Typical findings of epidemiological and clinical characteristics of patients with coronary artery diseases in South India: a retrospective analysis.
Cardiovascular diseases (CVD) are the commonest cause of death globally and are the major contributor to the burden of premature mortality and morbidity. Cardiovascular diseases accounted for 85 millions disability adjusted (DALYs) life years in 1990.  By the year 2020, coronary heart disease and stroke will hold first and fourth places, respectively, in the World Health Organization's list of leading causes of disability. 
It is now common knowledge that Coronary artery disease (CAD) is leading cause of death and account for approximately 12 million deaths annually worldwide.  In 2004, few American reports showed that CAD resulted in 6, 95,000 hospital admissions and $31 billion hospital charges. [5-7] It is believed that the identification of major risk factors and their effective control through population based strategies of prevention and awareness can reduce the incidence of CAD. Extensive epidemiological research has established cigarette smoking, as the major risk factor associated with diabetes, hyperlipidemia, and hypertension as independent risk factors for CAD. [4,5,8,9] In addition, treatment of these risk factors has been convincingly shown to reduce the risk of future cardiac events. 
The gold standard for the diagnosis of CAD invariably uses invasive coronary angiography (CA), defines therapeutic options and determines prognosis.  CAD is defined as more than 50% angiographic diameter stenosis in one or more of the epicardial coronary arteries. Based on disease severity, obstructive CAD is classified as single, double-, or triple-vessel disease. [10,11] Further diagnosis can also be based on biomarkers which indicate a variety of health or disease characteristics, such as the level or type of exposure to an environmental factor, genetic susceptibility based on the phenotype of the individual, genetic responses to exposures, markers of sub-clinical or clinical disease, or indicators of response to therapy. Thus, Fox and Growdon  defining biomarkers have stated that--a simplistic way to think of biomarkers is as indicators of disease trait (risk factor or risk marker), disease state (pre-clinical or clinical), or disease rate (progression).
CVD, the leading cause of mortality in the United States and in Western countries,  is no less common in the developing countries. It is attributed to dietary insufficiency or malabsorption of folate, vitamin B12, or vitamin B6 which leads to hyperhomocysteinemia and consequently leads to an increased risk of CVD. [14,15] With the explosive rise in the incidence of CAD or CVD, it is now estimated that this will be the leading cause of mortality and morbidity even in the developing world by the year 2015.  Over 200 risk factors for CAD have been identified or postulated, of which dyslipidemia, hypertension, and smoking appear to be the most important.  A major component of this epidemic is due to treatable factors, which if controlled will go a long way in stemming the epidemic.
Most commonly associated complications like macrovascular complications are the leading causes of morbidity and mortality in diabetic patients; 60% of diabetic patients die of cardiovascular diseases.  In all populations studied, individuals with diabetes have a greatly increased risk of coronary heart disease (CHD) compared with nondiabetic individuals,  and risk of CVD death in diabetic individuals may be as high as that in nondiabetic individuals with previous myocardial infarction.  Despite such alarming scenarios, there is a paucity of information on the relative importance of CVD risk factors in persons with diabetes and strategies for risk factor reduction. A question of particular importance is the relative role of various lipoprotein abnormalities in determining CVD risk in diabetic individuals. In many individuals with diabetes, LDL cholesterol is not elevated,  but there is a characteristic dyslipidemia consisting of elevated triglycerides, decreased HDL cholesterol levels, and LDL particles of altered composition. Although 3 recent clinical trials of cholesterol lowering have shown that lowering LDL cholesterol in diabetic persons does reduce the incidence of CVD, [22,23] the relative importance of LDL cholesterol, compared with the characteristic dyslipidemia, in determining CVD risk in diabetic individuals is still a subject of debate.
In view of such lacunae in the knowledge, this retrospective study is taken to analyze the risk parameters in south Indian population, as the risk factors vary in different ethnic groups and also with geographic locations. Further the aim was to investigate the correlation of the clinical parameters with epidemiological findings and to determine the risk factors leading to CVD.
Materials and Methods
This retrospective study was carried out at the, Mahavir Hospital and Research Centre Hyderabad, India, during the period of July 2012-March 2014. To determine the risk parameters in the south Indian population we have recorded demographics, and analyzed the clinical and biochemical parameters and other characteristics like serum electrolytes, blood grouping, and angiographic records of 530 patients.
The study was approved by the hospital's ethics committee. Study populations consisted of patients with CAD, age 40 years and above, of both sexes that were undergoing coronary angiography for diagnostic or revascularization purposes.
Baseline demographics, clinical, and risk factors data was collected from hospital records and by discussing with the attending Cardiologists. Only conventional risk factors including diabetes mellitus, hypertension, dyslipidemia, smoking, and family history for premature CAD as defined in operational definitions were assessed in this study. The clinical presentations of patients were categorized as stable angina, unstable angina, and myocardial infarction.
Continuous variables were expressed as mean values and standard deviation for normally distributed data and median and interquartile range for non-normally distributed data, while categorical variables were expressed as frequencies and percentages. Relationships between two variables were analyzed by MedCalc version 14.10.2 (MedCalc Software, Mariakerke, Belgium).
The most common symptoms with patients in this study were angina (also called angina pectoris). Pain or discomfort in other areas of the upper body including the arms, left shoulder, back, neck, jaw, or stomach were also reported by some patients. Studies show that women's symptoms are less likely identified as heart disease related. The symptoms of coronary artery disease and heart attack can be different for women than they are in men.
A total of 530 patients were included in the study with 372 (70.18%) males, 158 (29.81%) females, 320 (60.37%) smokers and 210 (39.62%) were non smokers, alcoholic 55 (10%), Tobacco 135 (25.47%). Frequencies of risk factors for CAD were; hypertension 160 (30.18%), diabetes mellitus 215 (40%), dyslipidemia 250 (47.16%) as shown in Table 1. The majority in the study group were found not to consume fruits and salads.
The values of TC, HDL, LDL, and triglycerides were 205.26 [+ or -] 60.25, 40.23 [+ or -] 13.44, 134.28 [+ or -] 15.16, 148.33 [+ or -] 57.89, respectively (Table 2). In addition, the levels of TC, LDL-C, and triglycerides were higher in males than females as compared to HDL-C (Table 3).
Electrolyte levels measured before surgery were normal or slightly higher (in case of creatinine) before surgical intervention. Severe electrolyte depletion was observed in CAD patients after surgery. The differences between CAD patients before and after surgery was significant for creatinine (p < 0.001), potassium (p < 0.001), and sodium (p < 0.001) (Table 4).
In the Table 5, A 20.75%, B 38.67%, AB 10% and O 30.56% blood groups in patients. It has been found that CVD patient with B blood group are more in this study and next is O group then A and very less AB group.
Table 6 shows coronary artery involvement on angiography. Angiographic distribution of lesion shows 108 (20.37%) patients had single vessel disease (SVD), 130 (24.52%) patients had double vessel disease (DVD), 215 (42.56%) had triple vessel disease (TVD), 23 (4.33%) had left main disease and 54 (10.18%) had normal coronary angiogram.
The scenario of CVD is now widely recognized and the fact remains that at present developing countries contribute a greater share to the global burden of cardiovascular disease than developed countries.  The disease was very common in westernized population affecting the majority of adults over the age of 60 years, but now this is rising in developing world.
There was a clear high male ratio (70.18%) in the present study, which is in agreement with previous studies, suggested that it is predominantly a disease of men. [25, 26] Female represented 29.81% of patients. Although, this is a much higher frequency compared with data from other parts of India (5%).  All reported data show that smoking is the commonest risk factor encountered in patients with acute myocardial infarction. [28,29] This study also found that smoking was indeed the leading risk factor present in 60.37% patients while non smokers were 39.62%. The male preponderance and smoking being the major risk factors has been well documented in many studies in this subcontinent. [30, 31]
Even though heavy drinking of alcohol is associated with an increased risk of cardiovascular disease, It has not recorded as it is a known risk parameter and aware that there are social risks associated with heavy or binge drinking, particularly among young people.
Diabetes mellitus alone was a risk factor in 40.56% patients and hypertensions has been found in 30.18% patients. Family history for diabetes mellitus and hypertension were 22.64% and 16.98%, respectively. Dyslipidemia being the major risk factor was found in 47.16%. Dyslipidemia and diabetes mellitus is well known to have an adverse influence on the prognosis of patient with acute myocardial infarction. 
In addition to demographics, total cholesterol and LDL were found to be powerful risk factors for CAD, stroke, and peripheral arterial disease. [33, 34] Atherosclerosis accounts for nearly 80% of all deaths among North American diabetic patients compared with one third of all deaths in the general North American population.  More than 75% of all hospitalizations for diabetic complications are attributable to cardiovascular disease. Prolonged exposure to hyperglycemia is now recognized as the primary casual factor in the pathogenesis of diabetic complications.  Hyperglycemia induces a large number of alterations in vascular tissues that potentially promoted or accelerated atherosclerosis.
Coronary artery disease has a complex etiology generated by combined effects of both, genetic and environmental factors.  The polymorphic genes, encoding products involved in atherosclerotic process, predispose individuals to a greater or lower extent to CAD. However, traditional risk factors, such as cigarette smoking, hypercholesterolemia, hypertension and overweight, interacting with the genetic risk factors (in cumulative or synergistic ways), may increase or not the risk of the disease. It is known that interactions between genetic and environmental factors are very important in subjects with a high-risk genetic profile.  Genetic factors have greater contribution to the development of CAD at younger age. 
Since as many as half of the patients have no symptoms, despite the presence of CAD, coronary deaths in India are expected to be double over 20 years (Ghaffar et al., 2004). They may have silent ischemia orbe unaware of the potentially dangerous abnormal heartrhythms (arrhythmias). The absence of chest pain or other common symptoms can also set the stage for a heart attack that occurs without warning. Hence, it is important to look at biomarkers for early detection of CAD.
Therefore, the present study determined the level of biochemical parameters, such as TC, LDL, HDL and triglycerides in South Indian patients with coronary artery disease.
A large body of epidemiological and pathological data documents that diabetes is an independent risk factor for cardiovascular disease (CVD) in both men and women. [36,37] In the present study, there was an abnormally higher level of total cholesterol ([greater than or equal to] 200 md/dl) and LDL-C ([greater than or equal to] 130 mg/dl) in CVD patients, also lower levels of HDL-C (<40 mg/dl) and triglycerides ([greater than or equal to] 150 mg/dl). In addition, the levels of TC, LDL-C and triglycerides were higher in males than females as compared to HDL-C (Table 3). The results are no different with those presented elsewhere, that most CAD patients have high levels of LDL cholesterol and total cholesterol.  Moreover, a low level of HDL cholesterol has been observed in CAD patients. 
The study demonstrates that patients undergoing cardiac-surgical procedures with extracorporeal circulation are at high risk for electrolyte depletion and so potassium supplementation was given throughout the surgical procedure. The reason for this appears to be a combination of increased urinary excretion and intracellular shift, induced by a combination of extracorporeal circulation and decreased body temperature during surgery (hypothermia induced diuresis and intracellular shift).
This cross-sectional study covered a relatively small number of patients in a single center study, so that future studies of larger patient populations with longitudinal cohort design are necessary to assess this finding. The present study populations included both type 1 (28%) and type 2 (72%) DM patients. However, when performed the analyses for type 2 DM patients only, the overall results were similar. Finally, the confounding factors for logistic regression analysis and sequential logistic regression models were based on previously reported findings, so that a more complete description for this analysis may be necessary.
It can be concluded that strong case exists for the efficacy and safety of primary prevention through lifestyle changes. Further awareness and primary prevention efforts need to be extended to both public health and clinical arenas. The essential changes in life leading to preventive measures include smoking avoidance or cessation, lowering alcohol consumption, modifying intakes of foods and nutrients, weight control, and physical activity.
The authors are grateful for the support of the entire staff of the Division of Cardiology of Mahavir Hospital and research centre. We are grateful to Bhagwan Mahavir medical Research Centre for the facilities provided. Further, we thank the study group for volunteering for carrying out this investigation. Besides, we are thankful to Superintendent Dr. S. Avulappa (MBBS, MCCP, DCCP, MIPHA, and FCGP) for his encouragement.
[1.] Maskey A, Sayami A, Pamdey MR: coronary artery dieseae: an emerging epidemic in Nepal. J. Nepal Med Association 2003; 42:122-4.
[2.] Murry CJ, Lopez AD. Mortality by cause for eight regions of the world: global burden of the disease study. Lancet 1997; 349:1269-76.
[3.] Khan S, Kundi A, Sharieff S. Prevalence of right ventricular myocardial infarction in patients with acute inferior wall myocardial infarction. Int J Clin Pract 2004; 58:354-7.
[4.] Maskey A, Sayami A, Pamdey MR. coronary artery disease: An emerging epidemic in Nepa l. J. Nepal Med Assoc 2003; 42:122-4.
[5.] Murry CJ, Lopez AD. Mortality by cause for eight regions of the world:gGlobal burden of the disease study. Lancet 1997; 349:1269-76.
[6.] Russo CA, Andrews RM. The National Hospital Bill: The most expensive condition by Payer, 2004. Agency for Healthcare Research and Quality; 2006. HCUP statistical brief No.13. JAMA 2006; 4:18-25.
[7.] Rosamond W, Flegal K, FurieK, Friday G, Furie K, Go A. Heart disease and stroke statistics-2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117:25-146.
[8.] Gaziano MJ, Manson JE, Ridker PM. Primary and secondary prevention of coronary heart disease. In : Libby P, BonowRO. Mann DL, Zipes DP, editors. Braunwalds heart disease. A textbook of cardiovascular medicine. 8th ed. Saunders: Philadelphia;2008:1119-48.
[9.] Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circulation 1998; 97:596-601.
[10.] Nikus KC. Coronary angiography; Current methods and their applications for cardiovascular multimodal imaging. In: Pahlm O, Wagner GS. Multimodal cardiovascular imaging: Principles and clinical applications.1st ed. Philadelphia: The McGraw-Hill Companies:2011:57-80.
[11.] Gauchan N, Rawat B, Vaidya A, Rajbhandari S, Bhatta Y, Jaiswal JP. Coronary angiographic findings of Nepalese patients with critical coronary artery disease: which vessels and how severe? Webmed Central Cardiology 2012; 3:1-13.
[12.] Fox N, Growdon JH. Biomarkers and surrogates. Neuro Rx. 2004;1:181.
[13.] Graham IM, Daly LE, Refsum HM et al: Plasma homocysteine as a risk factor for vascular disease: the European concerted action project. JAMA, 1997; 277: 1775-81.
[14.] Pancharuniti N, Lewis CA, Sauberlich HE et al: Plasma homocysteine, folate, and vitamin B12 concentrations and risk for early onset coronary artery disease. Am J Clin Nutr, 1994; 59: 940-8.
[15.] Hopkins PN, Wu LL, Wu J et al: Higher plasma homocyst(e)ine and increased susceptibility to adverse effects of low folate in early familial coronary artery disease. Arterioscler Thromb Vasc Biol, 1995; 15: 1314-20.
[16.] Reddy KS. Cardiovascular disease in India. Would Health Stat Q 1993;46:101-7.
[17.] Castelli WP. Lipids risk factors and ischemic heart disease. Atherosclerosis 1996;124:S1-S9.
[18.] World Health Organization. Prevention of diabetes mellitus. In: WHO Technical Report Series #844. Geneva, Switzerland: World Health Organization;1994.
[19.] Wingard DL, Barrett-Connor E. Heart disease and diabetes. In: National Diabetes Data Group, ed. Diabetes in America. 2nd ed. Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH publication No. 95-1468, 1995:429-48.
[20.] Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med1998;339:229-34.
[21.] Cowie CC, Howard BV, Harris MI. Serum lipoproteins in African Americans and Whites with non-insulin-dependent diabetes in the US population. Circulation. 1994;90:1185-93.
[22.] Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. Diabetes Care. 1997;20:614-20.
[23.] Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, Langendorfer A, Stein EA, Kruyer W, Gotto AM Jr. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/ TexCAPS: Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA. 1998;279:1615-22.
[24.] Gaziano MJ, Manson JE, Ridker PM. Primary and secondary prevention of coronary heart disease. In: Libby P, Bonow RO. Mann DL, Zipes DP, editors. Braunwalds Heart disease. A text book of cardiovascular medicine. 8th ed. Saunders: Philadelphia; 2008. P. 1119-48.
[25.] Jackson R, Chambless L, Higgins M. Sex differences in ischemic heart disease mortality and risk factors in 46 communities: an etiologic analysis. Cardiovasc Risk Factors 1997;7:43-54.
[26.] Mckeigue PM, Adelstein AM, Shipley MJ, Riemersma RA, Mamot MG, Hunt SP et al. Diet and risk factors for coronary heart disease in Asian in North west London Lancet 1985; 2:1086-90.
[27.] Choudhury l, Marsh JD. Myocardial infarction in young patients. Am J Med. 1999; 107: 257-61. Faridpur Med. Coll. J. 2011;6(2):82-5.
[28.] Hong MK, Cho SY, Hong BK, Chang KJ, Chung IM, Lee MH et al. Acute myocardial infarction in young adults. Yonsei Med J. 1994; 35:184-9.
[29.] Siwach SB, Singh H, Sharma D, Katyal VK. Profile of young acute myocardial infarction in Harayana. J Assoc Physicians India 1998; 46:424-6.
[30.] Rahman A, Mojumder AAS, Ali A, Shaha GK. Risk factors, Clinical and Coronary Angiographic Profile of Coronary Artery Disease in Young Bangladeshi Population. Circul J 2005; 69(suppl I):10-12.
[31.] Ahmad I, Shafique Q. Myocardial infarction under age 40: risk factor and coronary arteriographic findings. Ann King Edward Med Coll. 2003; 9:262-5.
[32.] Ishaq M, Beg MS, Ansari SA, Hakeem A, Ali S. Coronary artery disease risk profiles at a specialized tertiary care centre in Pakistan. Pakistan J Cardiol. 2003;14:61-8.
[33.] Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes JI. Factors of risk in the development of coronary heart disease six year follow-up experience; the Framingham Study. Ann Intern Med 1961; 55:33-50.
[34.] Siwach SB, Singh H, Sharma D, Katyal VK. Profile of young acute myocardial infarction in Harayana. J Assoc Physicians India 1998; 46:424-6.
[35.] Rahman A, Mojumder AAS, Ali A, Shaha GK. Risk factors, Clinical and Coronary Angiographic Profile of Coronary Artery. Disease in Young Bangladeshi Population. Circulation Journal, 2005; 69(suppl I):10-12.
[36.] Ghaffar A, Reddy KS, Singhi M.Burden of non-communicable diseases in South Asia.BMJ. 2004 Apr 3;328(7443):807-10.
[37.] Wilson PW, D'Agostino RB, Levy D et al. Prediction of coronary heart disease using risk factor categories. Circulation, 1998; 97: 1837-47.
[38.] Wilson PW. Diabetes mellitus and coronary heart disease. Am J Kidney Disease, 1998; 32: S89-S100.
[39.] McGill HC Jr, McMahan CA. Determinants of atherosclerosis in the young: pathobiological determinants of atherosclerosis in youth (PDAY) research group. Am J Cardiol, 1998; 82: 30T-36T.
[40.] Newairy AA, Mansour HA, Yousef MI, Sheweita SA. Alteration of lipid profile in plasma and liver of diabetic rats: influence of hypoglycemic herbs. J EnvSci and Health Vlo B, 2002; 37 (5): 112-22.
Source of Support: The authors (JA and KPR) acknowledge the partial funding to carry out this work from UGC/NON-Net Fellowship (JA) and UGC-F-26/SAI (SAP) (KPR) at Osmania University.
CAD Coronary artery disease
CA Coronary angiography
HDL High density lipoproteins
LDL Low density lipoproteins
BMI Body mass index
CI Confidence interval
DM Diabetes mellitus
E Early diastolic wave velocity
E' Spectral pulsed-wave Doppler-derived early diastolic velocity from the septal mitral annulus
EF Ejection fraction
GFR Glomerular filtration rate
GLS Global longitudinal strain
HF Heart failure
LAVI Left atrial volume index
OR Odds ratio
Javeed Ahmad Tantray (1,2), K Pratap Reddy (2), Kaiser Jamil (1), Y Shiva Kumar (3)
(1) Department of Genetics, Bhagwan Mahavir Medical Research Centre, Hyderabad, Telangana, India.
(2) Department of Zoology, Osmania University, Hyderabad, Telangana, India.
(3) Department of Cardiology, Mahavir Hospital and Research Centre, Hyderabad, Telangana, India.
Correspondence to: Kaiser Jamil, E-mail: email@example.com
Received July 15, 2016. Accepted July 26, 2016
Table 1: Demographic risk factors and clinical diagnosis of patient with coronary artery disease (N=530) Characteristics No. of patients Percentage (%) Male 372 70.18 Female 158 29.81 Smoker 320 60.37 Non Smoker 210 39.62 Alcohol 55 10.37 Tobacco 135 25.47 Hypertension 160 30.18 Family history HTN 90 16.98 Diabetes mellitus 215 40.56 Family history DM 120 22.64 Dyslipidemia 250 47.16 Table 2: Clinical characteristics/mean lipid levels of patients with heart diseases (n=530) Parameters assessed Mean values for Normal values CAD patients Pulse 85.43 [+ or -] 24.12 72 beats per minute Systolic blood 130 [+ or -] 48.50 less than 120 mmHg pressure Diastolic blood 82 [+ or -] 16.70 less than 80 mmHg Pressure Total cholesterol 205.26 [+ or -] 60.25 150-200 mg/dl (mg/dl) HDL (mg/dl) 40.23 [+ or -] 13.44 40-45mg/dl (males), 45-60 mg/dl (females) LDL (mg/dl) 134.28 [+ or -] 15.16 <130 mg/dl Triglycerides (mg/dl) 148.33 [+ or -] 57.89 50-150 mg/dl Table 3: Cholesterol levels in males (n = 372) and females (n = 158) High Values Male Percentage Female Percentage (%) (%) TC [greater than or 150 40.32 56 35.44 equal to] 200 mg/dl HDL-C<40 mg/dl 75 20.16 35 22.15 LDL-C [greater than or 162 43.54 55 34.81 equal to] 130 mg/dl Triglycerides [greater 95 25.53 32 20.25 than or equal to] 150 mg/dl Table 4: Serum electrolytes mean values in CAD patients before and after surgery Electrolytes Cases before Cases after p-Value surgery surgery Creatinine 2 [+ or -] 0.75 0.9 [+ or -] 0.25 0.001 Potassium 3.99 [+ or -] 1.0 1.7 [+ or -] 0.65 0.001 Sodium 135.86 [+ or -] 5.5 132 [+ or -] 3.55 0.001 Table 5: Patients profile of blood grouping (n = 530) Blood group No. of patients Percentage (%) A 110 20.75 B 205 38.67 AB 53 10 O 162 30.56 Table 6: Clinical features of coronary artery disease on angiography (n = 530) Angiographic findings No. of patients Percentage (%) SVD 108 20.37 DVD 130 24.52 TVD 215 40.56 LM 23 4.33 Normal CAG 54 10.18 Total 530
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Original Research|
|Author:||Tantray, Javeed Ahmad; Reddy, K. Pratap; Jamil, Kaiser; Kumar, Y. Shiva|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Jan 1, 2017|
|Previous Article:||Study of serum transferrin and serum ferritin during pregnancy and their correlation with pregnancy outcome.|
|Next Article:||A cross sectional study to determine the menarcheal age of adolescent bania girls from Punjab.|