Cardiovascular Outcomes in SMuRF-less Acute Coronary Syndrome - A Large Database Analysis Using TriNetX

Document Type

Conference Proceeding

Publication Date

4-2026

Publication Title

Journal of the Society for Cardiovascular Angiography & Interventions

Abstract

Background: Patients presenting with acute coronary syndromes (ACS) without standard modifiable cardiovascular risk factors (SMuRF-less: no hypertension, diabetes, hyperlipidemia, or smoking) represent a substantial minority of ACS presentations and paradoxically experience higher early mortality despite fewer traditional risk factors. Prior studies are largely non-US or single-system analyses, limiting generalizability. Large-scale validation of treatment patterns and outcomes in SMuRF-less ACS within a US population is lacking. Methods: We conducted a retrospective cohort study using the TriNetX Research Network, including adults hospitalized with a first ACS event (STEMI, NSTEMI, or unstable angina) between 2010–2024. SMuRF-less patients were compared with SMuRF-positive patients (≥1 risk factor). Propensity score matching (1:1) was performed for age, sex, and race. Primary outcomes included 30-day all-cause mortality and initiation of optimal medical therapy (ASA, P2Y12 inhibitor, betablocker (BB), ACE inhibitor/ARB) within 1 week. Secondary outcomes included 1-year mortality, revascularization (PCI/CABG) and cardiogenic shock during index hospitalization. Results: Among 665,643 ACS patients, 127,316 (19.1%) were SMuRF-less. After matching, 112,886 patients were included in each cohort. SMuRF-less patients had significantly higher 30-day mortality compared with SMuRF-positive patients (RR 1.39, p< 0.001), along with lower rates of early medical therapy and revascularization. SMuRF-less patients consistently received less ASA (RR 0.73), P2Y12i (RR 0.72), statins (RR 0.72), BB (RR 0.71), ACEi/ARBs (RR 0.77), PCI (RR 0.11), and CABG (RR 0.10), but had lower risk of cardiogenic shock (RR 0.51). At 1 year, mortality rates were comparable between groups (RR 0.99, p=0.9537), suggesting late hazard normalization. Conclusions: In a large US EHR-based cohort, SMuRF-less ACS patients experience excess early mortality associated with lower use of optimal medical therapy and revascularization, despite similar 1-year mortality. These findings highlight a critical early treatment gap and underscore the need for improved recognition and aggressive early management of this unique population.

Volume

5

Issue

4 Suppl

First Page

104415

Comments

SCAI (Society for Cardiovascular Angiography & Interventions) Scientific Sessions, April 23-26, 2026, Montreal, Canada

Last Page

104415

DOI

10.1016/j.jscai.2026.104415

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