Key result
SMuRF-less status is linked to ~70% higher in-hospital mortality after PCI.
Why the study?
Patients without standard modifiable risk factors (SMuRF-less) remain at risk of mortality after PCI, and the clinical mechanisms mediating their short- and long-term mortality are not well understood.
Does the absence of standard modifiable risk factors (SMuRF-less) increase the risk of in-hospital and 1-year mortality in patients undergoing percutaneous coronary intervention?
Cohort (n=12,190)
Yes
Does the absence of standard modifiable risk factors (SMuRF-less) increase the risk of in-hospital and 1-year mortality in patients undergoing percutaneous coronary intervention?
In patients without standard modifiable risk factors undergoing PCI, higher early mortality is largely driven by STEMI presentation, whereas long-term mortality risk is mediated by the underuse of guideline-directed secondary prevention therapies (statins, RAAS blockade, and beta-blockers).
SMuRF-less patients warrant closer in-hospital monitoring after PCI; leaves open whether targeting STEMI presentation and GDMT gaps improves survival.
Background Standard modifiable risk factors (SMuRFs), including hypertension, hypercholesterolemia, diabetes, and smoking, contribute substantially to atherosclerosis. However, patients with SMuRF-less remain at risk of mortality after percutaneous coronary intervention (PCI). The mechanisms underlying this risk are not well understood. Purpose This study aimed to identify clinical pathways mediating short- and long-term mortality among SMuRF-less patients undergoing PCI. Methods Data from a multicenter Thai PCI registry was used including patients who underwent PCI at 39 cardiac centers between 2018-2019. Patients with prior coronary artery syndromes were excluded. Clinical data, procedural characteristics, medication use during PCI and at discharge, and outcomes (in-hospital and 1-year-death) were collected. Mediation analyses were performed using generalized structural equation modeling to assess indirect effects of SMuRF-less on death through STEMI presentation, antiplatelet therapy, procedural complications, guideline-directed medical therapy (GDMT: RAAS, beta-blocker and statins). Results Among 12,190 eligible patients, 684 (5.6%) were SMuRF-less. In-hospital death was significantly higher in SMuRF-less than at-least-one SMuRF (5.6% vs 3.5%). After adjusting covariates, SMuRF-less was significantly higher odds of death [OR = 1.70 (95% CI: (1.31, 2.23)]. STEMI significantly mediated this association [indirect OR = 1.33 (1.20, 1.88)], whereas mediation through clopidogrel and procedural complication was minimal. Among hospital survivors, SMuRF-less was not significantly associated with 1-year death [OR= 0.96 (0.66, 1.25)]; however, lower use of RAAS blockade [OR = 1.29 (1.16, 1.45)], beta-blocker[OR=1.05 (1.01, 1.12)] and statins [OR = 1.38 (1.10, 1.76)] significantly mediated increased 1-year-death. Conclusion Early mortality among SMuRF-less patients undergoing PCI is largely driven by STEMI presentation, whereas long-term risk is influence by underuse of secondary prevention therapies. Ensuring equitable GDMTs is essential to improving outcomes in this population.
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Kiatchoosakun et al. (2026) conducted a cohort in Coronary artery disease undergoing percutaneous coronary intervention (PCI) (n=12,190). Absence of standard modifiable risk factors (SMuRF-less) vs. Presence of at least one standard modifiable risk factor (SMuRF) was evaluated on In-hospital death (OR 1.70, 95% CI 1.31-2.23). Absence of standard modifiable risk factors (SMuRF-less) was associated with higher in-hospital mortality after PCI compared to having ≥1 SMuRF (5.6% vs 3.5%; OR 1.70; 95% CI 1.31-2.23).
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