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Year : 2014  |  Volume : 2  |  Issue : 3  |  Page : 65-69

Clinical characteristics, angiographic profile and in hospital mortality in acute coronary syndrome patients in south indian population

1 Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
2 Department of Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Date of Web Publication5-Sep-2014

Correspondence Address:
Rajni Sharma
Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jaya Nagar, 9th Block, Bannergahtta Road, Bengaluru - 560 069, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-449x.140228

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Aims: The aim was to study the clinical profile, risk factors prevalence, angiographic distribution, and severity of coronary artery stenosis in acute coronary syndrome (ACS) patients of South Indian population. Materials and Methods: A total of 1562 patients of ACS were analyzed for various risk factors, angiographic pattern and severity of coronary heart disease, complications and in hospital mortality at Sri Jayadeva Institute of Cardiovascular Research and Sciences, Bengaluru, Karnataka, India. Results: Mean age of presentation was 54.71 ± 19.90 years. Majority were male 1242 (79.5%) and rest were females. Most patients had ST elevation myocardial infarction (STEMI) 995 (63.7%) followed by unstable angina (UA) 390 (25%) and non-STEMI (NSTEMI) 177 (11.3%). Risk factors; smoking was present in 770 (49.3%), hypertension in 628 (40.2%), diabetes in 578 (37%), and obesity in (29.64%) patients. Angiography was done in 1443 (92.38%) patients. left anterior descending was most commonly involved, left main (LM) coronary artery was least common with near similar frequency of right coronary artery and left circumflex involvement among all three groups of ACS patients. Single-vessel disease was present in 168 (45.28%) UA, 94 (56.29%) NSTEMI and 468 (51.71%) STEMI patients. Double-vessel disease was present in 67 (18.08%) UA, 25 (14.97%) NSTEMI and 172 (19.01%) STEMI patients. Triple vessel disease was present in 28 (7.55%) UA, 16 (9.58%) NSTEMI, 72 (7.95%) STEMI patients. LM disease was present in 12 (3.23%) UA, 2 (1.19%) NSTEMI and 9 (0.99%) STEMI patients. Complications; ventricular septal rupture occurred in 3 (0.2%), free wall rupture in 2 (0.1%), cardiogenic shock in 45 (2.9%), severe mitral regurgitation in 3 (0.2%), complete heart block in 11 (0.7%) patients. Total 124 (7.9%) patients died in hospital after 2.1 ± 1.85 days of admission. Conclusion: STEMI was most common presentation. ACS occurred a decade earlier in comparison to Western population. Smoking was most prevalent risk factor. Diabetic patients had more of multivessel disease. Complications and in hospital mortality was higher in females and elderly population.

Keywords: Acute coronary syndrome, coronary angiogram, non-ST elevation myocardial infarction, ST elevation myocardial infarction, unstable angina

How to cite this article:
Sharma R, Bhairappa S, Prasad S R, Manjunath CN. Clinical characteristics, angiographic profile and in hospital mortality in acute coronary syndrome patients in south indian population . Heart India 2014;2:65-9

How to cite this URL:
Sharma R, Bhairappa S, Prasad S R, Manjunath CN. Clinical characteristics, angiographic profile and in hospital mortality in acute coronary syndrome patients in south indian population . Heart India [serial online] 2014 [cited 2022 Jan 28];2:65-9. Available from: https://www.heartindia.net/text.asp?2014/2/3/65/140228

  Introduction Top

Coronary artery disease (CAD) is leading cause of mortality worldwide [1] and by the year 2020, will be first in the leading causes of disability. [2] While the death rates have been declining for the past three decades in the west, these rates are rising in India. In the last three decades, the prevalence of CAD has increased from 1.1% to about 7.5% in the urban population and from 2.1% to 3.7% in the rural population. [3] CAD tends to occur at a younger age in Indians, with more extensive angiographic involvement [4] contributed genetic, metabolic, conventional and nonconventional risk factors. [5],[6] The objective of this study was to represents the clinical profile, prevalence of risk factors and distribution of coronary artery stenosis in acute coronary syndrome (ACS) patients of South Indian population.

  Materials and methods Top

One thousand five hundred and sixty-two consecutive patients presented to Sri Jayadeva Institute of Cardiovascular Research and Sciences, Bengaluru, Karnataka, India with first episode of ACS were analyzed. The clinical presentations of patient were categorized as unstable angina (UA), non-ST elevated myocardial infarction (NSTEMI) and STEMI according to American College of Cardiology/American Heart Association (ACC/AHA) definitions and treated as per ACC/AHA recommendations. [7],[8] Patients with concomitant valvular heart disease or cardiomyopathy were excluded from this study.

The following data were included for analysis: Age and gender and CAD risk factor profile, comprised of current cigarette/bidi smoking history, dyslipidemia was defined as the presence of any of the following: Patients on lipid lowering drugs or total cholesterol >240 mg/dl, triglycerides (TG) >150 mg/dl, low-density lipoprotein >130 mg/dl, and high-density lipoproteins (HDL) <50 mg/dl for female and <40 mg/dl for male. Diabetes mellitus symptoms of diabetes and plasma glucose concentration ≥200 mg/dl (11.1 mmol/L), or fasting blood sugar ≥126 mg/dl (7.0 mmol/L) or 2-hp ≥200 mg/dl (11.1 mmol/L), hypertension (systolic blood pressure ≥140 and/or diastolic ≥90 mmHg and/or on anti-hypertensive treatment), family history of CAD (first degree relatives before the age of 55 years in men and 65 years in women), obesity was defined using the body mass index (BMI) with a value >30. BMI was calculated using Quetlet's formula (weight in kg/height in m 2 ). Clinical manifestations, left ventricular ejection fraction, hematologic indices, coronary angiographic findings, and treatment strategy were reported. Selective coronary angiogram was done using standard technique within 48 h of admission unless patient is hemodynamically unstable or with deranged renal parameters. Expert opinion on coronary angiography was taken by two cardiologist. Significant CAD was defined as a diameter stenosis >50% in each major epicardial artery. Normal vessels were defined as the complete absence of any disease in the left main coronary artery (LMCA), left anterior descending (LAD), right coronary artery (RCA), and left circumflex (LCX) as well as in their main branches (diagonal, obtuse marginal, ramus intermedius, posterior descending artery, and posterolateral branch). Patients were classified as having single-vessel disease (SVD), double-vessel disease (DVD) or triple vessel disease (TVD) accordingly.

Statistical analysis

The results were reported as mean ± standard deviation for the quantitative variables and percentages for the categorical variables. The groups were compared using the Student's t-test for the continuous variables and the Chi-square test for the dichotomous variables. P < 0.05 were considered as statistically significant. All the statistical analyses were carried out via Statistical Package for Social Sciences version 20 (SPSS, IL, Chicago Inc., USA).

  Results Top

Among 1562 ACS patients majority were male 1242 (79.5%) and 320 (20.5%) were female. The mean age of presentation for male was 53.28 ± 11.54 and for female was 60.23 ± 17.67 (P = 0.001). Most common presentation in ACS was STEMI with 995 (63.7%) patients followed by UA 390 (25%) and NSTEMI 177 (11.3%). Baseline characteristics are mentioned in [Table 1].
Table 1: Baseline characteristics

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Risk factor analysis

A total of 578/1562 (37%) patients were diabetic and 628/1562 (40.2%) patients were hypertensive. Smoking was most prevalent risk factor seen in 770/1562 (49.30%) patients. Active smoking in our study was noticed only in male, that is, 770 (62%) of total male (1242) patients. Women were rather tobacco chewers. Dyslipidemia was present in 593/1562 (37.96%) patients. Obesity in 463/1562 (29.64%) patients and family history of CAD was significant in 152/1562 (9.73%) patients.

Angiographic profile

Most common coronary artery to be involved was LAD followed by near similar frequencies of RCA and LCX involvement with least common involvement of LMCA in all three groups (UA, NSTEMI and STEMI). [Table 2] among UA patients SVD was seen in 168 (45.28%) patients, DVD in 67 (18.06%) patients, TVD in 28 (7.55%) patients, LM disease in 12 (3.23%) patients and normal vessels or nonsignificant lesion seen in 96 (25.88%) patients out of 371 patients. In NSTEMI SVD was present in 94 (56.29%), DVD in 25 (14.97%), TVD in 16 (9.58%), LM in 2 (1.19%) and normal vessel or nonsignificant lesion seen in 30 (17.97%) out of 167 patients. In STEMI, SVD was seen in 468 (51.71%), DVD in 172 (19.01%), TVD in 72 (7.95%), LM in 9 (0.99%) and normal vessel or nonsignificant lesions seen in 184 (20.34%) out of 905 patients [Table 3].
Table 2: In ACS patients various pattern of coronary artery involvement

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Table 3: Distribution of coronary vessels involvement in ACS patients

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Single-vessel disease was present in 127 (46.02%) of female patients whereas 603 (51.67%) of male patients (P < 0.001). DVD was present in 44 (15.94%) female patients in comparison to 220 (18.85%) male patients. TVD was seen in 27 (9.78%) female patients but in 89 (7.62%) male patients. LMCA disease was seen in 3 (1.09%) female patients whereas in 20 (1.71%) male patients (P > 0.05). Normal or mild disease was present in 75 (27.17%) of female patients compared with 235 (20.15%) of male patients (P < 0.01). Diabetic patients had trend toward multivessel disease in comparison to nondiabetic patients. DVD was seen in 113 (21.08%) of diabetic patients, whereas in 151 (16.65%) of nondiabetic patients. TVD was present in 52 (9.70%) diabetic patients, but in 64 (7.06%) nondiabetic patients. LMCA disease was present in 9 (1.68%) diabetic patients in comparison to 14 (1.54%) nondiabetic patients (P > 0.05).

Complication of acute coronary syndrome

Three (0.2%) patients had ventricular septal rupture (VSR) and all three were female. Two (0.1%) patients had free wall rupture, one male and one female. Severe mitral regurgitation was seen in 3 (0.2%) patients, two were female and one patient was male. Cardiogenic shock was seen in total 45 (2.9%) patients, 11/320 (3.44%) were female and 34/1242 (2.73%) were male. Eleven (0.7%) patients had complete heart block, 3 (0.2%) were female and 8 (0.5%) were male. Ventricular tachycardia occurred in 8 (0.5%) patients, three were female and five were male patients. Pulmonary edema occurred in total 37 (2.4%) patients, 14 (4.37%)/320 were female and 23/1242 (1.85%) were male patients.

Mortality data

Among 1562 ACS patients 124 (7.9%) patients died in hospital after 2.18 ± 1.85 days of admission. Mortality was more in elderly population with mean age of 61.14 ± 12.33 years in comparison to patients discharged from hospital having mean age of 54.14 ± 20.32 years (P < 0.001). Mortality was more in female patients 44/320 (13.75%), whereas in men mortality occurred in 80/1242 (6.44%) patients with P < 0.01. The mean age of mortality in female was higher 62.18 ± 11.9 years in comparison to male 60.70 ± 12.56 years (P > 0.05). In hospital mortality occurred in 43/578 (7.44%) diabetic patients whereas in 81/984 (8.23%) nondiabetic patients (P > 0.05). In diabetics mean age of mortality was 61.19 ± 11.80 years in comparison to 61.30 ± 13.4 years in nondiabetics (P > 0.05).

  Discussion Top

Epidemiological studies have revealed that the prevalence of CAD is increasing along with the rising prevalence of conventional risk factors for CAD in India. Present health transition from predominance of infections to the preponderance of cardiovascular disorders, such as hypertension, diabetes, and CAD is now responsible for 53% of all deaths. [6],[ 6],[9] Indians have one of the highest rates of heart disease in the world. The disease also tends to be more aggressive and manifests at a younger age. [10] However, in our study, the mean age of presentation was 54.70 ± 19.90 years comparable to other studies done in India, that is, CREATE registry (56 ± 13 years) and Jose and Gupta study (57 ± 12 years) but lower than the western population as in COURAGE trial 62 ± 5 years conducted in USA, study by Hochman et al.[11] (69 years), and Chang et al. (73 years). [12] The skewed gender distribution males 79.5% versus females 20.5% of the study population can be attributed to the gender bias and atypical presentation, which is also a feature in INTERHEART study and its South Asian cohort (overall male, 76% and South Asian cohort, 85%). [13] MI without previous angina pectoris is more common in younger patients with CAD [14],[15] as seen in our study, the mean age of STEMI patients was 53.38 ± 11.53 years compared with UA patients (57.85 ± 14.34 years). Studies on histopathology has shown that those plaques would have been more lipid containing with relative lack of acellular scar tissue and present for a shorter period of time or developed more quickly than plaques seen in older patients. These plaques are more unstable and likely to rupture, attributing for having more of STEMI at younger age than chronic stable angina. [16] The most common presentation among ACS patients is STEMI in comparison to UA or NSTEMI. Our study showed that the prevalence of diabetics was 37%, which is higher than the reported prevalence in other nations (INTERHEART study) but near to other Indian studies (CREATE, Jose and Gupta). [6],[16],[17] Indians natives now constitute the largest population of diabetics in the world. The number of diabetics in India is projected to surpass 57.2 million by 2025. [5] The relatively high prevalence of DVD (21.08%) and TVD (9.70%) in diabetic patients when compared with nondiabetics (16.65%) and (7.06%) respectively along with a similar mean age confirms the role of diabetes as a chronic risk factor in CAD. Others have also reported diabetes to be a predictor of presence of multivessel disease. [16] Hypertension is another conventional risk factor implicated in CAD. In our study 40.2% patients were hypertensive. The prevalence of hypertension in South Asian cohort of INTERHEART study (31.1%) is comparatively lower than in our study but near to other Indian studies. [6],[17] The higher prevalence of diabetes and hypertension in this region could be explained by the comparatively higher development and increasing epidemic of CAD. [18]

Tobacco smoking is a known modifiable risk factor for CAD. In our study, 49.3% patients were smoker. Patients who were smoking had more commonly STEMI compared with UA/NSTEMI. In our study, 560/770 (72.73%) of smoker patients had STEMI comparable to other studies. [19] The prevalence of obese patients was 29.64% which is less than the prevalence seen in South Asian cohort of INTERHEART study (44.2%). May be obesity prevalence has turned out low in study because of using BMI as marker of obesity instead of waist: Hip ratio used in INTERHEART study population. Lakka et al. in their study have reported that abdominal obesity is an independent risk factor for ACS in middle-aged men and combination with smoking, the risk of coronary events increases by 5.5 times. [19] Obesity has become an epidemic and rapidly growing public health hazard. Central obesity (visceral fat) corresponding to increased waist circumference is an important component of the insulin resistance-hyperinsulinemia syndrome, and has been found to be more frequent in persons of Indian origin. Whereas no significant correlation could be found between the levels of lipid parameters and the severity of CAD on angiography. Others have also reported similar findings in their study except that they reported a relationship between the C/HDL-cholesterol (HDL-C) ratio and the severity of CAD. [19] Hughes et al. showed an increased relative risk of MI directly with TG and inversely with HDL-C levels in Asian Indians. [20]

Single-vessel involvement was most prevalent in all groups of ACS including UA/NSTEMI and STEMI, followed by double-vessel and triple vessel similar to Kumar et al. study and Tewari et al. [16],[21] SVD was also most commonly involved in male as well as female patients followed by DVD, and TVD with statistical significance, similar to Kumar et al. and Tewari et al. study from north India. Left main disease did not show statistical significant difference in view of diabetes or gender distribution. UA was more commonly associated with normal coronaries (15.6%) compared to NSTEMI (11.4%) and STEMI (9.72%). In UA group many patients may have been over diagnosed, false positive as ACS especially in females. Angiographically the absolutely normal vessels were present in 9.42% cases of STEMI have been attributed to complete recanalization whether spontaneous or postthrombolysis. [22]

Complications occurred more commonly in female patients and elderly population as VSR, cardiogenic shock, free wall rupture and pulmonary edema as explained by other studies as well. [23],[24] In hospital mortality was also significantly higher in female patients. Diabetes did not influence the short term outcome and in hospital mortality in our studies. Recently, studies has shown that yet diabetes prevalence is on increase but all complications in diabetic patients is toward downhill course, maximum fall is seen in acute MI and mortality. [25]

The study limitations include the noninclusion of factors like detailed dietary habits, exercise frequency and alcohol consumption, as the primary aim was to study the clinical correlation with angiographic profile of the first event of ACS patients. The waist hip ratio, which is better marker for measurement of obesity, was not used in our study. In mortality group, only five patients could undergo angiogram because of unstable condition, which restricted us in commenting on how CAD severity influenced the mortality group.

  Conclusion Top

Acute coronary syndrome occurs 5-10 years earlier in Indian population compared to western population. Higher prevalence of diabetes and hypertension in Indian subcontinent. Overall SVD was most prevalent in ACS patients. Diabetic patients had more of multivessel disease than nondiabetics. Complications such as VSR, free wall rupture, heart failure and cardiogenic shock were more commonly seen in elderly female patients. Mortality is more in female patients with higher mean age than in male patients. In hospital mortality was more in first 2-3 days of ACS presentation. Diabetes did not impact on short term outcome or mortality of ACS patients.

  References Top

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  [Table 1], [Table 2], [Table 3]

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