MORTALITY RISK DETERMINANTS IN ACUTE CORONARY SYNDROME:
AN EVIDENCE-BASED LITERATURE REVIEW
Ika Ainur RofiAoah *1.
Rudi Hariyono2 Faculty of Health Sciences.
Bina Sehat PPNI University.
Mojokerto *Corresponding Email: ikaainur.
ns@gmail.
ABSTRACT
Keywords Acute Coronary Syndrome (ACS) remains a major global health problem and a leading cause of mortality, particularly in low- and middle-income countries where delays in treatment and limited access to reperfusion persist.
Early identification of mortality determinants is essential for optimizing management and improving outcomes.
This evidence-based review aimed to summarize contemporary predictors of mortality in ACS, incorporating clinical, demographic, laboratory, and hemodynamic factors.
comprehensive search was conducted using PubMed.
Scopus, and Google Scholar for articles published between 2017 and 2025.
Eleven studies met the eligibility criteria and were synthesized narratively.
The findings show that hemodynamic instability, including hypotension, tachycardia, and cardiogenic shock, is the most consistent predictor of early and in-hospital mortality.
Renal impairment, high Killip class, reduced left ventricular ejection fraction, and cardiac arrest at presentation also substantially increase risk.
Age and comorbidities such as diabetes, hypertension, and chronic kidney disease contribute to both short- and long-term mortality.
System delays, including prolonged symptom-to-door and door-to-balloon times, further worsen outcomes, particularly in resource-limited settings.
The Simple Risk Index (SRI) emerges as a practical early risk-stratification tool.
Strengthening early recognition, ensuring timely reperfusion, and improving management of comorbidities are crucial steps to reduce ACS-related mortality.
Acute Coronary Syndrome.
Mortality Predictors.
Risk Factors.
Simple Risk
Index
INTRODUCTION
Acute Coronary Syndrome (ACS) remains a leading cause of global morbidity and mortality, significantly exacerbating the burden of cardiovascular disease despite progress in diagnostic and treatment Ischemic heart disease, including acute coronary syndrome, is responsible for over 9 million fatalities per year, rendering it the foremost cause of mortality globally.
Recent epidemiological estimates indicate that the global incidence of Acute Coronary Syndrome (ACS) is 3-4 International Journal of Nursing and Midwifery Science (IJNMS).
Volume 9.
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December 2025 instances per 1,000 individuals yearly, with elevated rates in low- and middle-income countries where preventative and acute care infrastructures are inadequate.
Globally, acute coronary syndrome (ACS) remains a significant cause of mortality, especially in instances of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) that lack prompt and efficient intervention (Bergmark et al.
, 2.
The clinical severity of ACS is exacerbated by consequences including heart failure, cardiogenic shock, and lifethreatening arrhythmias, all of which substantially increase the risk of both shortand long-term death.
Recent studies indicate that changing patterns of degenerative illnesses, along with a rise in comorbidities, worsen the clinical course of ACS and elevate mortality risk (Zheng et al.
, 2.
developing countries like Indonesia.
ACS obstacles, including delayed care-seeking behavior, limited access to PCI-capable facilities, and a high prevalence of major cardiovascular risk factors such as hypertension, diabetes mellitus, and dyslipidemia (Wahyuni et al.
, 2.
National health records indicate that the prevalence of coronary heart disease in Indonesia has attained 1.
5% of the population, with acute coronary syndrome considerably contributing to emergency cardiovascular admissions.
In-hospital mortality rates for ACS patients remain high, mostly due to delayed reperfusion, hemodynamic instability, and inequities in acute cardiac treatment (Juzar et al.
, 2.
Timely and precise mortality risk evaluation is an essential element in the management of ACS.
Risk classification enables doctors to prioritize therapies, select appropriate reperfusion techniques, and identify high-risk patients who require intensive monitoring.
Multiple risk assessments have been formulated and verified, including the TIMI Risk Index.
GRACE Score, and Simple Risk Index (SRI).
Numerous studies indicate that the SRI is straightforward, usable during the pre-hospital phase, and effective in forecasting death, particularly in STEMI cases (Moriwaki et al.
, 2.
Nonetheless, variations in populations, comorbidity profiles, and clinical factors underscore the necessity to reassess the uniformity of mortality determinants across diverse Numerous international and national studies have investigated predictors of ACS mortality, yet the results differ significantly across nations and healthcare Comprehensive studies in Europe show that early mortality in ACS is strongly linked to cardiogenic shock, ventricular arrhythmias, and impaired left ventricular function (Yang et al.
, 2.
While findings from Asia highlight reperfusion delay, diabetes, and renal impairment as key contributors (Oraii et al.
, 2024.
Song et al.
In Indonesia, mortality predictors vary among institutions, including higher Killip class, hypotension, prehospital delays, and limited PCI access (Pramudyo et al.
Rante et al.
, 2.
These variations reflect the absence of a consistent understanding of factors influencing ACS mortality across regions.
Therefore, the purpose of this review is to identify, summarize, and synthesize contemporary evidence on mortality determinants in Acute Coronary Syndrome, encompassing clinical, demographic, laboratory, and hemodynamic predictors that shape short- and long-term outcomes, while providing scientific particularly in resource-limited settings.
International Journal of Nursing and Midwifery Science (IJNMS),Volume 7.
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December 2023
METHOD
Search Strategy.
A comprehensive literature analysis was conducted using PubMed.
Scopus, and Google Scholar to identify relevant articles published from January 2017 to December 2025.
The utilized keywords included: Auacute coronary syndrome,Ay Aumortality,Ay Aurisk factors,Ay Aumortality predictors,Ay AuSimple Risk Index,Ay AuSTEMI,Ay and AuNSTE-ACS,Ay employed in conjunction with Boolean operators (AND.
OR).
The reference lists of selected papers were manually examined to identify additional acceptable studies.
This review aimed to identify, summarize, and synthesize current research on the determinants of mortality in Acute Coronary Syndrome, demographic, laboratory, and hemodynamic variables that affect both short- and longterm outcomes.
Inclusion and Exclusion Criteria.
Studies were eligible if published between 2017 and 2025, accessible in full text, written in English, and categorized as original research papers, cohort studies, observational studies, systematic reviews, or meta-analyses.
Eligible studies investigated mortality risk, mortality predictors, or risk stratification in patients with acute coronary syndrome (ACS), encompassing those with ST-elevation (STEMI), non-ST-elevation myocardial infarction (NSTEMI), or unstable angina.
Studies were rejected if they comprised conference papers, editorials, letters, or concentrated exclusively on pediatric or animal populations.
failed to address mortality outcomes or were irrelevant to ACS.
or were provided as case reports or single-case descriptions.
Screening and Selection Process.
The database search initially produced 1,247 entries from PubMed.
Scopus, and Google Scholar.
Following the elimination of 312 duplicates, 935 articles were retained for title and abstract evaluation.
A total of 842 papers were removed for being irrelevant to ACS mortality, non-original study types.
The remaining 93 articles underwent full-text screening.
Following an assessment of methodological quality, result clarity, and mortality relevance, 82 papers were removed.
Eleven studies met all eligibility criteria and were included in the final review.
Data Extraction and Synthesis.
Data were retrieved from each included study, including author.
, year, country or study location, study design, sample size, type of ACS population, assessed risk factors, statistical methodologies, and principal The retrieved data were comparisons of consistent and variable mortality factors across diverse populations and healthcare environments.
Particular emphasis was placed on mortality factors linked to prevalent risk scores, such as the Simple Risk Index.
TIMI, and GRACE.
RESULTS
Table 1.
Article Review Author (Yea.
Country / Setting Yang et al Europe.
multicenter adults with ACS Objective Method To analyze the Observational and registry.
>10,000
causes of death ACS
after ACS
(KM,
Cox Key Findings Indexing Cardiogenic ventricular arrhythmias, cardiac arrest, and low LVEF predict early Late mortality driven by Scopusindexed International Journal of Nursing and Midwifery Science (IJNMS).
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April 2024 Author (Yea.
Country / Setting Objective Method Key Findings Indexing outcome: early & all-cause progression, recurrent ischemia, multi-organ decline, and older age Szabo & et Europe.
To determine Retrospective al .
tertiary of cohort.
cardiac centre.
hundred ACS-shock in cases.
ACS with ACS with regression.
hospital mortality Mortality with advanced age, persistent hypotension, renal dysfunction, high hemodynamic collapse Scopusindexed Ulvenstam Sweden.
identify Longitudinal et al .
populationpredictors of cohort.
>5,500 ACS
based registry.
long-term Cox ACS survivors outcomes post- regression.
ACS
outcome: long-term Mortality predicted by older age, prior CVD, failure, previous stroke, and male sex Scopusindexed Song et al China.
CAMI
Registry.
NSTEMI
To develop a Prospective risk observational.
for 22,000 NSTEMI.
multivariate logistic NSTEMI inhospital mortality Predictors: age.
HR.
SBP.
Killip elevation, cardiac arrest on presentation Scopusindexed Rante et al Indonesia .
(Jakart.
ACS
identify Retrospective 200 ACS ACS regression.
inhospital mortality Higher mortality linked to STEMI, prehospital shock.
OHCA, renal impairment, low EF.
SINTAindexed Pramudyo Indonesia To determine Retrospective et al .
(Bandun.
in-hospital n = 1,011.
logistic regression.
ACS predictors in outcome:
ACS
hospital mortality Determinants included Killip Oui, tachycardia.
CKD, older cardiac arrest.
early PCI improved survival SINTAindexed Oraii et al Iran.
PCI To assess Retrospective .
mortality risks cohort.
1,000
STEMI patients.
Cox
STEMI
with regression.
PPCI
inPPCI hospital & shortterm mortality Predictors: symptomto-door delay, door-toballoon delay, low SBP.
LVEF, cardiac arrest before PCI Scopusindexed Moriwaki Japan.
EMS To evaluate the Multicenter et al .
of 1,748 STEMI.
STEMI
prehospital SRI logistic regression.
30-day High SRI predicted mortality via older age, tachycardia, low SBP, prehospital Killip OuII, and long FMC-toballoon time.
Scopusindexed International Journal of Nursing and Midwifery Science (IJNMS),Volume 7.
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December 2023 Author (Yea.
Country / Setting Objective Method Key Findings Indexing Juzar et al Indonesia, evaluate Observational .
national ACS
ACS
ACS and mortality- patients.
inhospital mortality Mortality with late presentation, limited PCI access, instability, arrhythmias.
SINTAindexed Marfianti Indonesia.
To assess SRI Observational et al .
hospitalas a predictor of analytic.
STEMI STEMI
STEMI.
inhospital mortality Mortality influenced by high SRI .
HR.
SBP).
Killip iAeIV.
SINTAindexed Meutia & Indonesia To validate SRI Retrospective Nasution (RSCM).
examine cohort.
>300 ACS
ICCU
ACS ACS mortality patients.
ICU/hospital Predictors included high SRI, renal dysfunction, higher Killip class, instability, absence of PCI, and comorbid SINTAindexed Table 2.
Summary of Key Mortality Predictor Categories in Acute Coronary Syndrome Category Number of Supporting Studies Factors Hemodynamic Shock, low SBP, high HR
10/11
Comorbidities Diabetes mellitus, chronic kidney disease, advanced age
8/11
System-level Reperfusion delay, limited PCI availability 7/11 Table 1 indicates that a review of eleven studies conducted in Europe.
Asia, and Indonesia reveals that hemodynamic instability, patient comorbidities, and system-related contribute to ACS mortality.
Premature mortality is regularly associated with cardiogenic shock, ventricular arrhythmias, cardiac arrest, hypotension, and diminished left ventricular function.
Comorbidities, including advanced age, diabetes mellitus, chronic renal illness, and previous cardiovascular conditions, considerably impact both short- and long-term mortality.
Systemic delays, such as extended reperfusion durations and restricted access to percutaneous coronary intervention, continue to be significant predictors in developing regions.
Risk indices, such as the Simple Risk Index and Killip class, demonstrate significant and consistent efficacy in detecting high-risk individuals.
The data suggest that clinical severity, underlying comorbidities, and healthcare system performance all influence mortality outcomes in acute coronary syndrome (ACS).
According to Table 2, the majority of research demonstrates that hemodynamic factors, specifically shock, reduced systolic blood pressure, and increased heart rate, are the most reliable predictors of death in acute coronary syndrome, as evidenced by 10 out of 11 studies.
Comorbidities, including diabetes mellitus, chronic renal disease, and advanced age, significantly influence outcomes, as indicated in 8 of 11 studies.
Moreover, system-level factors, such as reperfusion delays and limited PCI availability, exacerbate mortality risk, as evidenced by 7 of 11 trials.
These data International Journal of Nursing and Midwifery Science (IJNMS).
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April 2024 emphasize that a confluence of acute clinical severity, preexisting comorbidities, and the efficacy of the healthcare system influences mortality risk in ACS.
Figure 1.
Conceptual Framework of Patient.
Clinical, and System Level Determinants of Mortality in Acute Coronary Syndrome Figure 1 illustrates the conceptual framework outlining how patient-related factors, clinical severity, and system-level variables collectively influence mortality in acute coronary syndrome.
Patient attributes, including age and comorbidities, influence indicators such as Killip class and the Simple Risk Index physiological severity and directly affect Systemic variables, such as delays in care and access to PCI, influence outcomes by impacting the timing and efficacy of treatment.
Collectively, these interrelated areas constitute a holistic framework for comprehending mortality risk in acute coronary syndrome (ACS).
DISCUSSION