When youth meets risk: a simple score predicting heart failure after early-onset acute coronary syndrome

Introduction

Acute coronary syndrome (ACS) in young adults (≤45 years) carries a substantial long-term risk of heart failure (HF). Existing prediction models, derived from older populations, may not accurately stratify younger patients. A simple, clinically applicable score for early identification of high-risk individuals could enhance preventive care and long-term outcomes.

Objective

To develop and validate a pragmatic risk score for predicting HF in young adults following ACS.

Methods

We performed a retrospective, single-centre study of patients aged ≤45 years admitted with ACS between January 2013 and October 2023. Median follow-up was 4.5 ± 2.9 years. Demographic, clinical, and angiographic variables were collected. Logistic regression analysis was performed to identify predictors of HF. Six predictors were included in the final score: left ventricular ejection fraction (LVEF) < 50% (3 points), left anterior descending artery (LAD) occlusion (2), and STEMI, multivessel disease, obesity, and smoking (1 each). Discrimination for incident HF was assessed by receiver-operating-characteristic (ROC) analysis.

Results

A total of 130 patients were analysed (mean age 41.8 ± 4.2 years; 77.7% male). Almost all (97.9%) had at least one cardiovascular risk factor: smoking 79.2%, overweight/obesity 75.2%, dyslipidaemia 74.6%, hypertension 30.8%, diabetes 20.0%. Family history of premature ACS occurred in 20%. At presentation, 60.8% had STEMI, 30.0% NSTEMI, and 9.2% unstable angina; 3.1% presented with cardiac arrest. LVEF < 50% was observed in 38.5%. Single-vessel disease predominated (74.6%), mainly involving the LAD (61.5%). Atherosclerosis was the leading aetiology (76.9%), followed by in-stent restenosis (8.5%), embolism (5.4%), and spontaneous dissection (2.3%).

During follow-up, 20.8% developed HF; among them, 59.3% had reduced LVEF.

The score demonstrated excellent discrimination for HF (AUC 0.866, 95% CI 0.79–0.94; p < 0.001). HF incidence was 0% in the low-risk group, 52,4% in the intermediate (score = 6), and 71,8% in the high-risk group (scores 7–9).

The positive predictive value for high risk was 69,7%, and the negative predictive value for low risk 100%.

Conclusion

A concise six-variable risk score accurately identifies young ACS survivors at high risk of HF. The model uses readily available clinical data and shows excellent discrimination. This simple stratification tool may guide personalised follow-up and early preventive interventions in young adults after ACS. Prospective external validation is warranted.