Key result
Adding log(BUN/EF) to clinical risk models improves recurrent ischemic event prediction by ~0.06 AUC in young ACS.
Why the study?
Traditional risk models derived from older populations may not adequately capture the interplay between cardiac dysfunction and systemic stress in young ACS patients, who face substantial residual risk of recurrent ischemic events. Whether the log-transformed BUN-to-EF ratio provides incremental prognostic value beyond conventional clinical risk factors in this population was unknown.
Does adding the log-transformed BUN-to-ejection fraction ratio (log[BUN/EF]) to a conventional clinical risk model improve the prediction of recurrent ischemic events in young patients with acute coronary syndrome?
Cohort (n=672)
Does adding the log-transformed BUN-to-ejection fraction ratio (log[BUN/EF]) to a conventional clinical risk model improve the prediction of recurrent ischemic events in young patients with acute coronary syndrome?
Incorporating the simple, widely available log(BUN/EF) biomarker into traditional clinical risk models significantly improves the prediction of recurrent ischemic events in young patients with acute coronary syndrome.
Answers are grounded in this paper and cite their sources.
May refine ischemic risk prediction in young ACS; hypothesis-generating and requires prospective validation before adoption.
Background Young patients with acute coronary syndrome (ACS) represent a distinct clinical population with a substantial residual risk of recurrent ischemic events despite contemporary therapies and guideline-directed management. Traditional risk models are primarily derived from older populations and may not adequately capture the interplay between cardiac dysfunction and systemic stress in younger individuals. Biomarkers reflecting integrated cardiorenal stress may provide additional prognostic insights and improve individualized risk stratification. Purpose To investigate whether cardiorenal stress phenotyping using the log-transformed blood urea nitrogen to left ventricular ejection fraction ratio (log[BUN/EF]) provides incremental prognostic value beyond conventional clinical risk factors for predicting recurrent ischemic events in a young ACS population beyond conventional clinical risk factors. Methods This retrospective cohort study included 672 consecutive patients presenting with ACS. A baseline clinical model incorporating age, sex, diabetes, hypertension, smoking status, clinical presentation, and multivessel diseases was developed. The incremental value of log(BUN/EF) was assessed using receiver operating characteristic (ROC) analysis, net reclassification improvement, integrated discrimination improvement, calibration metrics, and decision curve analysis to evaluate clinical utility. Median follow-up was 3.5 years (IQR 2.0–4.7 years). Results During follow-up, 50 patients (7.4%) experienced recurrent ischemic events. Addition of log(BUN/EF) significantly improved model discrimination, increasing the area under the curve from 0.78 to 0.84 (ΔAUC +0.056; p=0.0005). Continuous net reclassification improvement was 0.65 (95% CI 0.37–0.91; p<0.001), and the integrated discrimination improvement was 0.063 (95% CI 0.03–0.09; p<0.001). The calibration remained robust with a calibration slope near unity and a lower Brier score (0.060 vs 0.064), indicating a reduced prediction error. Decision curve analysis demonstrated higher net clinical benefit across clinically relevant threshold probabilities, supporting the clinical relevance of incorporating log(BUN/EF) into the risk assessment. Conclusions Cardiorenal stress phenotyping using log(BUN/EF), a simple and widely available biomarker integrating renal function and ventricular performance, provides significant incremental prognostic information beyond traditional risk factors and may enhance individualized risk stratification in young patients with ACS.tablesfigures
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Celik et al. (2026) conducted a cohort in Acute coronary syndrome (n=672). Log-transformed blood urea nitrogen to left ventricular ejection fraction ratio (log[BUN/EF]) added to baseline clinical model vs. Baseline clinical model incorporating age, sex, diabetes, hypertension, smoking status, clinical presentation, and multivessel disease was evaluated on Recurrent ischemic events (ΔAUC +0.056 (AUC 0.84 vs 0.78); Continuous NRI 0.65, 95% CI 0.37-0.91, p=0.0005). Adding log(BUN/EF) to a baseline clinical model improved prediction of recurrent ischemic events in young ACS patients, increasing AUC from 0.78 to 0.84 (ΔAUC +0.056; p=0.0005).
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