Research Article

Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes

Volume: 52 September 10, 2026
TR EN

Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes

Abstract

Endothelial dysfunction, inflammation, and microvascular injury are key mechanisms involved in the development and progression of acute coronary syndrome (ACS). The Endothelial Activation and Stress Index (EASIX) and its derivatives have emerged as readily available biomarkers of endothelial stress; however, the prognostic value of modified EASIX (m-EASIX), which incorporates C-reactive protein, remains uncertain. This study evaluated the prognostic performance of EASIX-derived indices and investigated whether high admission m-EASIX was independently associated with long-term post-discharge all-cause mortality in patients with ACS. Adult patients admitted with ACS between January 2019 and February 2020 who survived the index hospitalization and were discharged alive were retrospectively identified from a tertiary referral center. EASIX, simplified EASIX (s-EASIX), and m-EASIX were calculated from admission laboratory measurements, and their prognostic performance was evaluated using receiver operating characteristic analysis, Kaplan–Meier survival curves, and multivariable Cox proportional hazards models. Among 102 patients who survived the index ACS hospitalization, 29 (28.4%) died during a mean post-discharge follow-up of 68.2 ± 28.0 months. m-EASIX showed the numerically highest AUC for post-discharge all-cause mortality (AUC 0.730, 95% CI 0.617–0.843; p<0.001), followed by EASIX (AUC 0.715) and s-EASIX (AUC 0.629). However, paired DeLong comparisons showed no significant difference between m-EASIX and EASIX (p=0.809) or between m-EASIX and s-EASIX (p=0.158). Patients with m-EASIX ≥1.21 had significantly higher mortality than those with lower values (53.7% vs. 11.5%; p<0.001). After adjustment for age, hemoglobin concentration, and left ventricular ejection fraction, high m-EASIX remained independently associated with post-discharge all-cause mortality (HR 2.759, 95% CI 1.109–6.865; p=0.029). Among the evaluated indices, m-EASIX showed the numerically highest AUC, although its discriminatory performance was not statistically superior to that of EASIX or s-EASIX. Further prospective validation is required before clinical implementation.

Keywords

Supporting Institution

No financial support was received for this study.

Ethical Statement

This study was approved by the Bursa Uludağ University Health Research Ethics Committee (Approval Date: 10 June 2026; Decision No: 2026/312/11-16) and was conducted in accordance with the principles of the Declaration of Helsinki.

Thanks

The authors have no acknowledgements.

References

  1. 1. Byrne, R.A.; Rossello, X.; Coughlan, J.J.; Barbato, E.; Berry, C.; Chieffo, A.; Claeys, M.J.; Dan, G.-A.; Dweck, M.R.; Galbraith, M.; et al. 2023 ESC Guidelines for the management of acute coronary syndromes: Developed by the Task Force on the management of acute coronary syndromes of the European Society of Cardiology (ESC). Eur. Heart J. 2023, 44, 3720–3826. https://doi.org/10.1093/eurheartj/ehad191
  2. 2. Bauer, D.; Toušek, P. Risk stratification of patients with acute coronary syndrome. J. Clin. Med. 2021, 10, 4574. https://doi.org/10.3390/jcm10194574
  3. 3. Tsalamandris, S.; Koliastasis, L.; Miliou, A.; Oikonomou, E.; Papageorgiou, N.; Antonopoulos, A.; Hatzis, G.; Mourouzis, K.; Vogiatzi, G.; Siasos, G.; Xaplanteris, P.; Tousoulis, D. Endothelial function and pro-inflammatory cytokines as prognostic markers in acute coronary syndromes. Diagnostics 2025, 15, 1033. https://doi.org/10.3390/diagnostics15081033
  4. 4. Xiong, X.; Wang, J.; Ren, L.; Li, Z.; Liu, Y.; Xia, P.; Duan, L. The emerging pathological mechanism of coronary microvascular dysfunction: A narrative review. Metab. Target Organ Damage 2025, 5, 54. https://doi.org/10.20517/mtod.2025.71
  5. 5. Ziogos, E.; Chelko, S.P.; Harb, T.; Engel, M.; Vavuranakis, M.A.; Landim-Vieira, M.; Walsh, E.M.; Williams, M.S.; Lai, S.; Halushka, M.K.; Gerstenblith, G.; Leucker, T.M. Platelet activation and endothelial dysfunction biomarkers in acute coronary syndrome: The impact of PCSK9 inhibition. Eur. Heart J. Cardiovasc. Pharmacother. 2023, 9, 636–646. https://doi.org/10.1093/ehjcvp/pvad051
  6. 6.Finke, D.; Hund, H.; Frey, N.; Luft, T.; Lehmann, L.H. EASIX(endothelial activation and stress index) predicts mortality inpatients with coronary artery disease. Clin. Res. Cardiol. 2025, 114, 1008–1018. https://doi.org/10.1007/s00392-024-02534-y
  7. 7.Sang, M.; Ma, X.; Zhu, F.; Zhu, C.; Ying, Z. Association between endothelial activation and stress index and 30-day mortality risk in acute myocardial infarction patients: A study based on the Medical Information Mart for Intensive Care-IVdatabase. BMC Cardiovasc. Disord. 2024, 24, 699.https://doi.org/10.1186/s12872-024-04353-5
  8. 8.Karauzum, K.; Tanık, V.O.; Taş, A.; Mirzamidinov, D.; Şimşek, U.; Gencer, E.; Çelik, F.; Badalova, N.; Büyükbaş, F.C.; Yılmaz, I.; et al. The role of endothelial activation and stress index (EASIX) for predicting contrast-induced nephropathy and in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Diagnostics 2026, 16, 1123. https://doi.org/10.3390/diagnostics16081123

Details

Primary Language

English

Subjects

Cardiovascular Medicine and Haematology (Other)

Journal Section

Research Article

Publication Date

September 10, 2026

Submission Date

July 22, 2026

Acceptance Date

August 18, 2026

Published in Issue

Year 2026 Volume: 52

APA
Alak, Ç., Turhan, K., Hunutlu, F. C., Kumral, Z., & Özdemir, B. (2026). Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes. Journal of Uludağ University Medical Faculty, 52. https://doi.org/10.32708/uutfd.2000692
AMA
1.Alak Ç, Turhan K, Hunutlu FC, Kumral Z, Özdemir B. Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes. Journal of Uludağ University Medical Faculty. 2026;52. doi:10.32708/uutfd.2000692
Chicago
Alak, Çetin, Kaan Turhan, Fazıl Cagrı Hunutlu, Zeynep Kumral, and Bülent Özdemir. 2026. “Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients With Acute Coronary Syndromes”. Journal of Uludağ University Medical Faculty 52 (September). https://doi.org/10.32708/uutfd.2000692.
EndNote
Alak Ç, Turhan K, Hunutlu FC, Kumral Z, Özdemir B (September 1, 2026) Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes. Journal of Uludağ University Medical Faculty 52
IEEE
[1]Ç. Alak, K. Turhan, F. C. Hunutlu, Z. Kumral, and B. Özdemir, “Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes”, Journal of Uludağ University Medical Faculty, vol. 52, Sept. 2026, doi: 10.32708/uutfd.2000692.
ISNAD
Alak, Çetin - Turhan, Kaan - Hunutlu, Fazıl Cagrı - Kumral, Zeynep - Özdemir, Bülent. “Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients With Acute Coronary Syndromes”. Journal of Uludağ University Medical Faculty 52 (September 1, 2026). https://doi.org/10.32708/uutfd.2000692.
JAMA
1.Alak Ç, Turhan K, Hunutlu FC, Kumral Z, Özdemir B. Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes. Journal of Uludağ University Medical Faculty. 2026;52. doi:10.32708/uutfd.2000692.
MLA
Alak, Çetin, et al. “Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients With Acute Coronary Syndromes”. Journal of Uludağ University Medical Faculty, vol. 52, Sept. 2026, doi:10.32708/uutfd.2000692.
Vancouver
1.Çetin Alak, Kaan Turhan, Fazıl Cagrı Hunutlu, Zeynep Kumral, Bülent Özdemir. Modified Endothelial Activation and Stress Index (mEASIX) Predicts Long-Term Mortality in Patients with Acute Coronary Syndromes. Journal of Uludağ University Medical Faculty. 2026 Sep. 1;52. doi:10.32708/uutfd.2000692

ISSN: 1300-414X, e-ISSN: 2645-9027

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