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Cathepsin S Levels and Survival Among Patients With Non-ST-Segment Elevation Acute Coronary Syndromes

Lookup NU author(s): Professor Kimon Stamatelopoulos, Dr Georgios Georgiopoulos, Dr Nikolaos VlachogiannisORCiD, Dr Kateryna Sopova, Dr Simon Tual-Chalot, Dr Aikaterini GatsiouORCiD, Professor Ioakim SpyridopoulosORCiD, Christian Mueller, Professor Konstantinos StellosORCiD



This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND).


© 2022 The Authors. Background: Patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) are at high residual risk for long-term cardiovascular (CV) mortality. Cathepsin S (CTSS) is a lysosomal cysteine protease with elastolytic and collagenolytic activity that has been involved in atherosclerotic plaque rupture. Objectives: The purpose of this study was to determine the following: 1) the prognostic value of circulating CTSS measured at patient admission for long-term mortality in NSTE-ACS; and 2) its additive value over the GRACE (Global Registry of Acute Coronary Events) risk score. Methods: This was a single-center cohort study, consecutively recruiting patients with adjudicated NSTE-ACS (n = 1,112) from the emergency department of an academic hospital. CTSS was measured in serum using enzyme-linked immunosorbent assay. All-cause mortality at 8 years was the primary endpoint. CV death was the secondary endpoint. Results: In total, 367 (33.0%) deaths were recorded. CTSS was associated with increased risk of all-cause mortality (HR for highest vs lowest quarter of CTSS: 1.89; 95% CI: 1.34-2.66; P < 0.001) and CV death (HR: 2.58; 95% CI: 1.15-5.77; P = 0.021) after adjusting for traditional CV risk factors, high-sensitivity C-reactive protein, left ventricular ejection fraction, high-sensitivity troponin-T, revascularization and index diagnosis (unstable angina/ non–ST-segment elevation myocardial infarction). When CTSS was added to the GRACE score, it conferred significant discrimination and reclassification value for all-cause mortality (Delta Harrell's C: 0.03; 95% CI: 0.012-0.047; P = 0.001; and net reclassification improvement = 0.202; P = 0.003) and CV death (AUC: 0.056; 95% CI: 0.017-0.095; P = 0.005; and net reclassification improvement = 0.390; P = 0.001) even after additionally considering high-sensitivity troponin-T and left ventricular ejection fraction. Conclusions: Circulating CTSS is a predictor of long-term mortality and improves risk stratification of patients with NSTE-ACS over the GRACE score.

Publication metadata

Author(s): Stamatelopoulos K, Mueller-Hennessen M, Georgiopoulos G, Lopez-Ayala P, Sachse M, Vlachogiannis NI, Sopova K, Delialis D, Bonini F, Patras R, Ciliberti G, Vafaie M, Biener M, Boeddinghaus J, Nestelberger T, Koechlin L, Tual-Chalot S, Kanakakis I, Gatsiou A, Katus H, Spyridopoulos I, Mueller C, Giannitsis E, Stellos K

Publication type: Article

Publication status: Published

Journal: Journal of the American College of Cardiology

Year: 2022

Volume: 80

Issue: 10

Pages: 998-1010

Print publication date: 06/09/2022

Online publication date: 29/08/2022

Acceptance date: 31/05/2022

Date deposited: 13/10/2022

ISSN (print): 0735-1097

ISSN (electronic): 1558-3597

Publisher: Elsevier Inc.


DOI: 10.1016/j.jacc.2022.05.055


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Funder referenceFunder name
German Heart Foundation