|Year : 2014 | Volume
| Issue : 1 | Page : 11-14
Risk-factor profile for coronary artery disease among young and elderly patients in Andhra Pradesh
Srinivasa Jayachandra1, Gopinath Agnihotram2, R Prabhakar Rao3, CR Vasudev Murthy4
1 Department of Physiology, Kunhitharuvai Memorial Charitable Trust Medical College and Hospital, Mukkam, Kozhikode, Kerala, India
2 Department of Biochemistry, Kunhitharuvai Memorial Charitable Trust Medical College and Hospital, Mukkam, Kozhikode, Kerala, India
3 Department of Medicine, Santhiram Medical College and General Hospital, Nandyal, Andhra Pradesh, India
4 Department of Pathology, International Medical University, Kuala Lumpur, Malaysia
|Date of Web Publication||3-Mar-2014|
Department of Physiology, Kunhitharuvai Memorial Charitable Trust Medical College and Hospital, Mukkam, Kozhikode - 673 602, Kerala
Source of Support: None, Conflict of Interest: None
Background: Coronary artery disease (CAD) is a worldwide health epidemic. Acute coronary syndrome is a potentially life-threatening condition and patient may die or become disabled in the prime of life. The aim of this study was to determine the conventional risk factors of CAD in young and elderly aged patients in Andhra Pradesh. Materials and Methods: Total of 190 CAD patients admitted in ICCU at Santhiram Medical College General Hospital, Nandyal, Andhra pradesh were selected for the study. In this, 90 patients were aged between 18-45 years, and 100 were more than 45 years of age. These patients were evaluated for risk factor contributing to occurrence of CAD. Results: The hypertension (20%), smoking (22%), diabetes mellitus (11%) and dyslipidemia (8%) were the most common risk factors in young patients. Overall risk factors were more likely in males compared to females (18 to <45 years, 79%; ≥65 years, 69.1%). With reference to elderly patients, the diabetes mellitus (21%), hypertension (14%), smoker (17%), kidney disease (11%) and dyslipidemia (9%) were the most common risk factors. Conclusion: Young patients had a different risk-factor profile when compared with older patients. Hypertension and smoking were the most common risk factors in young patients of CAD, whereas diabetes mellitus, kidney disease, and smoking were found in elderly patients.
Keywords: CAD (coronary artery disease), DM (diabetes mellitus), dyslipidemia, HTN (hypertension)
|How to cite this article:|
Jayachandra S, Agnihotram G, Rao R P, Murthy CV. Risk-factor profile for coronary artery disease among young and elderly patients in Andhra Pradesh. Heart India 2014;2:11-4
|How to cite this URL:|
Jayachandra S, Agnihotram G, Rao R P, Murthy CV. Risk-factor profile for coronary artery disease among young and elderly patients in Andhra Pradesh. Heart India [serial online] 2014 [cited 2020 Feb 19];2:11-4. Available from: http://www.heartindia.net/text.asp?2014/2/1/11/127974
| Introduction|| |
Coronary artery disease is an emerging health problem in India, various risk factors contributing to increase prevalence of coronary artery disease (CAD) in different age groups. Hypertension, diabetes mellitus, smokers and dyslipidemia are the most common cause of CAD. ,
The high incidence of risk factor for coronary disease in young individuals is hypertension, whereas diabetes is common within the elderly patients. In elderly patients aging is associated with changes in beta cell function and insulin resistance that predisposes to diabetes. ,,,
In the last few decades it has been in upsurge in the epidemiological study by World Health Organization population-based MONICA study,  INTERHEART,  and Euroheart ACS epidemiologic studies,  along with randomized controlled trials have shown that certain risk factors and baseline characteristics, such as family history, obesity, dyslipidemia, and use of tobacco products, are more potent predictors of outcomes in the young than in their older counterparts. Very limited data is available regarding the prevalence of various risk factors for CAD in younger and elderly patients of a tertiary teaching hospital in Andhra. Keeping in view the facts, a preliminary study of conventional risk factors in young and elderly patients of acute myocardial infarction (MI) was planned. To our knowledge, this is one of pioneer study focusing on the assessment of conventional risk factors for CAD at a tertiary teaching hospital in Andhra.
| Materials and Methods|| |
This study was a hospital based involving 190 patients of acute myocardial infarction (MI) admitted at ICCU of Department of Medicine, Santhiram Medical College and General Hospital, Nandyal during the period January 2009 to December 2010. The Institution Ethics committee approval was taken prior to the study. Pro forma was prepared that incorporated information name, age, sex, detail history of risk factor, and investigations. Total of 190 patients were divided in two groups; Group 1: 20-45 years of age and Group 2: more than 46 years of age (elderly patients). Complete detail history and examination were performed at bed side. All patients were subjected for complete hematological and biochemical investigations including Troponin T, electrocardiogram (ECG) to confirm acute MI. Among these patients coronary risk factors like smoking, diabetes mellitus, hypertension, dyslipidaemia, gender, kidney disease, alcohol history and also prior MI, heart failure and angina class were studied. The significance of each risk factor between the groups was calculated by employing the chi-square test and P < 0.05 was taken as significant.
| Results|| |
The characteristics of patients between both groups are displayed in [Table 1]. Mean age of patients enrolled in this study was about 40.5 ± 4.1 for younger group and 56.4 ± 6 for elderly patients. Significant differences observed for different risk factors in both groups are shown in [Table 2]. In this study, the risk factors for younger patients were hypertension (20%) , smoker (22%), dyslipidemia (8%), obesity (4%), diabetes mellitus (11%), and kidney disease(5%) and in most of cases the factors were detected at the time of acute coronary events. Regarding age group more than 45 years, observed risk factors were diabetics (21%), hypertension (14%) and smoker (17%), dyslipidemia (9%), obesity (8%), kidney disease (11%) and alcohol intake (7%) [Table 2]. In addition, younger patients were more likely to be male; none of them were taking lipid-lowering drugs before infarction. At the time of MI, younger patients were less likely to be aware of their dyslipidemia, diabetes. Similarly 2.5% of younger patients who were previously not known to have diabetes were diagnosed with diabetes during presentation. Younger patients were having anterior infarction which was characterized by ST-segment elevation and were treated acutely with the thrombolytic and medical therapy.
| Discussion|| |
The global burden of cardiovascular diseases (CVD) is rapidly increasing, predominantly due to a sharp rise in the incidence and prevalence of the same in the developing countries. India, a developing nation, is undergoing the same phase and is now in the middle of a CAD epidemic. During the past three decades, prevalence of most of the cardiovascular risk factors including smoking, diabetes mellitus, hypertension, dyslipidemia etc. has increased markedly in India. ,
In this study, total 90 patients were <45 years of age. Most of them had anterior MI and these patients were treated more aggressively and as compared to older patients. This is consistent with previous reports. ,,
Previous studies have shown that the male gender is one of the classic risk factors for CAD. , This study also concur with previous findings that overall risk factors were more likely in males when compared to females.
Our study showed that smoking is a major risk factor for CAD in both study groups. The effect of cigarette smoking on coronary risk factors is pervasive. Unfavorable effects include enhancement of platelet function. Platelet activation by cigarette smoking is linked to thrombosis formation, including onset of myocardial infarction. 
High prevalence of hypertension (20% and 14% in young and elderly patients, respectively) was seen among the study population. Hence, hypertension was revealed as a significant risk factor among the studied population. This agrees with the previous studies by Sofia and EUROSPIRE, hypertension has been seen as a major risk factor for CAD.  A high incidence of diabetes was seen among the elderly population. Indians are genetically prone to develop type-2 diabetes mellitus due to insulin resistance. The hyperinsulinimia in these patients accelerates the atherosclerotic process in the coronary arteries. Diabetes is second only to CAD as a health burden in India. During the past decade, the number of people with diabetes in India increased from 32 million to 50 million, and the projected figure may reach 87 million by 2030.  Hyperinsulinemia, insulin resistance, and the higher rate of prevalence of metabolic syndrome in people with type-2 diabetes were attributed to high coronary risk in south Asians. ,
In this study, the fasting lipid profile tests revealed evidence of dyslipidemia in 8% of the young patients and 9% of the elderly subjects. The importance of dyslipidemia in the pathogenesis of CAD is well-known. In a study conducted by Mohan et al., between 1998 and 2002 on a North Indian population showed that CAD occurred at much lower levels of total cholesterol and LDL-C than other populations, and high triglyceride and low HDL levels were of a universal phenomenon in this population. 
In view of obesity as the risk factor for CAD, based on the BMI, only 4% of the young patients had a BMI higher than 30, whereas 8% of the elderly had a BMI higher than 30. Although most of the co-morbidities relating obesity to CAD increase as BMI increases, they also relate to body fat distribution. It might indicate that obesity as such not only relates to but independently predicts coronary atherosclerosis.
Our study also showed that elderly patients with chronic kidney disease (CKD) had an 11% prevalence of CAD. In 1998, the U.S. National Kidney Foundation Task Force on Cardiovascular Disease in Chronic Renal Disease recommended that patients with CKD be considered to belong to the highest risk group for the development of cardiovascular events.  These patients present unique challenges to physicians attempting manage concomitant ischemic heart and CKD.
Younger patients were more likely to have an MI as their first event (70.5%), whereas heart failure was a more common first event in older patients (60.5%). Importantly, the relative proportion of sudden death events was similar across age groups.
The declining effect of individual risk factors with advancing age is likely because of the influence of competing risk factors. In contrast to their younger counterparts, elderly patients often presented with a more complex cardiovascular risk profile. The individual risk factors contribute disproportionately to risk in younger patients underscores the importance of addressing modifiable risk factors in younger patients, as those risk factors present in younger patients appear to be associated with differentially greater risk. ,,
Additionally, this study also showed that most of the patients had multiplicity of risk factor. As many risk factor are synergetic to each other were shown in various studies. ,, We observed an age-dependent variation in hazard associated with smoking and hypertension, with greater relative hazard in the youngest cohort of patients. However, diabetes mellitus and kidney disease were more prevalent in elderly patients in this study. Finally, the most common risk factors were smoking, hypertension, diabetes followed by dyslipidemia in both study groups.
This study represents risk factors contributing in MI patients with two age groups. As this study was confined to a small population of south India and had several limitations. Therefore, it is imperative to undertake large population-based, prospective studies in developing countries such as India to identify CAD-risk factors, both conventional and novel. There are many emerging risk factors [lipoprotein (a), triglyceride remnants, lipid subtypes, insulin resistance, C-reactive protein, inflammatory factors] or genetic markers that have been implicated in premature CHD, were not studied. Recent estimates suggest that 80 per cent of CVD deaths occur in developing countries with substantial contribution from India. This preliminary study throw significant light on the causative factors like smoking, hypertension, diabetes, dyslipidemia for CAD from Andhra Pradesh and thus pave the way for prevention of this silent killer.
| Conclusion|| |
Though acute coronary syndrome fortunately is an uncommon entity in young adults aged 45 years or less, it constitutes an important challenge for both the patient and the treating physician. Hypertension and smoking were strong and quite common coronary risk factors in the CAD patients. Besides hypertension in elderly patients, diabetes mellitus and chronic kidney disease were other coronary risk factors. Prevention and control of premature cardiovascular diseases in India needs urgent control of these factors. Target oriented control of hypertension, lipid levels and glycemia are required.
| Acknowledgement|| |
We sincerely thank the patients who participated in the study.
| References|| |
|1.||Jalowiec DA, Hill JA. Myocardial infarction in the young and in women. Cardiovasc Clin 1989;20:197-206. |
|2.||Yusuf S, Ounpuu S. Tracking the growing epidemic of cardiovascular disease in South Asia. J Am Coll Cardiol 2001;38:688-9. |
|3.||Lamm G. The epidemiology of acute myocardial infarction in young age groups. In: Roskamm H, editor. Myocardial infarction at young age. Berlin: Springer-Verlag; 1981. pp. 5-12. |
|4.||Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J Med 1999;107:254-61. |
|5.||Fullhaas JU, Rickenbacher P, Pfisterer M, Ritz R. Long-term prognosis of young patients after myocardial infarction in the thrombolytic era. Clin Cardiol 1997;20:993-8. |
|6.||Kannel WB, Abbott RD. Incidence and prognosis of unrecognized myocardial infarction. An update on the Framingham Study. N Engl J Med 1984;311:1144-7. |
|7.||Mahonen MS, McEldruff P, Dobson AJ, Kuulasmaa KA, Evans AE. WHO MONICA Project. Current smoking and the risk of non-fatal myocardial infarction in the WHO MONICA project populations. Tob Control 2004;13:244-50. |
|8.||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. |
|9.||Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, et al. Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey. Eur Heart J 2006;27:789-95. |
|10.||Kasliwal RR, Kulshreshtha A, Agrawal S, Bansal M, Trehan N. Prevalence of cardiovascular risk factors in Indian patients undergoing coronary artery bypass surgery. J Assoc Physicians India 2006;54:371-5. |
|11.||Gupta R. Meta-analysis of hypertension in India. Indian Heart J 1997;49:43-8. |
|12.||Von Eyben FE, Bech J, Madsen J, Efsen F. High prevalence of smoking in young patients with acute myocardial infarction. J R Soc Health 1996;116:153-6. |
|13.||Jörgensen S, Köber L, Ottesen M, Torp-Pedersen C, Videbaek J, Kjøller E. The prognostic importance of smoking status at the time of acute myocardial infarction in 6676 patients. J Cardiovasc Risk 1999;6:23-7. |
|14.||Pfeffer M, McMurray J, Leizorovicz A, Maggioni AP, Rouleau JL, Van De Werf F, et al. VALIANT investigators. Valsartan in acute myocardial infarction trial (VALIANT): Rationale and design. Am Heart J 2000;140:727-50. |
|15.||Kalin MF, Zumoff B . Sex hormones and coronary disease: A review of the clinical studies. Steroids 1990;55:330-52. |
|16.||Assmann G, Cullen P, Jossa F, Lewis B, Mancini M. Coronary heart disease: Reducing the risk. The scientific background to primary and secondary prevention of coronary heart disease. A worldwide view. International Task force for the prevention of coronary heart disease. Arterioscler Thromb Vasc Biol 1999;19:1819-24. |
|17.||Inoue T. Cigarette smoking as a risk factor of coronary artery disease and its effects on platelet function. Tob Induc Dis 2004;2:27-33. |
|18.||Euroaspire III: Lifestyle, risk factor and therapeutic management in people at high risk of developing cardiovascular disease from 12 European regions. Heart 2009;95:4. |
|19.||Mohan V, Radhika G, Vijayalakshmi P, Sudha V. Can the diabetes/cardiovascular disease epidemic in India be explained, at least in part, by excess refined grain (rice) intake? India J Med Res 2010;131:369-72. |
|20.||McKeigue PM, Ferrie JE, Pierpoint T, Marmot MG. Association of early-onset coronary heart disease in South Asian men with glucose intolerance and hyperinsulinemia. Circulation 1993;87:152-61. |
|21.||Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-30. |
|22.||Levey AS, Beto JA, Coronado BE, Eknoyan G, Foley RN, Kasiske BL, et al. Controlling the epidemic of cardiovascular disease in chronic renal disease: What do we know? What do we need to learn? Where do we go from here? National Kidney Foundation Task Force on Cardiovascular Disease. Am J Kidney Dis 1998;32:853-906. |
|23.||Lipscombe LL, Hux JE. Trends in diabetes prevalence, incidence, and mortality in Ontario, Canada 1995-2005: A population-based study. Lancet 2007;369:750-6. |
|24.||Statistics Canada. Portrait of the Canadian population in 2006, by age and sex. July 17, 2007. Available from: www12.statcan.ca/english/census06/release/release_agesex.cfm [Last accessed on 2009 Sept 12]. |
|25.||Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887-98. |
|26.||Shepard J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): A randomized controlled trial. Lancet 2002;360:1623-30. |
|27.||Beg MA, Siddique MKJ, Abbasi AS, Ahmad N. Atherosclerosis in Karachi . J Pak Med Assoc 1967;17:236-40 |
|28.||Khan N. Epidemiology of coronary heart disease in Peshawar. Pakistan Heart J 1973;6:64-9. |
[Table 1], [Table 2]