|Year : 2021 | Volume
| Issue : 1 | Page : 40-45
A descriptive study of socioclinical characteristics of young patients presenting for coronary angiography at Goa Medical College
Manjunath Desai1, Michelle Viegas1, Shirish Borker2, Umesh Subhash Kamat3, Jagadish A Cacodcar3, Stanislaus Bosco Pinto1
1 Department of Cardiology, Goa Medical College, Bambolim, Goa, India
2 Department of CVTS, Goa Medical College, Bambolim, Goa, India
3 Department of Preventive and Social Medicine, Goa Medical College, Bambolim, Goa, India
|Date of Submission||25-Nov-2020|
|Date of Decision||23-Jan-2021|
|Date of Acceptance||23-Feb-2021|
|Date of Web Publication||30-Mar-2021|
Dr. Umesh Subhash Kamat
Department of Preventive and Social Medicine, Goa Medical College, Bambolim, Goa
Source of Support: None, Conflict of Interest: None
Background: The magnitude of risk factor clustering for coronary artery disease (CAD), as well as the CAD, is increasing in developing countries, especially in the young.
Objectives: The objective of this study was to study the sociodemographic, clinical, and angiographic profile of young patients (<45 years of age) presenting for coronary angiography at the Department of Cardiology, Goa Medical College, Bambolim.
Materials and Methods: Ninety-four patients aged <45 years were interviewed using a semi-structured questionnaire between August 2018 and February 2019. The data were presented as proportions and means, and an appropriate test of statistical significance was applied toward drawing statistically sound conclusions.
Results: There was a striking male preponderance with males contributing 97.9% of the patients. The proportion of patients with normal coronaries and single-, double-, and triple-vessel disease was, respectively, 21.3%, 56.8%, 18.9%, and 24.3%. Diabetes mellitus and use of tobacco were associated with CAD in a statistically significant manner (P < 0.05). Only around one-third of diabetics in the study group were subjected to fasting or random blood sugar estimation, and HbA1c was estimated in only 17%.
Conclusion: Public awareness of the early-onset CAD and its risk factors, proper laboratory workup of patients to identify clustering of risk factors, and further research to dwell in to the sex bias among the reported patients is required.
Keywords: Coronary angiography, coronary artery disease, young myocardial infarction
|How to cite this article:|
Desai M, Viegas M, Borker S, Kamat US, Cacodcar JA, Pinto SB. A descriptive study of socioclinical characteristics of young patients presenting for coronary angiography at Goa Medical College. Heart India 2021;9:40-5
|How to cite this URL:|
Desai M, Viegas M, Borker S, Kamat US, Cacodcar JA, Pinto SB. A descriptive study of socioclinical characteristics of young patients presenting for coronary angiography at Goa Medical College. Heart India [serial online] 2021 [cited 2021 Apr 17];9:40-5. Available from: https://www.heartindia.net/text.asp?2021/9/1/40/312493
| Introduction|| |
The incidence of coronary artery disease (CAD) worldwide is increasing at an exponential rate. Asians, by virtue of their genetic predisposition and newly accultured western lifestyle, are at an increased risk of CAD almost a decade earlier than their western counterparts. More than 50% of CAD deaths in India occur before the patient reaches the age of 50 years. Similarly, 25% of myocardial infarction (MI) in Indians occur before the age of 40 years. CAD in young has distinct psychological, social, economic consequences as it affects the economically productive age group, apart from the fact that most people in this age group are in the formative phase of their family cycle., Earlier incidence of CAD also adds to the existing prevalence pool and by virtue of its chronic nature, there is a considerable impact on its epidemiology.
Goa Medical College Hospital (GMCH) is the only state-sponsored tertiary medical center in the state of Goa (India) with the Department of Cardiology and Cardiovascular Thoracic Surgery commissioned in the year 2015. A system of maintaining sociodemographic and clinical information pertaining to the patients presenting for coronary angiography (CAG) was initiated in August 2018. This paper is based on the analysis of a subset data of young patients. The objective of this paper is to study the sociodemographic, clinical, and angiographic profile of young patients (<45 years of age) presenting for CAG at the Department of Cardiology, Goa Medical College, Bambolim.
| Materials and Methods|| |
This cross-sectional descriptive study was carried out among 978 consecutive patients who underwent CAG at the Department of Cardiology-GMCH during the period August 2018 to February 2019. The patients undergoing CAG as a preoperative workup for valve repair surgeries were excluded from the analysis. The study protocol was approved by the Institutional Ethics Committee of the GMCH, Bambolim, Goa. The patients were enrolled in the study following their written informed consent. Data collection was done by trained interns in face-to-face interview, using a semi-structured questionnaire, with the patients; as well as by going through their hospital records. A detail information pertaining to the sociodemographic parameters of the patient, diet, physical activity, medical history, regularity of follow-up, indication for CAG and its outcome along with the relevant clinical and laboratory measurements was collected.
Patients <45 years of age were categorized as young and included in the study. Obesity was defined as per the consensus statement for diagnosis of obesity, abdominal obesity, and metabolic syndrome for Asian Indian adults as body mass index (BMI) of >24.9 kg/m2 and overweight as BMI of 23–24.9 kg/m2. Diabetes was defined as having a history of diabetes diagnosed and/or treated with medication and/or diet or fasting blood glucose 126 mg/dl or greater. Hypertension was defined as having a history of hypertension diagnosed and/or treated with medication, diet, and/or exercise, blood pressure >140 mmHg systolic or 90 mmHg diastolic on at least two occasions. Hyperlipidemia was defined as a history of dyslipidemia diagnosed and/or treated by a physician or total cholesterol >200 mg/dl, low-density lipoprotein ≥130 mg/dl, or high-density lipoprotein <40 mg/dl. A current smoker was defined as a person smoking cigarettes within 1 month of the current admission. The patterns of occlusion on CAG were classified as clinically insignificant coronary occlusion (normal); single-vessel disease (SVD); double-vessel disease (DVD); and triple-vessel disease (TVD).
The data were entered in EpiData Entry Client and analyzed using International Business Machine Corporation's Statistical package for Social Sciences, version 22.0 for Windows, Armonk, NY: IBM Corp. Means and proportions were used to describe the quantitative and categorical variables, respectively. Statistical significance of the difference between the proportions and means was tested using, respectively, the Chi-square test and the independent sample t-test at 5% level of significance.
| Results|| |
Of the 978 patients who underwent CAG during the reference period, a total of 94 patients were below the age of 45 years, 9.81% of the study population; of which 92 were male, while only 2 were female as depicted in [Table 1]. CAD as diagnosed on CAG was detected in 766 patients, 74 of which (9.6%) belonged to the age group of <45 years. [Table 2] and [Table 3] present the background clinic-social characteristics of the study participants.
|Table 3: Background characteristics of the study population (quantitative variables)|
Click here to view
Records pertaining to HbA1c, FBSL, and RBSL were available only from 16 (17%), 32 (34%), and 28 (29.8%) cases, respectively. Similarly, lipid estimations were done in <14.9% of cases of young MI. Overall 21.3% (20 out of 94) of the young MI patients had normal coronaries. Out of the 74 patients with some coronary occlusion on CAG 42 (56.8%) had a SVD, 14 (18.9%) had a DVD, and 18 (24.3%) had a TVD. [Table 4] and [Table 5] present the association between CAD and few clinical variables. The factors significantly associated with CAD in our study included diabetes mellitus (P = 0.004) and sedentary lifestyle (P = 0.002). None of the patients with diabetes mellitus had normal coronaries on CAG, and none of the patients who engaged in daily physical activity of at least 30 min for at least 5 days in a week had a significant coronary blockade on CAG.
|Table 5: Association between coronary artery disease and some quantitative variables|
Click here to view
| Discussion|| |
CAD in young has been studied worldwide in age groups varying from 35 to 55 years., However, considering the fact that CAD in South East Asians presents almost a decade earlier than the rest of the world,, the cutoff of <45 years of age was considered to be appropriate for this study. CAD in individuals <40 years of age is known to represent 1%–3% of all the CAD globally. The age group of <40 years was found to account for 5% of the CAD in a tertiary medical college hospital in Imphal, India. In our study, 9.6% of the total CAD was found in the age group of <45 years. Studies elsewhere have quoted an equivalent estimate of 5%–10% for CAD in patients <45 years of age.,,, Thus, the study reinforces the higher vulnerability of the Asian-Indian population to CAD as reflected in the other studies in the UK, Trinidad, Singapore, and California. This higher preponderance and younger age at presentation of Asian-Indians is attributed to the typical Asian-Indian phenotype which is characterized by typical abdominal fat distribution and typical biochemical abnormalities including the insulin resistance, high triglycerides, high LDL, and low HDL.,,
Sex disparity in CAD in our study matches very well with other studies in India which have observed male preponderance ranging from 81.8% to 91.8%.,,,, Although most of these studies have considered age group of <40 years and also <30 years, the sex bias in favor of females does not go unnoticed and may be attributed to the protective role played by female sex hormones.
The pattern of CAD on angiography correlated well with other studies in India. For example, a study by Suresh et al. in South India found that 18.8% had normal coronaries, while 66.1%, 22.3%, and 11.6% had, respectively, SVD, DVD, and TVD. Similar findings were reported by Prakash et al. in a hospital-based study in a tertiary institute in Jamshedpur where 21.3% had normal coronaries and 55.5% had a SVD. In our study, all the patients who underwent CAG had either presented with an acute coronary event or were suspect CAD with a positive stress test or other comorbid CSD-risk conditions. Normal coronaries (clinically insignificant coronary occlusion) and SVD are known to be more common in young CAD patients compared to the older ones. This may result from Coronaries being blocked by a blood clot originating elsewhere, disorders of blood coagulation or coronary vasospasm induced by drugs like amphetamine and cocaine.
Diabetes mellitus, hypertension, dyslipidemia, sedentary lifestyle, use of tobacco, and obesity are known to be conventional risk factors for CAD.,,, Diabetes, apart from being an independent risk factor for CAD, represents conglomeration of other conventional risk factors such as hypertension, dyslipidemia, and obesity which predispose to CAD. A prothrombotic, procoagulant state resulting from excessive expression of glycoprotein II (b)/III (a), increased plasminogen activator inhibitor I, and reduced levels of protein c and antithrombin III account for this positive association between DM and CAD., Association between DM and CAD was further reinforced by an observation that those with CAD had a higher mean Hba1c, and fasting and random blood sugar level compared to those with normal coronaries. Favorable cardiovascular outcomes among better-controlled diabetics have been sufficiently emphasized in the medical literature. It is, however, a noteworthy observation that despite a vast body of knowledge regarding conventional CVD risk factors, routine laboratory workup of this high-risk CVD group was highly unsatisfactory [Table 5] with only 34%, 30.4%, and 17% tested, respectively, for fasting blood sugar, random blood sugar, and glycosylated hemoglobin and 10%–15% tested for lipid abnormalities. Considering chronic and progressive nature of these disorders, ignorance toward this aspect of laboratory workup is nothing less than a missed opportunity for an effective preventive strategy for recurrence of acute ischemic episodes. One reason that could deter a cardiologist from routinely investigating for lipid abnormalities is that irrespective of the lipid parameters, every patient who undergoes a remedial coronary intervention procedure is started on high-dose statin. However, this argument would not hold good for diabetes mellitus and its control.
Regular physical activity is known to delay atherosclerosis and has a positive impact on the prevention of CAD. However, a word of caution is also expressed in young patients with congenital cardiovascular anomalies such as hypertrophic cardiomyopathy, coronary artery anomalies, aortic stenosis, aortic dissection, arrhythmogenic left ventricle, and so many others which could potentiate an acute catastrophic cardiac event.
| Conclusion|| |
The paper provides an insight in to some of the factors associated with clinically significant CAD as diagnosed by CAG. Diabetes and physical inactivity were significantly associated with CAD. While CAD was more common in hypertensives, dyslipidemics, and alcoholics, sample size curtailed statistical significance of the association, though this does not undermine their clinical relevance. Poor laboratory workup of the patients implies the anatomically oriented short-term correction of coronary occlusion. The focus should, additionally, be on addressing the underlying metabolic abnormality to ensure a better long-term prognosis. Therefore, routine workup of the patients presenting for CAG for all the conventional CAD risk factors is of paramount importance.
The study suffers disadvantages of a small sample size and hospital-based data collection with selection bias in patients, thereby refraining the authors from making general comments on the epidemiology of CAD, and reserving the interpretation to the study population only.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The study was carried out as per the protocol approved by the Institutional Ethics Committee, Goa Medical College-Bambolim.
Dr. Manjunath Desai with Dr. Shirish Borker and Dr. Umesh Kamat conceptualized the study and made the study proposal, including the study instrument. Dr. Umesh Kamat and Dr. Jagadish analysed the data. Dr. Michelle Viegas, Dr. Stanislaus Pinto drafted the manuscript which was reviewed and revised by all the other authors.
| References|| |
Ebasone PV, Dzudie A, Ambassa JC, Hamadou B, Mfekeu LK, Yeika E. Risk factor profile in patients who underwent coronary angiography at the Shisong Cardiac Centre, Cameroon. J Xiangya Med 2019;4:27.
Suresh G, Subramanyam K, Kudva S, Saya RP. Coronary artery disease in young adults: Angiographic study – A single centre experience. Heart India 2016;4:132-5. [Full text]
Murray CJ, Lopez AD. Global and regional cause-of-death patterns in 1990. Bull World Health Organ 1994;72:447-80.
Enas EA, Senthilkumar A, Juturu V, Gupta R. Coronary artery disease in women. Indian Heart J 2001;53:282-92.
Kumbhalkar SD, Bisne VV. Clinical and angiographic profile of young patients with ischemic heart disease: A central India study. J clin Prev Caridol 2019;8:6-12.
Christus T, Shukkur AM, Rashdan I, Koshy T, Alanbaei M, Zubaid M, et al
. Coronary artery disease in patients aged 35 or less – A different beast? Heart Views 2011;12:7-11.
] [Full text]
Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al
. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009;57:163-70.
Aggarwal A, Srivastava S, Velmurugan M. Newer perspectives of coronary artery disease in young. World J Cardiol 2016;8:728-34.
Sharma M, Ganguly NK. Premature coronary artery disease in Indians and its associated risk factors. Vasc Health Risk Manag 2005;1:217-25.
Ardeshna DR, Bob-Manuel T, Nanda A, Sharma A, Skelton WP, Skelton M, et al
. Asian-Indians: A review of coronary artery disease in this understudied cohort in the United States. Ann Transl Med 2018;6:12.
Klein LW, Nathan S. Coronary artery disease in young adults. J Am Coll Cardiol 2003;41:529-31.
Narayanaswamy G, Kshetrimayum S, Sharma HD, Devi KB, Manpang NN, Chongtham DS. Profile of patients undergoing coronary angiography at tertiary care center in Northeast India. J Med Soc 2019;33:28-32. [Full text]
Egred M, Viswanathan G, Davis GK. Myocardial infarction in young adults. Postgrad Med J 2005;81:741-5.
Mohammad AM, Jehangeer HI, Shaikhow SK. Prevalence and risk factors of premature coronary artery disease in patients undergoing coronary angiography in Kurdistan, Iraq. BMC Cardiovasc Disord 2015;15:155.
Balarajan R. Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales. BMJ 1991;302:560-4.
Miller GJ, Beckles GL, Maude GH, Carson DC, Alexis SD, Price SG, et al
. Ethnicity and other characteristics predictive of coronary heart disease in a developing community: Principal results of the St James Survey, Trinidad. Int J Epidemiol 1989;18:808-17.
Lee J, Heng D, Chia KS, Chew SK, Tan BY, Hughes K. Risk factors and incident coronary heart disease in Chinese, Malay and Asian Indian males: The Singapore Cardiovascular Cohort Study. Int J Epidemiol 2001;30:983-8.
Enas E, Senthilkumar A. Coronary Artery Disease In Asian Indians: An Update And Review. The Internet Journal of Cardiology, 2001; 1(2). Accessed on https://ispub.com/IJC/1/2/4493
Patel SA, Shivashankar R, Ali MK, Anjana RM, Deepa M, Kapoor D, et al
. Is the “South Asian Phenotype” Unique to South Asians?: Comparing cardiometabolic risk factors in the CARRS and NHANES studies. Glob Heart 2016;11:89-96.
Enas EA, Mohan V, Deepa M, Farooq S, Pazhoor S, Chennikkara H. The metabolic syndrome and dyslipidemia among Asian Indians: A population with high rates of diabetes and premature coronary artery disease. J Cardiometab Syndr 2007;2:267-75.
Unnikrishnan R, Anjana RM, Mohan V. Diabetes in South Asians: Is the phenotype different? Diabetes 2014;63:53-5.
Prakash B, Jaiswal A, Shah MM. Demographic & angiographic profile of young patients aged 40 year & less undergoing coronary angiography in a tier II city of Eastern India. J Family Med Prim Care 2020;9:5183-7. [Full text]
Gopalakrishnan A, Sivadasanpillai H, Ganapathi S, Nair KK, Sivasubramonian S, Valaparambil A. Clinical profile & long-term natural history of symptomatic coronary artery disease in young patients (<30 yr). Indian J Med Res 2020;152:263-72.
] [Full text]
Zimmerman FH, Cameron A, Fisher LD, Ng G. Myocardial infarction in young adults: Angiographic characterization, risk factors and prognosis (Coronary Artery Surgery Study Registry). J Am Coll Cardiol 1995;26:654-61.
Noeman A, Ahmad N, Azhar M. Coronary artery disease in young: Faulty life style or heredofamilial or both. Ann King Edwards Coll 2007;13:162-4.
Leon BM, Maddox TM. Diabetes and cardiovascular disease: Epidemiology, biological mechanisms, treatment recommendations and future research. World J Diabetes 2015;6:1246-58.
Morgan KP, Kapur A, Beatt KJ. Anatomy of coronary disease in diabetic patients: An explanation for poorer outcomes after percutaneous coronary intervention and potential target for intervention. Heart 2004;90:732-8.
Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Mark Estes NA, et al
. Exercise and acute cardiovascular events placing the risks into perspective – A scientific statement from the American Heart Association, Council on Nutrition, physical activity, and metabolism and the council on clinical cardiology in collaboration with the American College of Sports Medicine. Circulation 2007;115:2358-68.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]