Baseline characteristics
Patients with ACS were categorised into three groups based on the non-HDL-c tertile method. Patients in the T3 group were younger and exhibited higher lipid levels and BMI than those in the T1 and T2 groups (both p < 0.05). The combined initial characteristics are presented in Table 1.
Table 1
Fundamental traits categorised based on the tertiles of non-HDL-C
| Total (N = 1,695) | T1 (N = 577) | T2 (N = 553) | T3 (N = 565) | P |
Glycemia(mmol/L) | 7.71(5.83,11.45) | 7.24(5.62,11.20) | 7.76(5.86,11.39) | 8.24(6.02,11.66) | 0.006 |
Age(years) | 62 (54,71) | 64 (56,72) | 63 (54,71) | 58 (52,69) | < 0.001 |
BMI(kg/m2) | 23.88 (21.80,26.42) | 23.51(21.45,26.11) | 23.88 (21.93,26.12) | 24.04 (22.04,26.89) | 0.017 |
Creatinine(µmol/L) | 78 (66,94) | 81 (69,99) | 78 (65,92) | 74 (63,92) | < 0.001 |
hs-CRP(mg/L) | 3.77(1.21,14.30) | 3.46(1.10,14.22) | 4.10(1.49,17.07) | 3.77(1.20,11.99) | 0.086 |
SBP (mmHg) | 123 (111,136) | 122 (111,135) | 122 (111,135) | 125 (112,138) | 0.254 |
DBP (mmHg) | 75 (67,84) | 75 (68,83) | 75 (67,84) | 76 (68,86) | 0.107 |
LVEF (%) | 56 (46,61) | 56 (47,61) | 55 (44,60) | 56 (47,60) | 0.174 |
eGFR (mL/min/1.73 m2) | 87.73(70.43,105.03) | 84.30(68.13,99.87) | 88.35(70.97,104.67) | 92.06(73.07,108.71) | < 0.001 |
Hb (g/L) | 138 (125,151) | 136 (122,147) | 138 (125,150) | 142 (130,154) | < 0.001 |
HbA1c (%) | 6.50 (5.80,8.00) | 6.50 (5.80,7.60) | 6.50 (5.70,8.30) | 6.70 (5.80,8.40) | 0.018 |
HDL-C (mmol/L) | 1.09 (0.93,1.27) | 1.03 (0.87,1.20) | 1.09 (0.93,1.26) | 1.16 (1.01,1.31) | < 0.001 |
LDL-C (mmol/L) | 2.96 (2.35,3.60) | 2.13 (1.81,2.38) | 3.00 (2.76,3.25) | 3.89 (3.60,4.29) | < 0.001 |
TC (mmol/L) | 4.85 (3.97,5.76) | 3.65 (3.20,4.01) | 4.86 (4.56,5.18) | 6.19 (5.74,6.83) | < 0.001 |
TG (mmol/L) | 1.88 (1.26,2.89) | 1.39 (1.02,2.16) | 1.83 (1.30,2.83) | 2.47 (1.71,3.95) | < 0.001 |
Uric acid(µmol/l) | 353 (294,431) | 349 (295,425) | 350 (291,428) | 364 (299,441) | 0.129 |
Male | 1,208 (71.3) | 445 (77.1) | 382 (69.1) | 381 (67.4) | < 0.001 |
Smoking | | | | | < 0.001 |
Current | 714 (42.1) | 235 (40.7) | 233 (42.1) | 246 (43.5) | |
Former | 210 (12.4) | 108 (18.7) | 51 (9.2) | 51 (9.0) | |
Never | 771 (45.5) | 234 (40.6) | 269 (48.6) | 268 (47.4) | |
Previous MI | 559 (33) | 249 (43.2) | 160 (28.9) | 150 (26.5) | < 0.001 |
Previous CABG | 14 (0.8) | 3 (0.5) | 6 (1.1) | 5 (0.9) | 0.567 |
Previous PCI | 190 (11.2) | 115 (19.9) | 45 (8.1) | 30 (5.3) | < 0.001 |
Hypertension grade | | | | | 0.468 |
1 | 97 (5.7) | 31 (5.4) | 33 (6.0) | 33 (5.8) | |
2 | 294 (17.3) | 109 (18.9) | 91 (16.5) | 94 (16.6) | |
3 | 643 (37.9) | 226 (39.2) | 218 (39.4) | 199 (35.2) | |
Dyslipidaemia | 754 (44.5) | 126 (21.8) | 226 (40.9) | 402 (71.2) | < 0.001 |
Previous stroke | 216 (12.7) | 101 (17.5) | 59 (10.7) | 56 (9.9) | < 0.001 |
Family history | 8 (0.5) | 0 (0.0) | 2 (0.4) | 6 (1.1) | 0.029 |
Insulin | 433 (25.5) | 146 (25.3) | 136 (24.6) | 151 (26.7) | 0.706 |
Oral hypoglycaemic drugs | 763 (45) | 264 (45.8) | 238 (43.0) | 261 (46.2) | 0.517 |
DM | 959 (56.6) | 321 (55.6) | 305 (55.2) | 333 (58.9) | 0.378 |
Diagnosis on admission | | | | | < 0.001 |
STEMI | 429 (25.3) | 100 (17.3) | 157 (28.4) | 172 (30.4) | |
NSTEMI | 434 (25.6) | 126 (21.8) | 152 (27.5) | 156 (27.6) | |
UA | 832 (49.1) | 351 (60.8) | 244 (44.1) | 237 (41.9) | |
Gensini score | 50 (32,78) | 45 (25,72) | 52 (32,80) | 52 (35,80) | < 0.001 |
The data are displayed in the form of averages ± standard deviations, median values (interquartile ranges), or percentages. |
Hb, haemoglobin; MI, myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction; LDL-C, low-density lipoprotein cholesterol; STEMI, ST-segment elevation myocardial infarction; LVEF, left ventricular ejection fraction; DBP, diastolic blood pressure; HDL-C, high-density lipoprotein cholesterol; DM, diabetes mellitus; PCI, percutaneous coronary intervention; TC, total cholesterol; TG, triglycerides; CABG, coronary artery bypass grafting; BMI, body mass index; SBP, systolic blood pressure; hs-CRP, high-sensitivity C-reactive protein; non-HDL-C, non-high-density lipoprotein; HbA1c, glycosylated haemoglobin; eGFR, estimated glomerular filtration rate; UA, unstable angina |
Clinical outcomes
Table 2 presents the correlations between all patients with ACS and elevated Gensini scores. The single-factor logistic regression analysis in Model 1 revealed a correlation between non-HDL-C and elevated Gensini scores (OR = 1.09; 95%CI = 1.02–1.18; p = 0.016). The T3 group exhibited a risk of elevated Gensini scores that were 1.37 times higher than those of the T1 group (OR = 1.37; 95%CI = 1.08–1.73; p = 0.008). The multifactorial logistic regression analysis in Model 2, accounting for possible risk elements, revealed non-HDL-C as a standalone risk factor for elevated Gensini scores (OR = 1.20; 95%CI = 1.10–1.31; p < 0.001). The T2 group had a 1.61 times higher risk (OR = 1.61; 95%CI = 1.25–2.07; p < 0.001), while the T3 group had a 1.8 times higher risk (OR = 1.80; 95%CI = 1.37–2.36; p < 0.001) of elevated Gensini scores than the T1 group.
Table 2
Correlations between non-HDL-C and the Gensini score
| Events/N | Model 1 | | | | Model 2 | | |
| | OR | 95CI% | P | | OR | 95CI% | P |
non-HDL-C | 834/1,695 | 1.09 | 1.02–1.18 | 0.016 | | 1.20 | 1.10–1.31 | < 0.001 |
T1 | 251/577 | Reference | | | | Reference | | |
T2 | 293/553 | 1.46 | 1.16–1.85 | 0.001 | | 1.61 | 1.25–2.07 | < 0.001 |
T3 | 290/565 | 1.37 | 1.08–1.73 | 0.008 | | 1.80 | 1.37–2.36 | < 0.001 |
P for trend | | | | 0.008 | | | | < 0.001 |
Non-HDL-C, non-high-density lipoprotein; OR, odds ratio; CI, confidence interval; DM, diabetes mellitus; non-HDL-C, non-high-density lipoprotein
The results of the restricted cubic spline analysis are shown in Fig. 2, which demonstrates a dose-response relationship between non-HDL-C and high Gensini scores in patients with ACS (nonlinear p = 0.513).
Subgroup analyses
Further categorisation was conducted according to sex, age groups, and DM status (diabetic or non-diabetic) to explore the correlation between non-HDL-C and high Gensini scores in the subgroups. The results of analysing patients with ACS with varying DM statuses are presented in Table 3. No significant interaction was noted between DM status and non-HDL cholesterol levels (interaction p-value = 0.110). After adjusting for potential risk factors, multifactorial logistic regression analysis (OR = 1.15; 95%CI = 1.02–1.29; p = 0.024) revealed non-HDL-C as an independent risk factor for elevated Gensini scores in patients with DM. Within the T2 (OR = 1.73; 95%CI = 1.22–2.44; p = 0.002) and T3 (OR = 1.65; 95%CI = 1.14–2.38; p = 0.007) groups, indicating that the risks were 1.73 and 1.65 times greater than those in the T1 group, respectively. Among patients without DM, after adjusting for potential risk factors, non-HDL-C continued to be an independent risk factor for elevated Gensini scores (OR = 1.29; 95%CI = 1.11–1.49; p < 0.001), with the T3 group showing a risk 1.98 times greater (OR = 1.98; 95%CI = 1.30–3.04; p = 0.002) than the T1 group.
Table 3
Correlations between non-HDL-C and Gensini scores across various diabetes conditions
| Events/N | Mode 1 | P | | | Model 2 | | | |
| | OR | 95CI% | P | | OR | 95CI% | P | P for interaction |
Glucose metabolism state | | | | | | | | | 0.110 |
DM | 461/959 | 1.03 | 0.94–1.13 | 0.528 | | 1.15 | 1.02–1.29 | 0.024 | |
T1 | 138/321 | Reference | | | | Reference | | | |
T2 | 165/305 | 1.56 | 1.14–2.14 | 0.006 | | 1.73 | 1.22–2.44 | 0.002 | |
T3 | 158/333 | 1.20 | 0.88–1.63 | 0.252 | | 1.65 | 1.14–2.38 | 0.007 | |
Non-DM | 373/736 | 1.20 | 1.07–1.35 | 0.002 | | 1.29 | 1.11–1.49 | < 0.001 | |
T1 | 113/256 | Reference | | | | Reference | | | |
T2 | 128/248 | 1.35 | 0.95–1.92 | 0.093 | | 1.43 | 0.97–2.10 | 0.069 | |
T3 | 132/232 | 1.67 | 1.17–2.39 | 0.005 | | 1.98 | 1.30–3.04 | 0.002 | |
non-HDL-C, non-high-density lipoprotein; OR, odds ratio; CI, confidence interval; DM, diabetes mellitus
Results from the examination of patients with ACS across different age groups are presented in Table 4. No significant interaction was observed between age and degree of non-HDL cholesterol (interaction p = 0.258). In elderly patients, after accounting for potential risk factors, the complex logistic regression analysis (OR = 1.18; 95%CI = 1.04–1.33; p = 0.009) revealed that non-HDL-C independently resulted in higher Gensini scores, and the risks of attaining high Gensini scores in the T3 group (OR = 1.45; 95%CI = 1.00–2.10; p = 0.048) was 1.45 times higher than that in the T1 group. In the younger group, after accounting for potential risk factors, the complex logistic regression analysis revealed non-HDL-C as an independent risk factor for increased Gensini scores (OR = 1.21; 95%CI = 1.06–1.40; p = 0.007). In contrast to the T1 group, the T2 (OR = 2.23; 95%CI = 1.47–3.39; p < 0.001) and T3 (OR = 2.56; 95%CI = 1.66–3.95; p < 0.001) groups exhibited 2.23 and 2.56 times higher risks, respectively, in attaining elevated Gensini scores.
Table 4
Correlations between non-HDL-C and Gensini scores across various age groups
| Events/N | Model 1 | | | | Model 2 | | | |
| | OR | 95CI% | P | | OR | 95CI% | P | P for interaction |
Age-years | | | | | | | | | 0.258 |
Age ≥ 60 | 477 /937 | 1.07 | 0.97–1.18 | 0.192 | | 1.18 | 1.04–1.33 | 0.009 | |
T1 | 180/369 | Reference | | | | Reference | | | |
T2 | 166/312 | 1.19 | 0.88–1.61 | 0.250 | | 1.36 | 0.98–1.89 | 0.069 | |
T3 | 131/256 | 1.10 | 0.80–1.51 | 0.557 | | 1.45 | 1.00-2.10 | 0.048 | |
Age < 60 | 357/758 | 1.15 | 1.03–1.29 | 0.012 | | 1.21 | 1.06–1.40 | 0.007 | |
T1 | 71/208 | Reference | | | | Reference | | | |
T2 | 127/241 | 2.15 | 1.47–3.15 | < 0.001 | | 2.23 | 1.47–3.39 | < 0.001 | |
T3 | 159/309 | 2.05 | 1.42–2.94 | < 0.001 | | 2.56 | 1.66–3.95 | < 0.001 | |
non-HDL-C, non-high-density lipoprotein; OR, odds ratio; CI, confidence interval
Table 5 shows the results of the sex-focused examination of patients with ACS. No significant interaction was found between sex and the levels of non-HDL-C (interaction p = 0.491). In the case of male patients, after accounting for potential risk factors, the comprehensive logistic regression analysis identified non-HDL-C as an independent risk factor for increased Gensini scores (OR = 1.15; 95%CI = 1.04–1.28; p = 0.010). Individuals in both the T2 (OR = 1.57; CI = 1.16–2.11; p = 0.003) and T3 (OR = 1.60; CI = 1.16–2.22; p = 0.004) groups exhibited an increase of 1.57 and 1.60 times higher, respectively, in attaining elevated Gensini scores than those in the T1 group. For female patients, after accounting for potential risk factors, the complex logistic regression analysis indicated that non-HDL-C independently led to higher Gensini scores (OR = 1.31; 95%CI = 1.10–1.57; p = 0.002). The T2 (OR = 1.90; CI = 1.14–3.17; p = 0.014) and T3 (OR = 2.54; CI = 1.48–4.35; p < 0.001) groups exhibited 1.90 and 2.54 times higher risks of having elevated Gensini scores than the T1 group.
Table 5
Correlations between non-HDL-C and Gensini scores across various sexes
| Events/N | Model 1 | | | | Model 2 | | | |
| | OR | 95CI% | P | | OR | 95CI% | P | P for interaction |
Sex | | | | | | | | | 0.491 |
Male | 601 /1208 | 1.07 | 0.98–1.17 | 0.116 | | 1.15 | 1.04–1.28 | 0.010 | |
T1 | 199 /445 | Reference | | | | Reference | | | |
T2 | 207 /382 | 1.46 | 1.11–1.92 | 0.007 | | 1.57 | 1.16–2.11 | 0.003 | |
T3 | 195 /381 | 1.30 | 0.99–1.71 | 0.064 | | 1.60 | 1.16–2.22 | 0.004 | |
Female | 233 /487 | 1.16 | 1.01–1.33 | 0.034 | | 1.31 | 1.10–1.57 | 0.002 | |
T1 | 52 /132 | Reference | | | | Reference | | | |
T2 | 86 /171 | 1.56 | 0.98–2.47 | 0.059 | | 1.90 | 1.14–3.17 | 0.014 | |
T3 | 95 /184 | 1.64 | 1.04–2.58 | 0.032 | | 2.54 | 1.48–4.35 | < 0.001 | |
non-HDL-C, non-high-density lipoprotein; OR, odds ratio; CI, confidence interval
Non-HDL-C predicts the incremental effect of high Gensini scores in patients with ACS
To assess patients with ACS, an ROC curve was formulated (Fig. 3), and the effectiveness of the initial risk, non-HDL-C (baseline risk model + non-HDL-C), and TC (baseline risk model + TC) models in predicting higher Gensini scores in patients with ACS was also examined. Table 6 illustrates the C-statistics, NRI, and IDI for different models. The C-statistic revealed that the non-HDL-C model showed an advancing predictive effect over the original risk model (0.6584 [95%CI; 0.6326–0.6841] versus 0.6483 [95%CI; 0.6224–0.6743], p = 0.043). Calculations of the NRI (0.0382 [95% CI = 0.0065–0.0699]; p = 0.018) and IDI (0.0091 [95% CI = 0.0047–0.0136]; p < 0.001] demonstrated a significant incremental predictive effect of the inclusion of non-HDL-C in the initial risk assessment.
Table 7 shows the outcomes of internally validating the model using the bootstrap technique involving 1000 resamplings, yielding an AUC of 0.6234; the AUC for the non-HDL-C model developed for this study was 0.6584, a comparable finding, indicative of the model's robustness level.
Table 6
Incremental predictive power and predictive strength of various models incorporating NRI, IDI, and C statistics
Model | C-statistic (95%Cl) | P | NRI (95%Cl) | P | IDI (95%Cl) | P |
Baseline risk model | 0.6483(0.6224–0.6743) | Ref | Ref | | Ref | |
+TC | 0.6566(0.6308–0.6824) | 0.065 | 0.0300(-0.0005-0.0604) | 0.054 | 0.0073(0.0033–0.0113) | < 0.001 |
+Non-HDL-C | 0.6584(0.6326–0.6841) | 0.043 | 0.0382(0.0065–0.0699) | 0.018 | 0.0091(0.0047–0.0136) | < 0.001 |
The baseline risk model includes age, BMI, SBP, DBP, TG, eGFR, creatinine, glycemia, uric acid, Hb, hs-CRP, HbA1c, LVEF, sex, smoking, previous MI, previous CABG, previous PCI, hypertension, previous stroke, family history, and insulin.
Hb, haemoglobin; MI, myocardial infarction; LVEF, left ventricular ejection fraction; DBP, diastolic blood pressure; PCI, percutaneous coronary intervention; TC, total cholesterol; TG, triglycerides; CABG, coronary artery bypass grafting; BMI, body mass index; SBP, systolic blood pressure; hs-CRP, high-sensitivity C-reactive protein; HbA1c, glycosylated haemoglobin; eGFR, estimated glomerular filtration rate; CI, confidence interval; IDI, Integrated Discriminant Improvement Index; NRI, Net Reclassification Index
Table 7
Results of bootstrap-based internal validation of models
AUC | Sensitivity | Specificity |
0.6182 | 0.6234 | 0.4513 |
AUC, area under the curve |