International Journal of Advances in Medicine

Dhanju AS et al. Int J Adv Med. 2022 May;9(5):571-574

http://www.ijmedicine.com pISSN 2349-3925 | eISSN 2349-3933

DOI: https://dx.doi.org/10.18203/2349-3933.ijam20221091
Original Research Article

A study of serum albumin levels in acute coronary syndrome and its

correlation with clinical outcome
Avtar Singh Dhanju, Gurpreet Singh Chhina, Praneet Manekar*, Pashaura Singh Sandhu

Department of Medicine, Government Medical College, Amritsar, Punjab, India

Received: 08 March 2022

Revised: 29 March 2022
Accepted: 02 April 2022

*Correspondence:
Dr. Praneet Manekar,
E-mail: manekarpanu@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Coronary artery disease (CAD) is major cause of death and mortality in the developed world. Coronary
atherosclerotic disease involves the epicardial coronary arteries and may manifest as an acute or chronic coronary
syndrome. Acute coronary syndrome (ACS) arises from atherosclerotic plaque rupture leading to coronary thrombosis
and/or spasm.
Methods: The present study was conducted in department of medicine, Guru Nanak Dev hospital attached to
government medical college, Amritsar from May 2021 to December 2021. This was a prospective observational study
in which a total of 50 patients of ACS were enrolled. Serum albumin levels of the patients were recorded and clinical
outcomes based on the albumin levels were compared between the patients.
Results: The patients with low serum albumin levels had worse outcomes. The mean serum albumin level of STEMI
and NSTEMI patients in hypoalbuminemia group was 2.88±0.11 g/dl and 3.15±0.26 g/dl (p=0.047). The mean serum
albumin level of patients having mortality in hypoalbuminemia group was 2.87±0.06 g/dl and those who didn’t have
mortality was 3.19±0.21 g/dl (p=0.013). The mean serum albumin level of patients developing new onset heart failure
in hypoalbuminemia group was 2.85±0.06 g/dl and those not developing had 3.11±0.19 g/dl (p=0.021).
Conclusions: We conclude that ACS patients presenting with hypoalbuminemia are more likely to develop worse
outcomes in the form of heart failure, cardiogenic shock and mortality. ACS patients presenting with low serum
albumin levels have more chances of developing STEMI.

Keywords: Acute coronary syndrome, Serum albumin, Hypoalbuminemia, Normoalbuminemia, ST elevation

myocardial infarction

INTRODUCTION classified into two main groups based on their presenting

electrocardiogram (ECG) as ST segment elevation
CAD is one of the major causes of death and mortality in myocardial infarction (STEMI) or non-ST segment
the developed world.1 Coronary atherosclerotic disease elevation myocardial infarction (NSTEMI).3 Albumin is
involves the epicardial coronary arteries and may the most abundant protein found in plasma which
manifest as an acute or chronic coronary syndrome. ACS constitutes about half of the total protein content (3.5 g/dl
arise from atherosclerotic plaque rupture leading to to 5 g/dl) of plasma. It is synthesized by hepatocytes and
coronary thrombosis and/or spasm. It results in occlusion rapidly excreted into the bloodstream at the rate of about
of the coronary arteries which leads to intense myocardial 10 g to 15 g per day.4 It also plays a role in
ischaemia or even myocardial necrosis which eventually atherothrombogenesis, a key event in ACS. Albumin is
manifests as unstable angina or myocardial infarction.2 also an inhibitor of endothelial apoptosis.5 Albumin is a
ACS patients with acute myocardial infarction are significant inhibitor of platelet activation and aggregation

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 Dhanju AS et al. Int J Adv Med. 2022 May;9(5):571-574

and an inhibitor of platelet induced coronary artery hypoalbuminemia group and 28 were in the
vasoconstriction. Plasma albumin concentration is related normoalbuminemia group. There were 12 and 17 females
to inflammatory and hemostatic processes.6 ACS is respectively in hypoalbuminemia and normoalbuminemia
considered an inflammatory condition and in response to group (Figure 1).
an inflammatory state, there will be a decline in serum
albumin concentration.7,8 The aim of the study was to 20
determine the serum albumin levels in patients of acute Hypoalbuminemia
Normoalbuminemia
coronary syndrome and to determine the correlation 15

No. of cases
between serum albumin levels and development of
STEMI or NSTEMI or new onset heart failure or 10
cardiogenic shock or in-hospital mortality in these
patients. 5

METHODS 0
FEMALE MALE
Current prospective observational study was conducted in SEX
the medicine department, Guru Nanak Dev hospital
attached to government medical college, Amritsar from Figure 1: Gender wise distribution between two
May 2021 to December 2021. A total of 50 patients of groups in the study population.
ACS were enrolled in this study. They were diagnosed as
ACS on basis of clinical symptoms, cardiac biomarker The males were 10 and 11 in numbers respectively. This
levels and/or ECG findings. The patients were divided association between gender wise distribution among the
into two groups based on serum albumin levels as two groups was not found to be significant (p=0.661).
hypoalbuminemia group (serum albumin <3.5 g/dl) and The serum albumin level in patients who developed new
normoalbuminemia group (serum albumin ≥3.5 g/dl). The onset heart failure among the two groups is shown in
endpoint of the study was the association between serum (Figure 2).
albumin levels and development of ACS in the form of
NSTEMI, STEMI and the complications in the form of
6
new onset heart failure, cardiogenic shock and in-hospital Hypoalbuminemia Normoalbuminemia
mortality in these patients. 5
Mean serum albumin (g/dl)

4
Inclusion criteria
3
Patients with acute myocardial infarction both STEMI
2
and NSTEMI proven by cardiac enzymes, ECG and
symptoms suggestive of acute coronary syndrome were 1
included in the study.
0
Absent Present
Exclusion criteria NEW ONSET HEART FAILURE

Acute renal failure on admission, pregnancy, chronic Figure 2: Distribution and comparison of mean
liver disease, end stage renal disease (ESRD), albumin level with new onset heart failure between
malignancy, septicemia, malnutrition and nephrotic two groups of study population.
syndrome.
In hypoalbuminemia group, serum albumin level in those
The data was summarized as mean±SD (standard who developed new onset heart failure was 2.85±0.057
deviation). The association between independent and g/dl and those who didn’t develop it was 3.106±0.198
dependent variables was done by chi-square (χ2) test. The g/dl and this was found to be statistically significant
p value less than 0.05 (p<0.05) was considered (p=0.021). Mean serum albumin level in
statistically significant. The analysis was performed on hypoalbuminemia group who developed and didn’t
SPSS software (Windows version 21.0). develop cardiogenic shock was 2.980±0.054 g/dl and
3.124±0.188 g/dl respectively and this relation was found
RESULTS to be statistically insignificant (p=0.126) as shown in
(Figure 3). The mean serum albumin level in
Total of 50 patients were enrolled in the study. The mean normoalbuminemia group was 5.40±1.979 g/dl in those
age of the study population was found to be 61.50±9.77 who developed cardiogenic shock and 4.8±0.873 g/dl in
years. The age groups were divided as 30-40, 41-50, 51- those who didn’t develop and this was statistically
60, 61-70 and >70 years. Maximum number of patients insignificant (p=0.393). Mean serum albumin level in
were in the age group of 61-70 years which included 18 hypoalbuminemia group who had mortality and who
patients. Out of these 50 patients, 22 were in the didn’t have was 2.867±0.057 g/dl and 3.189±0.205 g/dl

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 Dhanju AS et al. Int J Adv Med. 2022 May;9(5):571-574

respectively and this relation was found to be statistically DISCUSSION

significant (p=0.013) as shown in (Figure 4).
Albumin selectively inhibits tumor necrosis factor-alpha
6 induced VCAM-1 expression, monocyte adhesion and
Hypoalbuminemia Normoalbuminemia
nuclear factor-kappa B activation in endothelial cells of
Mean serum albumin (g/dl)

5
human aorta, suggesting its role as an anti-inflammatory
4
and anti-thrombogenic substance.9 Low serum albumin
3 level has been linked with worse clinical outcomes and
2 mortality in patients of ACS. In this background, this
1 study was conducted to study the association between
serum albumin levels and clinical outcomes in ACS
0
Absent Present patients. In the study of 50 patients, they were grouped in
CARDIOGENIC SHOCK age groups of 30-40, 41-50, 51-60, 61-70, >70 years.
Maximum number of patients were in the age group of
61-70 years, 18 patients and the mean age of the study
Figure 3: Distribution and comparison of mean population was 61.50±9.77 years. Mean age in the study
albumin level with cardiogenic shock between two of Hartopo et al was 57.5±10.0 years.10 In their study
groups of study population. Sujino et al recorded the mean age to be 88.1±2.5 years. 11
Hypoalbuminemia was seen in 22 (44%) patients and
6 normoalbuminemia was seen in 28 (56%) patients out of
Hypoalbuminemia
Normoalbuminemia total 50 patients. In study conducted by Hartopo et al out
Mean serum albumin (g/dl)

5
of total of 82 patients, 35 (43%) were in
4 hypoalbuminemia group and 47 (57%) were in
3 normoalbuminemia group.10 In another study conducted
by Polat et al hypoalbuminemia was detected in 34% of
2
the patients.12 Findings of our study were similar to these
1 studies.
0
Absent Present In hypoalbuminemia group out of 22 patients,12 (54%)
MORTALITY
presented with STEMI and 10 (46%) presented with
NSTEMI. In normoalbuminemia group of 28 patients,
Figure 4: Distribution and comparison of mean
STEMI was seen in 13 (46%) patients and NSTEMI in 15
albumin level with mortality between two groups of
(54%) patients. González-Pacheco et al also found that
study population. the patients with serum albumin levels <3.5 g/dl were
more likely to present with STEMI.13 In our study
Mean serum albumin level in hypoalbuminemia group population in hypoalbuminemia group, the mean serum
who presented with STEMI was 2.883±0.111 g/dl and albumin level in patients who presented with STEMI was
who presented with NSTEMI was 3.150±0.259 g/dl and 2.883±0.111 g/dl and those presented with NSTEMI was
this relation was found to be statistically significant 3.150±0.259 g/dl and this association was statistically
(p=0.047) as shown below in the (Figure 5). In significant (p=0.047). The mean serum albumin levels in
normoalbuminemia group the mean serum albumin level patients of hypoalbuminemia group who developed new
in patients of STEMI was 4.838±0.838 g/dl and that of onset heart failure was 2.85±0.057 g/dl and those who
those with NSTEMI was 4.847±1.043 g/dl and this was didn’t develop was 3.106±0.918 g/dl and this association
statistically insignificant (p=0.982). was found to be statistically significant (p=0.021).
Oduncu et al also concluded that hypoalbuminemia on
6
Hypoalbuminemia admission was a strong independent predictor for long-
Normoalbuminemia term mortality and development of advanced Heart
Mean serum albumin (g/dl)

5
Failure in patients with STEMI undergoing p-PCI.14 The
4
mean serum albumin level in hypoalbuminemia group
3 who had mortality was 2.867±0.057 g/dl and who didn’t
2
was 3.189±0.205 g/dl. This association was found to be
statistically significant (p=0.013). Plakht et al, Zhu L et al
1 and Xia M et al also observed that low serum albumin
0 level was associated with increased mortality among the
STEMI NSTEMI ACS patients.15-17 Boaci et al and Sujino et al also
ECG
recorded that low serum albumin level was associated
with adverse in-hospital outcomes in STEMI patients.18,11
Figure 5: Distribution and comparison of mean No significant association was seen between the serum
albumin level with ECG findings between two groups albumin levels and cardiogenic shock in our study
of study population. population.

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 Dhanju AS et al. Int J Adv Med. 2022 May;9(5):571-574

Limitations 9. Zhang WJ, Frei B. Albumin selectively inhibits

TNFα-induced expression of vascular cell adhesion
The limitation of our study was the small sample size molecule-1 in human aortic endothelial cells.
which may limit the clinical applicability of our results Cardiovasc Res. 2002;55(4):820-9.
and this needed to be confirmed by a large-scale study. 10. Hartopo AB, Gharini PP, Setianto BY. Low serum
Secondly, we did not have access to information about albumin levels and in-hospital adverse outcomes in
patient’s prior serum albumin levels, so we cannot be acute coronary syndrome. Int Heart J. 2010;51(4):
sure that hypoalbuminemia in our sample didn’t represent 221-6.
a chronic inflammatory state. 11. Sujino Y, Tanno J, Nakano S, Funada S, Hosoi Y,
Senbonmatsu T et al. Impact of hypoalbuminemia,
CONCLUSION frailty, and body mass index on early prognosis in
older patients (≥85 years) with ST-elevation
It was concluded that low serum albumin levels on myocardial infarction. J Cardiol. 2015;66(3):263-8.
admission are associated with worse in hospital outcomes 12. Polat N, Oylumlu M, Işik MA, Arslan B, Özbek M,
in ACS patients and also that patients with low serum Demir M et al. Prognostic significance of serum
albumin levels are more likely to present with STEMI. albumin in patients with acute coronary syndrome.
Angiology. 2020;71(10):903-8.
Funding: No funding sources 13. González-Pacheco H, Amezcua-Guerra LM, Sandoval
Conflict of interest: None declared J, Martínez-Sánchez C, Ortiz-León XA, Peña-Cabral
Ethical approval: The study was approved by the MA et al. Prognostic implications of serum albumin
Institutional Ethics Committee levels in patients with acute coronary syndromes. Am
J Cardiol. 2017;119(7):951-8.
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