Development and Validation of a Clinical and Laboratory-Based Nomogram for Predicting Coronary Microvascular Obstruction in NSTEMI Patients After Primary PCI

Figures & data

Figure 1 Flow chart.

Abbreviations: NSTEMI, non-ST elevation myocardial infarction; CMRI, cardiac magnetic resonance imaging; pPCI, primary percutaneous coronary intervention; CMVO, cardiac microvascular obstruction.

Table 1 Patient Characteristics

Variables	Validation Cohort (N=99)	Training Cohort (N=226)	P value
Age, years	56.83 ± 11.85	57.33 ± 13.29	0.746
Sex			0.582
Male, n (%)	86 (86.87)	191 (84.51)
Female, n (%)	13 (13.13)	35 (15.49)
Height, cm	167.51 ± 6.69	167.51 ± 14.65	0.996
Weight, kg	73.47 ± 12.50	73.61 ± 13.16	0.931
SBP, mmHg	126.79 ± 16.53	125.83 ± 18.30	0.654
DBP, mmHg	82.86 ± 13.32	80.09 ± 12.65	0.075
HR, times/min	79.45 ± 11.94	79.53 ± 13.28	0.963
Smoking, n (%)			0.266
NO	42 (42.42)	111 (49.12)
Yes	57 (57.58)	115 (50.88)
Drinking, n (%)			0.795
NO	65 (65.66)	145 (64.16)
Yes	34 (34.34)	81 (35.84)
Hypertension, n (%)			0.353
NO	51 (51.52)	129 (57.08)
Yes	48 (48.48)	97 (42.92)
Diabete, n (%)			0.325
NO	74 (74.75)	180 (79.65)
Yes	25 (25.25)	46 (20.35)
Ischemic stroke, n (%)			0.886
NO	92 (92.93)	211 (93.36)
Yes	7 (7.07)	15 (6.64)
History of CAD, n (%)			0.599
NO	74 (74.75)	175 (77.43)
Yes	25 (25.25)	51 (22.57)
Laboratory test
WBC, ×10^9/L	9.95 ± 2.76	11.47 ± 11.39	0.191
N, ×10^9/L	7.78 ± 2.58	8.02 ± 3.34	0.522
L, ×10^9/L	1.59 ± 1.11	1.88 ± 1.37	0.063
NLR, %	6.19 ± 3.88	6.60 ± 8.28	0.637
RBC, ×10^9/L	4.68 ± 0.62	4.79 ± 0.55	0.096
Hb, g/L	143.61 ± 17.20	145.02 ± 17.22	0.495
PLT, ×10^9/L	214.88 ± 56.22	218.50 ± 61.93	0.618
HsCRP, mg/dl	10.11 ± 13.25	9.58 ± 17.31	0.786
Albumin, g/L	39.55 ± 5.32	39.51 ± 4.37	0.94
SCr, mmol/L	64.63 ± 16.31	64.27 ± 14.19	0.841
eGFR, mL/min/1.73m2	108.50 ± 15.95	107.52 ± 14.86	0.593
Glucose, mmol/L	6.63 ± 3.10	6.48 ± 2.49	0.634
TC, mmol/L	4.78 ± 1.04	4.60 ± 2.35	0.464
TG, mmol/L	1.99 ± 1.58	1.92 ± 1.70	0.714
HDL cholesterol, mmol/L	1.02 ± 0.26	0.99 ± 0.27	0.335
LDL cholesterol, mmol/L	3.01 ± 0.95	2.82 ± 1.06	0.127
sdLDL cholesterol, mmol/L	0.98 ± 0.57	1.04 ± 0.54	0.317
Apo A, g/L	1.16 ± 0.20	1.17 ± 0.21	0.633
Apo B, g/L	1.00 ± 0.25	0.95 ± 0.29	0.221
Lpa, mg/L	271.16 ± 193.63	250.57 ± 183.46	0.361
LDH, U/L	519.64 ± 345.65	654.85 ± 705.51	0.071
CKMB, ng/mL	99.15 ± 77.59	103.15 ± 83.33	0.685
hsTnT, ng/L	3040.03 ± 3044.39	3552.49 ± 2977.84	0.157
NT-proBNP, pg/mL	1348.87 ± 1527.45	1629.01 ± 2023.15	0.219
cTnI, ng/L	17.73 ± 15.36	19.11 ± 16.45	0.479
FIB, g/L	2.90 ± 1.10	2.72 ± 0.77	0.081
DD2, ug/mL	0.32 ± 0.31	0.39 ± 0.56	0.276
HbA1c (%)	6.59 ± 1.37	6.64 ± 1.38	0.759
sUA, umol/L	307.69 ± 99.31	297.00 ± 93.78	0.354
Angiographic features
SBT, h	4.55 ± 3.05	4.39 ± 2.69	0.623
D2B, min	72.81 ± 24.13	67.62 ± 44.38	0.275
Pre-AP, n (%)			0.623
NO	76 (76.77)	179 (79.20)
Yes	23 (23.23)	47 (20.80)
Killip grade			0.728
Grade I, n (%)	83 (83.84)	186 (82.30)
Grade II, n (%)	10 (10.10)	29 (12.83)
Grade III, n (%)	6 (6.06)	11 (4.87)
History of stent implantation, n (%)			0.076
NO	96 (96.97)	207 (91.59)
Yes	3 (3.03)	19 (8.41)
Multivascular disease, n (%)			0.719
NO	33 (33.33)	80 (35.40)
Yes	66 (66.67)	146 (64.60)
LAD, n (%)			0.95
NO	50 (50.51)	115 (50.88)
Yes	49 (49.49)	111 (49.12)
LCX, n (%)			0.302
NO	84 (84.85)	201 (88.94)
Yes	15 (15.15)	25 (11.06)
RCA, n (%)			0.29
NO	64 (64.65)	132 (58.41)
Yes	35 (35.35)	94 (41.59)
Calcified lesions, n (%)			0.662
NO	94 (94.95)	217 (96.02)
Yes	5 (5.05)	9 (3.98)
Proximal lesions, n (%)			0.591
NO	47 (47.47)	100 (44.25)
Yes	52 (52.53)	126 (55.75)
Bifurcation lesion, n (%)			0.717
NO	81 (81.82)	181 (80.09)
Yes	18 (18.18)	45 (19.91)
Stent length, mm	28.91 ± 12.86	28.09 ± 10.56	0.547
Stent diameter, mm	2.98 ± 0.41	3.05 ± 0.40	0.173
Number of stents, n (%)	1.20 ± 0.40	1.13 ± 0.34	0.112
High thrombus load, n (%)			0.91
NO	73 (73.74)	168 (74.34)
Yes	26 (26.26)	58 (25.66)
No-reflow, n (%)			0.891
NO	73 (73.74)	165 (73.01)
Yes	26 (26.26)	61 (26.99)
Ischemic postconditioning, n (%)			0.791
NO	62 (62.63)	145 (64.16)
Yes	37 (37.37)	81 (35.84)
Temporary pacemaker, n (%)			0.811
NO	98 (98.99)	223 (98.67)
Yes	1 (1.01)	3 (1.33)
Procedural medication
Tirofiban, n (%)			0.612
NO	80 (80.81)	177 (78.32)
Yes	19 (19.19)	49 (21.68)
Atropine, n (%)			0.886
NO	92 (92.93)	211 (93.36)
Yes	7 (7.07)	15 (6.64)
Dopamine or Hydroxylamine, n (%)			0.584
NO	94 (94.95)	211 (93.36)
Yes	5 (5.05)	15 (6.64)
Nitroprusside, n (%)			0.648
NO	60 (60.61)	143 (63.27)
Yes	39 (39.39)	83 (36.73)

Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; WBC, white blood cell; N, neutrophils; L, lymphocytes; NLR, N/L ratio; RBC, red blood cell; Hb, hemoglobin; PLT, platelets; hsCRP, high-sensitivity C-reactive protein; sCr, serum creatinine; eGFR, estimated glomerular filtration rate; TC, total cholesterol; TG, triglycerides; HDL, high-density lipoprotein; LDL, low density lipoprotein; sdLDL, small dense low-density lipoprotein; Apo A, apolipoprotein A; Apo B, apolipoprotein B; Lpa, lipoprotein a; LDH, lactate dehydrogenase; CKMB, creatine kinase isoenzyme-MB; hsTnT, high-sensitivity troponin T; cTnI, cardiac troponin I; NT-proBNP, N-terminal pro-brain natriuretic peptide; FIB, fibrinogen; DD2, D-dimer; HbA1c, glycated hemoglobin; sUA, serum uric acid; SBT, symptom onset-to-balloon time; D2B, door-to-balloon time; pre-AP, pre-infarction angina; LAD, left anterior descending; LCX, left circumflex branch; RCA, right coronary artery.

Table 2 Univariate Logistic Regression Analysis of the Data from the Training Cohort

Variables	OR	95% CI	P value
Age, years	0.985	(0.965;1.004)	0.127
Sex	0.397	(0.177;0.891)	0.025
Height, cm	1.000	(0.982;1.018)	0.99
Weight, kg	1.004	(0.984;1.025)	0.674
SBP, mmHg	1.006	(0.991;1.02)	0.454
DBP, mmHg	1.009	(0.988;1.03)	0.418
HR, times/min	1.018	(0.997;1.038)	0.09
Smoking, n (%)	1.254	(0.74;2.124)	0.401
Drinking, n (%)	0.99	(0.572;1.714)	0.972
Hypertension, n (%)	0.798	(0.468;1.36)	0.407
Diabetes, n (%)	1.400	(0.731;2.68)	0.310
Stroke, n (%)	0.453	(0.14;1.467)	0.186
History of CAD, n (%)	1.488	(0.795;2.783)	0.214
Laboratory test
WBC, ×10^9/L	0.991	(0.963;1.019)	0.507
N, ×10^9/L	1.231	(1.124;1.348)	<0.001
L, ×10^9/L	0.889	(0.724;1.092)	0.263
NLR, %	1.017	(0.982;1.054)	0.345
RBC, ×10^9/L	1.534	(0.941;2.503)	0.086
Hb, g/L	1.048	(1.028;1.067)	<0.001
PLT, ×10^9/L	1.000	(0.995;1.004)	0.880
HsCRP, mg/dl	1.012	(0.996;1.028)	0.143
Albumin, g/L	1.024	(0.964;1.088)	0.440
SCr, mmol/L	1.006	(0.988;1.025)	0.503
eGFR, mL/min/1.73m2	1.014	(0.996;1.033)	0.133
Glucose, mmol/L	1.027	(0.924;1.141)	0.621
TC, mmol/L	1.122	(0.932;1.351)	0.224
TG, mmol/L	1.387	(1.154;1.667)	0.001
HDL cholesterol, mmol/L	2.036	(0.763;5.434)	0.156
LDL cholesterol, mmol/L	1.006	(0.785;1.288)	0.965
sdLDL cholesterol, mmol/L	0.988	(0.608;1.606)	0.962
Apo A, g/L	3.031	(0.845;10.866)	0.089
Apo B, g/L	1.292	(0.524;3.187)	0.578
Lpa, mg/L	0.9989	(0.9974;1.0004)	0.171
LDH, U/L	1.0006	(1.0001;1.0012)	0.015
CKMB, ng/mL	1.005	(1.002;1.008)	0.003
HsTnT, ng/L	1.0002	(1.0001; 1.0003)	<0.001
NT-proBNP, pg/mL	1.000	(0.9999; 1.0001)	0.899
CTNI, ng/L	1.022	(1.005;1.038)	0.010
FIB, g/L	1.002	(0.711;1.414)	0.989
DD2, ug/mL	0.750	(0.412;1.365)	0.347
HbA1c (%)	1.071	(0.885;1.296)	0.700
SUA, umol/L	1.001	(0.998;1.004)	0.572
Angiographic features
SBT, h	1.108	(1.003;1.224)	0.043
D2B, min	0.999	(0.993;1.005)	0.837
Pre-AP, n (%)	0.686	(0.353;1.332)	0.265
Killip grade	2.098	(1.222;3.602)	0.007
History of stent implantation, n (%)	0.744	(0.281;1.965)	0.550
Multivascular disease, n (%)	1.238	(0.712;2.152)	0.450
LAD, n (%)	1.23	(0.726;2.083)	0.442
LCX, n (%)	1.773	(0.767;4.098)	0.181
RCA, n (%)	0.65	(0.379;1.115)	0.117
Calcified lesions, n (%)	4.846	(0.984;23.87)	0.052
Proximal lesions, n (%)	0.887	(0.523;1.507)	0.658
Bifurcation lesion, n (%)	1.478	(0.767;2.845)	0.243
Stent length, mm	0.989	(0.964;1.014)	0.383
Stent diameter, mm	0.650	(0.334;1.266)	0.205
Number of stents, n (%)	0.725	(0.328;1.605)	0.428
High thrombus load, n (%)	3.420	(1.827;6.400)	<0.001
No-reflow, n (%)	2.891	(1.575;5.306)	0.001
Ischemic postconditioning, n (%)	0.370	(0.207;0.663)	0.001
Temporary pacemaker, n (%)	2.646	(0.236;29.608)	0.430
Procedural medication
Tirofiban, n (%)	1.336	(0.708;2.521)	0.371
Atropine, n (%)	1.154	(0.404;3.298)	0.789
Dopamine or Hydroxylamine, n (%)	0.634	(0.210;1.920)	0.421
Nitroprusside, n (%)	1.081	(0.627;1.865)	0.779

Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; WBC, white blood cell; N, neutrophils; L, lymphocytes; NLR, N/L ratio; RBC, red blood cell; Hb, hemoglobin; PLT, platelets; hsCRP, high-sensitivity C-reactive protein; sCr, serum creatinine; eGFR, estimated glomerular filtration rate; TC, total cholesterol; TG, triglycerides; HDL, high-density lipoprotein; LDL, low density lipoprotein; sdLDL, small dense low-density lipoprotein; Apo A, apolipoprotein A; Apo B, apolipoprotein B; Lpa, lipoprotein a; LDH, lactate dehydrogenase; CKMB, creatine kinase isoenzyme-MB; hsTnT, high-sensitivity troponin T; cTnI, cardiac troponin I; NT-proBNP, N-terminal pro-brain natriuretic peptide; FIB, fibrinogen; DD2, D-dimer; HbA1c, glycated hemoglobin; sUA, serum uric acid; SBT, symptom onset-to-balloon time; D2B, door-to-balloon time; preAP, pre-infarction angina; LAD, left anterior descending; LCX, left circumflex branch; RCA, right coronary artery.

Table 3 Multivariate Logistic Regression Analysis of the Data from the Training Cohort

Variable	OR	95% CI	P value
Killip grade, n (%)	2.19	(1.065;4.503)	0.033
N, ×10^9/L	1.166	(1.044; 1.303)	0.006
Hb, g/L	1.037	(1.013; 1.062)	0.002
TG, mmol/L	1.343	(1.059; 1.704)	0.015
High thrombus load, n (%)	3.146	(1.424; 6.952)	0.005
No-reflow, n (%)	3.142	(1.419; 6.955)	0.005
Ischemic postconditioning, n (%)	0.445	(0.209; 0.944)	0.035

Abbreviations: N, neutrophils; Hb, hemoglobin; TG, triglycerides.

Figure 2 Nomogram for predicting the possibility of CMVO after primary PCI in NSTEMI patients.

Abbreviations: NSTEMI, non-ST elevation myocardial infarction; PCI, percutaneous coronary intervention; CMVO, cardiac microvascular obstruction.

Figure 3 ROC curves for the nomogram in the training cohort (A) and the validating cohort (B).

Abbreviation: ROC, receiver operating characteristics.

Figure 4 The calibration plot for the nomogram in the training cohort (A) and the validating cohort (B). The predicted probability of CMVO is plotted on the x-axis and the actual probability is plotted on the y-axis.

Abbreviation: CMVO, cardiac microvascular obstruction.

Figure 5 The decision curve analysis (DCA) for the nomogram in the training cohort (A) and the validating cohort (B). The blue dotted line represents the intervention-none and the net benefit with zero, the green dotted line shows intervention-all-patients. The upper part of the green dotted line represents positive income, meanwhile, the lower part represents negative income. The red line represents a threshold of the model.