|Year : 2019 | Volume
| Issue : 3 | Page : 113-117
Clinical profile and outcomes of patients presenting with acute coronary syndrome in a tertiary care hospital
Vijay K. Kadam
Department of Cardiology, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India
|Date of Submission||20-Jan-2020|
|Date of Acceptance||21-Jan-2020|
|Date of Web Publication||16-Mar-2020|
Dr. Vijay K. Kadam
Dr. Vijay Kamalkishor Kadam, Department of Cardiology, MGM Medical College and Hospital, Sector-1, Kamothe, Navi Mumbai 410209, Maharashtra.
Source of Support: None, Conflict of Interest: None
Objective: This article aimed to study the clinical profile and outcomes of patients presenting with acute coronary syndrome at a tertiary care hospital and to draw conclusions from the above data with regard to characteristics of Indian patients presenting with acute coronary syndrome. Materials and Methods: This cross-sectional study was carried out in one of the teaching medical college hospitals. All patients presenting to casualty with an acute coronary syndrome were admitted to the Coronary Care Unit. Standard history was taken, data were entered into a pro forma sheet, and relevant investigations were performed. Patients with ST-segment elevation myocardial infarction were thrombolysed, taken up for percutaneous transluminal coronary angioplasty (PTCA), or managed conservatively. Prompt medical treatment was started in all cases. The hospital course of the patients including complications, if any, was documented. Results and Conclusion: A total of 100 patients presenting with the acute coronary syndrome were studied. The majority of the patients were found to be male (77%). Hypertension was the most common risk factor followed by smoking, diabetes mellitus, and dyslipidemia. Of all patients, 63% presented with myocardial infarction. Serious complications occurred in 23% patients. The mean age of all patients was 55.5 ± 12.1 years. The age of presentation of females was on average a decade more than that of males. A small but significant percentage (11%) included premature patients younger than 40 years. Most of the patients presented between 1 and 6h of symptom onset. Of all patients, 33% underwent successful PTCA and were discharged on appropriate medication; moreover, 25% were advised PTCA but did not undergo due to various reasons. These were then managed medically. Of all patients, 15% were advised coronary artery bypass grafting and 24% were put on aggressive medical management. A majority of patients presented with single-vessel coronary artery disease (44%) and 3% died during the index hospitalization.
Keywords: Acute coronary syndrome, coronary angiography, coronary artery bypass, coronary artery disease, hypertension
|How to cite this article:|
Kadam VK. Clinical profile and outcomes of patients presenting with acute coronary syndrome in a tertiary care hospital. MGM J Med Sci 2019;6:113-7
|How to cite this URL:|
Kadam VK. Clinical profile and outcomes of patients presenting with acute coronary syndrome in a tertiary care hospital. MGM J Med Sci [serial online] 2019 [cited 2020 Apr 6];6:113-7. Available from: http://www.mgmjms.com/text.asp?2019/6/3/113/280739
| Introduction|| |
Coronary artery disease (CAD) is the leading cause of mortality and morbidity in the world and acute coronary syndrome (ACS), which encompasses unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), is the most common cause of mortality in patients with CAD. In our country, we have not been able to halt or even slow down the march of CAD. Due to a number of reasons, CAD has run amok in India, leading to an “epidemic” of massive proportions. CAD affects Indians at a younger age than counterparts in developed countries, as well as many other developing countries, and thus, has a major economic impact on our country. Relatively little is known about the clinical spectrum, the patient profile, and outcomes of Indian patients. Age- and gender-specific differences also need further study. Therefore, we prepared this study with an aim to document the clinical characteristics, investigations, and outcomes of patients with ACS who were admitted to a tertiary care hospital in India.
| Materials and methods|| |
This cross-sectional study was carried out in one of the teaching medical college hospitals. All patients presenting to a casualty with an ACS were admitted to the Coronary Care Unit. ACS was defined as STEMI, NSTEMI, or UA per established clinical, ECG, and enzymatic definitions for the same. These patients were explained about the study and option was given to the patients to participate voluntarily. Informed consent was obtained. The study was conducted after obtaining clearance from the institutional ethics review board. Standard history was taken and data were entered into the pro forma sheet. Hypertension was defined as a blood pressure (BP) of >140/90mm Hg. Diabetes mellitus was defined as a fasting blood sugar (FBS) level of >126mg/dL or postprandial blood sugar (PPBS) level of >200mg/dL. Dyslipidemia was defined as fasting low-density lipoprotein (LDL) levels of >100mg/dL or high-density lipoprotein (HDL) levels of <40mg/dL. Smokers were defined as current smokers of tobacco of any form or those who had quit within the past month. Patients with STEMI were thrombolysed, taken up for primary angioplasty in myocardial infarction (PAMI), or managed conservatively. When thrombolysed, every effort was taken to ensure a door-to-needle time of <30min. Similarly, when taken up for PAMI, all efforts were taken to ensure a door-to-balloon time of <90min. Prompt medical treatment was started in all cases. The hospital course of the patients including complications, if any, was documented. The blood samples for investigations were collected using international safety guidelines. Two-dimensional (2D) echo was performed using standard views and left ventricular ejection fraction (LVEF) was estimated visually by an experienced operator. Coronary angiography was performed via radial or femoral approach and all standard cine views were obtained. Significant vessel size was defined as a vessel with a minimum of 2.25mm diameter. Vessel stenosis was estimated visually by an experienced operator and in multiple views. Significant stenosis was defined as stenosis of ≥70%. Left main coronary artery stenosis ≥ 50% was considered to be a significant disease. Stenotic lesions of <50% in the left main coronary artery and 70% in others were not considered. A regular follow-up of all patients was maintained.
| Results|| |
A total of 100 patients were enrolled in this study. A number of parameters were observed, including age, gender, risk factors, diagnosis, time to hospital admission, complications faced by the patient during the hospital stay, and coronary angiography (CAG) findings.
The mean age of all the patients was found to be 55.5 ± 12.1 years. The mean age of the male patients was found to be 53.2 ± 11.5 years, whereas the mean age of the female patients was found to be 62.95 ± 11.0925 years, approximately a decade more than their male counterparts. Of all the patients, 11% were below 40 years of age. More than 50% of such patients had SVCAD on angiography. All patients below the age of 40 years who presented with ACS were found to be male and none of them had traditional risk factors for CAD. All of them had a history of smoking and a few of them had the presence of dyslipidemia. The patients were almost equally distributed among 41–59 and >60 years age group and had a greater proportion of females as age increased, which suggests that the risk profile of females increases with age [Figure 1].
Of 100 patients, 77 were found to be male and 23 were found to be female [Figure 2].
Patients were evaluated for the presence or absence of several risk factors, including hypertension, dyslipidemia, diabetes mellitus, and smoking [Figure 3].
Hypertension was found to be the most common risk factor, followed closely by cigarette smoking, diabetes mellitus, and dyslipidemia. Patients were also evaluated on the basis of how long they took to come to the casualty of the hospital after experiencing the first symptom. Majority of the patients presented to our casualty between 1 and 6h of the onset of chest pain [Figure 4].
Patients were classified on the basis of the type of ACS they had, namely, myocardial Infarction, UA, or NSTEMI. The most common presentation in our casualty was acute myocardial infarction (63%) followed by UA (22%) and NSTEMI (15%) [Figure 5].
Furthermore, among myocardial infarction, anterior wall myocardial infarction (AWMI) was the most common presentation in patients followed by inferior wall myocardial infarction (IWMI): 71% had AWMI, whereas 29% had IWMI [Figure 6].
Of the enrolled patients, 23% in the study had complications. There was a 4% complication rate of cardiogenic shock. This resulted in a mortality rate of 75%. A single patient had ischemic ventricular septal rupture. Of the enrolled patients, 7% required temporary external pacing for symptomatic bradycardia. All these patients had IWMI and required only temporary pacing. They all survived and were discharged in a good state. Of the enrolled patients, 11% had a malignant tachyarrhythmia requiring defibrillation or an antiarrhythmic medication [Figure 7].
Coronary angiography findings of the enrolled patients were evaluated. Patients were classified as having left main disease (LMD), single-vessel coronary artery disease (SVCAD), double-vessel coronary artery disease (DVCAD), triple-vessel coronary artery disease (TVCAD), recanalized vessel (RV), or insignificant coronary artery disease (ICAD) [Figure 8].
SVCAD was the most common presentation followed by DVCAD and TVCAD. LMD was the most uncommon presentation.
Of the patients who presented to the casualty, 33% underwent successful percutaneous transluminal coronary angioplasty (PTCA) and were discharged on appropriate medication. Also, 25% were advised PTCA but did not undergo due to various reasons. In addition, 15% were advised coronary artery bypass grafting (CABG), 24% were put on medical management, and 3% died [Figure 9].
| Discussion|| |
In this study, the average age of patients was found to be similar to other studies carried out in the South Asian region.,,, However, when this study was compared to studies carried out in the western hemisphere,,, the results were found to be discordant. Compared to the GRACE and the ACCEPT registry, the difference in the mean age of patients ranges from 7 to 9 years. Hence, we conclude that in the population that was studied, patients presented at an average of 7–9 years earlier than those patients from the western hemisphere. This finding correlates to that made in the INTERHEART study, which concluded that the South Asian population encounters acute myocardial infarction 7–10 years earlier than their Western counterpart.
This study shows that 11% of patients presenting with ACS were ≤40 years of age. This correlates well with the study carried out by Kesavan et al. at LTMC Hospital, Sion, Maharashtra, India, which shows a similar prevalence rate (9.1%) of ACS in patients aged ≤40 years. This rate seems to be slightly higher than the one obtained from studies carried out in Oman and sub-Saharan Africa. Hence, we can conclude that the young patients form a small but not insignificant percentage of patients presenting to the hospital casualty with an ACS. The prevalence of such patients appears to be slightly higher in our region as compared to foreign countries. A majority of patients presenting with the ACS were found to be male. The same pattern was reflected in other studies.,, Four risk factors were evaluated, namely, hypertension, smoking, diabetes mellitus, and presence of dyslipidemia. In this study, the most important factors were the presence of hypertension and smoking, which occurred at nearly similar rates. Diabetes mellitus was the next most important factor followed by dyslipidemia. The results are similar to the CREATE registry and the study performed by Yadav et al. where smoking and hypertension are the most important factors followed by diabetes mellitus and dyslipidemia.
Majority of the patients in this study presented between 1 and 6h of symptom onset. This compares to the finding in the CREATE registry where they found that the median time taken by a patient to reach a hospital was 360min. The next most common category was patients presenting between 6 and 12h of symptom onset. Patients presenting within 1h or after 12h formed an equal share and were the last category among the patients studied.
In this study, the predominant presenting syndrome was STEMI. This was similar to the CREATE registry, which is the largest registry of patients with ACS in India. The tables are turned, however, when we compare the Indian studies to the ACCEPT registry and GRACE registry enrolling patients mainly in the western hemisphere. Here, the predominant presentation of the ACS was a non-ST-elevated syndrome (either UA or NSTEMI) with STEMI coming in second. Hence, we may conclude that in our country, the main form of presentation of the ACS is STEMI in contrast to the Western countries where a non-ST-elevated syndrome is a primary presentation.
The complication rate among the patients in this study was 23%. The most common complication turned out to be tachyarrhythmia requiring termination (47.82%), followed by bradyarrhythmia requiring temporary transvenous pacing (30.43%). The cardiogenic shock made up (17.39%) of all the complications. The mechanical complication was the least common (4.34%) of the complications that occurred in admitted patients. These figures for complication rates are comparable to the study conducted by Yadav et al., where the most common complication was arrhythmia (60%) followed by cardiogenic shock (35%) with mechanical complications having the least frequency (2.5%). Of the enrolled patients, 33% underwent successful PTCA and were discharged on appropriate medication; 25% were advised PTCA but did not undergo due to various reasons; 15% were advised CABG; 24% were put on medical management; and 3% died. Small sample size and data collected from a single tertiary care center constitute the limitations of this study
| Conclusion|| |
From this cross-sectional study, we can draw some valuable points regarding the clinical profile of Indian patients presenting with ACS. The mean age of patients presenting with ACS was 7–9 years earlier as compared to Western counterparts. The mean age of presentation of females was later than that of males. Young patients aged ≤40 made up a small but not insignificant part of the population presenting with the ACS. All of these young patients were male, had smoking followed by dyslipidemia as major risk factors, had a relative absence of traditional risk factors, and had SVCAD as the major finding on CAG. Male patients made up the majority of patients in this study. Hypertension was the most common risk factor present in patients followed by smoking. The majority of patients presented within 1–6h of chest pain. Patients presenting at the extremes <1h and >12h formed the least number of patients. Majority of patients in this study had a discharge diagnosis of STEMI with the rest having non-ST-elevated syndromes. Twenty-three percent patients had complications. Tachyarrhythmias were the most common complication and mechanical complications were the least frequent. Cardiogenic shock was the most lethal complication with a mortality rate of 75%. There was a mortality rate of 3% in this institution, which was comparable to the Western countries. Thirty-three percent patients underwent PTCA, 15% were advised to undergo CABG, 25% were advised PTCA but did not undergo the procedure, and 24% were kept on aggressive medical management.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Finegold JA, Asaria P, Francis DP. Mortality from ischaemic heart disease by country, region, and age: Statistics from World Health Organisation and United Nations. Int J Cardiol 2013;168: 934-45.
Gaziano TA. Cardiovascular disease in the developing world and its cost-effective management. Circulation 2005;112:3547-53.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al
. Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. Lancet 2008;371:1435-42.
Yadav P, Joseph D, Joshi P, Sakhi P, Jha RK, Gupta J. Clinical profile and risk factors in acute coronary syndrome. Natl J Community Med 2010;1:150-2.
Jafary MH, Samad A, Ishaq M, Jawaid SA, Ahmad M, Vohra EA. Profile of acute myocardial infarction in Pakistan. Pak J Med Sci 2007;23:485-9.
Bhalli MA, Kayani AM, Samore NA. Frequency of risk factors in male patients with acute coronary syndrome. J Coll Physicians Surg Pak 2011;21:271-5.
Fox KA, Eagle KA, Gore JM, Steg PG, Anderson FA; GRACE and GRACE2 Investigators. The Global Registry of Acute Coronary Events, 1999 to 2009—GRACE. Heart 2010;96:1095-101.
Piva e Mattos LA, Berwanger O, Santos ES, Reis HJ, Romano ER, Petriz JL, et al
. Clinical outcomes at 30 days in the Brazilian Registry of Acute Coronary Syndromes (ACCEPT). Arq Bras Cardiol 2013;100:6-13.
Gautam MP, Sogunuru G, Subramanyam G, Thapa LJ, Paudel R, Ghimire M, et al
. Acute coronary syndrome in an intensive care unit of a tertiary care centre: The spectrum and coronary risk factors. JNMA J Nepal Med Assoc 2013;52:316-21.
Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al
; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:937-52.
Kesavan S, Suryaprakash A, et al
. Clinico angiographic profile of young patients presenting with acute coronary syndrome at a tertiary care center in western India. Indian Heart J 2010;62:462-543.
Panduranga P, Sulaiman K, Al-Zakwani I, Abdelrahman S. Acute coronary syndrome in young adults from Oman: Results from the Gulf Registry of Acute Coronary Events. Heart Views 2010;11:93-8.
] [Full text]
Sarr M, Ba DM, Ndiaye MB, Bodian M, Jobe M, Kane A, et al
. Acute coronary syndrome in young Sub-Saharan Africans: A prospective study of 21 cases. BMC Cardiovasc Disord 2013;13:118.
Misiriya KJ, Sudhayakumar N, Khadar SA, George R, Jayaprakasht VL, Pappachan JM. The clinical spectrum of acute coronary syndromes: Experience from a major center in Kerala. J Assoc Physicians India 2009;57:377-83.
Singh PS, Singh G, Singh SK. Clinical profile and risk factors in acute coronary syndrome. J Indian Acad Clin Med 2013;14:130-2.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]