (n, %) 103 (75.7) emergency room from the antecubital vein by careful venipuncture Statin (n, %) 103 (75.7) using a 21-guage needle attached to a sterile syringe without stasis. ACE inhibitors/ARB (n, %) 51 (37.5) Hematological parameters such as red blood cells, platelets, white Beta-blockers (n, %) 57 (41.9) blood cells (WBC) and their subtypes were measured in blood Calcium-channel blockers (n, %) 36 (26.4) collected in dipotassium ethylenediaminetetraacetic acid (EDTA) Hematological parameters containing tubes by flow cytometry in an automated blood cell Red blood cell count (X106/ μL) 5.0 ± 0.32 counter (Sysmex, XT-2000i) immediately within 30 minutes after Platelet count (X106/ μL) 284.56 ± 92.28 sampling. Neutrophil to lymphocyte ratio (NLR) was calculated WBC count (X103/ μL) 7.9 ± 1.1 as the mean value of the ratio of neutrophils to lymphocytes, both WBC count ≥ 7.85 X103/µL (n) 53 (39.0) obtained from the same blood sample. 3 Neutrophil (X10 / μL) 6.2 ± 0.88 Statistical Analysis Neutrophil ≥ 6.25 X103/ µL (n) 45 (33.1) NLR 4.5 ± 1.05 Statistical Package for Social Sciences (SPSS) version 17.0 (SPSS NLR ≥ 4.5 (n) 67 (49.3) Inc., Chicago, Illinois, USA) was used for all statistical calculations. Angiographic and procedural characteristics A two tailed P value lower than 0.05 was considered to be statistically 1, 2, 3 diseased vessels (n, %) 45 (33.1), 58 (42.6), 33 (24.3) significant. The categorical variables were shown as numbers of Culprit vessel cases with percentages. Continuous variables were defined as mean LM (n, %) 6 (4.0) ± standard deviation for parametric; and median with minimum LAD (n, %) 55 (40.4) and maximum levels for nonparametric variables. Derivation of the risk score has been described in the original publication. Presence of LCX (n, %) 44 (32.4) diabetes mellitus (DM), ≥ 7.85 X 103/ µL WBC and ≥ 6.25 X 103/ µL RCA (n, %) 21 (15.4) neutrophil count were assigned with 2 points; high NLR (≥ 4.5) with Culprit not clearly identified (n, %) 10 (7.4) 1 point and older age (≥ 70 years old) with -1 point. These individual Stenosis of culprit vessel (%) 84.4 ± 9.9 points were then added together to provide a total risk score for every Treatment decision patient. Receiver operating characteristic (ROC) curve analysis was PCI (n, %) 120 (88.2) performed in order to determine success of the model. An area under CABG (n, %) 9 (6.7) the curve (AUC) value of 0.5 denotes random predictions and a value Conservative (n, %) 7 (5.1) of 1 indicates perfect prediction of poor collateralization. Positive Rentrop Grade and negative predictivity were calculated using score-collateralization Rentrop 0 (n, %) 28 (20.6) cross tabulations. Effects of eliminations of the parameters assigning Rentrop 1 (n, %) 36 (26.5) lowest scores (i.e.