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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 106-110

Clinical profile of young Indian women presenting with acute coronary syndrome


1 Department of Cardiology, MS Ramaiah Medical College, Bengaluru, Karnataka, India
2 Department of Cardiology, MS Ramaiah Memorial Hospital, Bengaluru, Karnataka, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Dr. U M Nagamalesh
Department of Cardiology, MS Ramaiah Memorial Hospital, MSR Nagar, MSRIT Post, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCPC.JCPC_48_17

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  Abstract 

Introduction: Coronary artery disease is an important public health issue in India. Over the last few decades, several studies have led to an understanding of the disease with respect to Indian population. However, lacunae still exist in several aspects of this burning health issue. There is a lack of data on acute coronary syndrome (ACS) in the young Indian population. Our study targeted an important subgroup of Indian population which is the young Indian women. In this study, we present a brief overview of the clinical and laboratory characteristics of young Indian women who presented in our Institute with ACS. Methods: A total of 63 female patients aged ≤45 years with a diagnosis of ACS after satisfying inclusion-exclusion criteria were chosen for the study. Baseline demographics, laboratory investigations, electrocardiogram, echocardiographic assessment, and coronary angiogram with subsequent treatment approach and outcomes were recorded. Results: Dyslipidemia was the most common prevalent risk factors among the study patients, while diabetes and hypertension were other common risk factors noted. Among 63 patients admitted with ACS, 77% (n = 21) received primary percutaneous coronary intervention (PCI) and 11.1% (n = 7) received thrombolytic therapy. The average duration of hospital stay was 4 ± 1 day. Conclusion: It was observed that dyslipidemia was major risk factor for ACS among young Indian woman included in our study. Other risk factors included diabetes mellitus and hypertension. Chest pain (95.2%) was the most common complaint. In 76% cases, the coronary angiogram revealed single vessel disease with left anterior descending coronary artery being the culprit vessel in 69.8% cases. Majority of the participants had preserved left ventricular function at the time of discharge. Nearly 85% of our patients received PCI as the revascularization strategy of choice.

Keywords: Acute coronary syndrome, acute coronary syndrome in young women, myocardial infarction, percutaneous coronary intervention


How to cite this article:
Nagamalesh U M, Abhinay T, Naidu K C, Ambujam N, Hegde AV, Prakash V S. Clinical profile of young Indian women presenting with acute coronary syndrome. J Clin Prev Cardiol 2018;7:106-10

How to cite this URL:
Nagamalesh U M, Abhinay T, Naidu K C, Ambujam N, Hegde AV, Prakash V S. Clinical profile of young Indian women presenting with acute coronary syndrome. J Clin Prev Cardiol [serial online] 2018 [cited 2020 May 26];7:106-10. Available from: http://www.jcpconline.org/text.asp?2018/7/3/106/236332


  Introduction Top


Coronary heart disease is still a major public health problem in the modern world. Only a small percentage (<10%) is below the age of 45 years.[1],[2] The actual figure in real-world scenario seems largely underestimated with some autopsy series showing coronary atherosclerosis in nearly 50% individuals.[3] Young women have been considered low risk for coronary artery disease (CAD) till they attain menopause due to hormonal protection from estrogen. Atypical symptoms and low awareness of risk of CAD among young women could lead to missed diagnosis.

In developed countries, the actual prevalence of the disease, in men and women between the age group 35–44 years was found to be 0.5% and 0.18%, respectively whereas the prevalence of the disease over the age of 60 years was found to be 20.5% in men and 17.1% in women.[4]

No prospective national cohort registries in India have been published on CAD incidence among young women. CAD in total prevalence rates can be estimated from several studies over the past several decades in either rural or urban cohorts. Unadjusted rates of CAD have ranged from 1.6% to 7.4% in rural populations and 1%–13.2% in urban populations.[5] In 2000, CAD in India was estimated to be 29.8 million (3%) out of total population of 1.03 billion.[5] Indians are prone to be affected with a greater frequency and at a younger age when compared to its counterparts in developed and developing countries. Bahl et al. studied CAD in 9702 cases. Out of this, 2344 (24.2%) were women with 45 (1.9%) being in the age group 20–40 years.[6]

The prevalence of risk factors is on the rise in young adults and children. This will result in an increased disease burden in the near future. Smoking, which has been traditionally recognized as the most common risk factor for heart disease, has been shown to be increasingly prevalent in young adults and adolescents reaching up to 9%.

In UK, the smoking burden was found to be more among girls who also continued to stay as smokers for longer in their life.[7] Although myocardial infarction (MI), fortunately, is an uncommon entity in young adults aged <45 years, it constitutes an important problem for both the patient and the treating physician. It has a devastating effect on the more active lifestyle of young patients. These young patients also have a different risk factor profile, clinical presentation, and prognosis in comparison with older patients, which has to be taken into consideration when treating these young adults presenting with MI. The increased prevalence of risk factors for CAD may set up an alarming trend.


  Methods Top


We conducted a retrospective study at MS Ramaiah Hospital, Bengaluru, Karnataka, India, during the period 2012–2016 spanning duration of 50 months. Our initial search criteria included all the young women aged <45 years during the index hospitalization for acute coronary syndrome (ACS) including both ST elevation MI (STEMI) and non-ST elevated ACS (NSTE-ACS) which included both NSTEMI and unstable angina (UA). Then, among the initial chosen patient population, we defined the exclusion criteria which included all patients who attained menopause at the time of presentation irrespective of age, those who underwent hysterectomy whether or not they were on hormonal replacement therapy, and patients who either left the hospital or died before a complete evaluation could be performed. We also excluded patients with incomplete data or those who did not consent for the study. Out of the 67 patients initially identified, 4 patients were excluded due to insufficient data. A total of 63 patients were finally included in our study after meeting the inclusion-exclusion criteria.

Defining the key parameters for our study has been an important first step in our approach. We employed the standard guideline-based definitions that were widely agreed on at the time of onset of the study. We defined hypertension as those patients who were already diagnosed to be hypertensive and on antihypertensive medications and also included treatment naïve or newly diagnosed patients with blood pressure more than 140/90 mmHg as per JNC 7 guidelines.

We used the American Diabetes Association definition of diabetes mellitus and included patients who were already diagnosed as having diabetes mellitus and on treatment for diabetes mellitus. For those patients who were treatment naïve or newly diagnosed, we included HBA1C of ≥6.5% or FPG ≥126 mg/dL for diagnosis of diabetes mellitus.

As all our patients were cases of acute coronary syndrome we used low-density lipoprotein (LDL) (>130 mg/dL), total cholesterol (TC) (>200 mg/dL), and high-density lipoprotein (HDL) (<40 mg/dL) as cutoff values to consider dyslipidemia as defined in the NCEP/ATP 3 guidelines.

STEMI was defined according to ACCF/AHA guidelines as “new ST-segment elevation at the J-point in at least 2 contiguous leads ≥2 mm in men, ≥1.5 mm in women in leads V2 to V3, or ≥1 mm in other contiguous chest leads or the limb leads.”

As per the ACC/AHA guideline statement, the absence of ST elevation on ECG with positive symptoms of angina classified our patients as having NSTE-ACS. NSTE-ACS can be further subdivided on the basis of cardiac biomarkers. If cardiac biomarkers are elevated and the clinical context is appropriate, the patient is considered to have NSTEMI; otherwise, the patient is deemed to have UA.

Clinical profiles of all the patients were recorded, and they were subjected to the following investigations: complete blood count, renal function tests, serum electrolytes, fasting lipid profile, electrocardiogram, two dimensional (2D)-echocardiogram, and chest X-ray. Other investigations such as serum troponin and coronary angiogram were done as deemed necessary. All patients underwent treatment as per institutional protocol which included antiplatelets, statins, anticoagulants, thrombolytic agents, angiotensin-converting enzyme inhibitors, beta blockers, diuretics, revascularization, and other medications as deemed necessary according to individual patient scenario.

Statistical analysis

Data collected were tabulated and analyzed using SPSS software version 20.0 (Armonk, NY: IBM Corp). Variables were presented as mean or percentages in either tabular or graphical form.


  Results Top


Our study period started on January 2012 and concluded on December 31, 2016. During this period, a total of 2260 patients underwent percutaneous coronary intervention (PCI). Out of this, 66.2% (1497) patients underwent PCI for ACS which included both STEMI and NSTEMI/UA. About 42% (628) of patients who underwent PCI for ACS were females. In our study, we observed that 2.8% (63) patients of the total were female patients <45 years of age. This culminated to 10% of total female cohort that underwent PCI for ACS at our Institute.

Of the 63 patients included in the study, 21 (33.3%) participants belonged to 26–35 age group, and the remaining 42 (66.7%) were in the age group 36–45 [Table 1]. None of the participants included in this study group were younger than 25 years.
Table 1: Age group

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Dyslipidemia (69.8%, n = 44), diabetes mellitus (42.9%, n = 27), and hypertension (20.6%, n = 13) were the most common risk factors identified among our study participants. Family history of premature CAD (9.5%, n = 6), current smoking status (4.8%, n = 3), and chronic kidney disease (6.4%, n = 4) were other identified risk factors [Figure 1] and [Table 2].
Figure 1: Risk factors among young women

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Table 2: Risk factors among young women

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Dyslipidemia [Table 3] was the most prevalent risk factor in our cohort of patients accounting for 69% of all cases of ACS. Majority of them had elevated LDL 57.1% (n = 36) with mean of 134 mg/dL (range of 88-198 mg/dL). 28.6% (n = 18) had low HDL and 28.6% had elevated HDL/TC ratio.
Table 3: Lipid profile among young women

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Symptom analysis of the study population showed that chest pain (95.2%, n = 60) and dyspnea (20.6%, n = 13) were the two most common symptoms [Figure 2]. Syncope at admission was present in 6.4% (n = 4) of patients [Table 4]. None of the patients were asymptomatic at the time of presentation. There were no reported incidences of arrhythmias (i.e., ventricular tachycardia, ventricular fibrillation, or atrial tachyarrhythmia) in our study population.
Figure 2: Common presenting symptoms

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Table 4: Common presenting symptoms

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All patients admitted with ACS underwent coronary angiogram. Majority of the patients had single vessel disease 76.2% (n = 48), and only 12.7% (n = 8) of patients had either two or three vessel disease each. Coronary angiogram identified left anterior descending artery (LAD) as the most common culprit vessel in 69.8% (n = 44) followed by left circumflex artery in 33.3% (n = 21) and right coronary artery in 25.4% (n = 16) [Table 5]. None of the patients had the significant left main disease.
Table 5: Angiogram data

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Majority of our study patients received PCI as the preferred reperfusion strategy. Overall, PCI was offered to 81% (n = 51) of patients with ACS. Patients with recanalized vessel were admitted and observed for 5 days with medical management consisting of antiplatelet, statin, and anticoagulant. None of those five patients (7.9%) with recanalized vessel required any form of intervention for ACS. Intravenous thrombolysis was carried out in 11.1% (n = 7) participants and later continued on guideline-directed medical therapy due to insignificant CAD identified on coronary angiogram [Table 6]. We used tenecteplase as the preferred thrombolytic as per our institutional protocol. Those patients with triple vessel disease underwent culprit vessel PCI due to hemodynamically insignificant lesion in other vessels.
Table 6: Reperfusion strategy

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A 2D echocardiogram was conducted in all the patients both at baseline and at predischarge. Majority of the patients had preserved LV function 87.3% (n = 55) at discharge. Nearly 9.5% (n = 6) had mild LV dysfunction and 3.2% (n = 2) had moderate LV dysfunction but none of them had severe LV dysfunction at the time of discharge from hospital [Table 7].
Table 7: Predischarge left ventricular function

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  Discussion Top


Young women have been considered low risk for CAD till they attain menopause due to hormonal protection from estrogen. One of the studies from Singapore showed mean age of the patients at presentation was 43.9 ± 5.4 years, and there was no significant difference among the various ethnic groups.[8],[9] In our study group, mean age of the patients at presentation was 42.2 years. Demographically, all these patients belonged to older subset of reproductive age group. 66.7% (n = 42) belonged to 36–45-year-old group and 26–35 age group had 33.3% (n = 21). None of them belonged to below 25 years age group. This suggests that older subset among young women carry higher risk for CAD with traditional risk factors, especially those with dyslipidemia.

Xie et al. in their comparative study of three ethnic groups in Singapore reported that dyslipidemia was more common among the Indian ethnic group (81.8%) as compared to the Chinese (41.2%) or Malay population (50%).[8],[10] In this study, majority of young women had dyslipidemia 69.8% (44). Raised LDL (57.1%), increased TC (50.8%), and elevated triglycerides (47.6%) were the common patterns of dyslipidemia observed in our study cohorts, which are major causes of CAD. Smoking, which has been traditionally recognized as the most common risk factor for heart disease, has been shown to be increasingly prevalent in young adults and adolescents reaching up to 9% and among young women. Diabetes was next most common risk factor which constituted to 42.9% (n = 27) and hypertension was reported among 20.6% (n = 13). A study from Singapore showed very high incidence of diabetes 63.6% and hypertension 13% among Indians.[8] This incidence of diabetes among Indian ethnic group in Singapore is probably due to high socioeconomic status of Indians living in Singapore. In this study, 4.8% (n = 3) participants were smokers without other risk factors.

In the present study, chest pain was the most common presenting symptom reported in 95.2% (n = 60) of patients. 20.6% (n = 13) presented with dyspnea, and syncope was recorded among 6.3% (n = 4). All patients who presented with ACS underwent coronary angiogram, and among these, the majority had single vessel disease 76.2% (n = 48) with LAD lesion being the most common culprit vessel in 69.8% (n = 44) participants. Only 12% (n = 8) of patients had double- and triple-vessel disease, which is similar to study from Singapore where 90% of Indian women had single vessel disease.[8] There were no in-hospital mortality reported among our study participants reflecting improved management strategies involving reperfusion therapy and management of ACS.

Primary PCI was successfully carried out in 81% (n = 51) participants while 7.9% (n = 5) of patients had recanalized vessel without significant lesion who were further managed by guideline-directed medical therapy. In the remainder, 11.1% (n = 7) thrombolytic therapy was instituted followed by medical management due to insignificant CAD detected subsequently on coronary angiogram. Hence, there were significant numbers of patients with thrombotic pathology. We report no major adverse cardiovascular outcomes including CV death in our patient cohort postdischarge till 6 months follow-up.

Predischarge echocardiogram showed preserved LV function in 87% (n = 55) reflecting timely institution of treatment for ACS, thus avoiding significant myocardial damage. Proximity to the hospital of majority of our patients with shorter door to balloon time averaging 68 min could have been a major contributor toward better predischarge outcome. Only 9.5% (n = 6) of patients had mild LV dysfunction and 3.2% (n = 2) had moderate LV dysfunction. None of them had severe ventricular dysfunction.


  Conclusion Top


CAD has become an emerging modern pandemic among the Indian population with increasing recognition among the young Indian females. Dyslipidemia, diabetes mellitus, and hypertension have become the three important risk factors identified in our studyparticipants. Chronic kidney disease and current smoking status are also becoming the emergent risk factors. Family history of CAD is also becoming an important risk predictor among this group of patients. With most of them having one or more risk factors for CAD, these counteracted the hormonal protection present in this age group. Majority of them had single-vessel disease identified on coronary angiogram with LAD being the most common culprit vessel. Early institution of reperfusion strategy resulted in prompt recovery of majority of these patients with no reported mortality finally resulting in preserved LV function at discharge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
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Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J Med 1999;107:254-61.  Back to cited text no. 2
    
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Strong JP, Malcom GT, McMahan CA, Tracy RE, Newman WP 3rd, Herderick EE, et al. Prevalence and extent of atherosclerosis in adolescents and young adults: Implications for prevention from the pathobiological determinants of atherosclerosis in youth study. JAMA 1999;281:727-35.  Back to cited text no. 3
    
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Fox KA. Registries and surveys in acute coronary syndrome. Eur Heart J 2006;27:2260-2.  Back to cited text no. 4
    
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Gupta R, Misra A, Pais P, Rastogi P, Gupta VP. Correlation of regional cardiovascular disease mortality in India with lifestyle and nutritional factors. Int J Cardiol 2006;108:291-300.  Back to cited text no. 5
    
6.
Bahl VK, Prabhakaran D, Karthikeyan G. Coronary artery disease in Indians. Indian Heart J 2001;53:707-13.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
    
8.
Xie CB, Chan MY, Teo SG, Low AF, Tan HC, Lee CH, et al. Acute myocardial infarction in young Asian women: A comparative study on Chinese, Malay and Indian ethnic groups. Singapore Med J 2011;52:835-9.  Back to cited text no. 8
    
9.
Hoit BD, Gilpin EA, Henning H, Maisel AA, Dittrich H, Carlisle J, et al. Myocardial infarction in young patients: An analysis by age subsets. Circulation 1986;74:712-21.  Back to cited text no. 9
    
10.
Hong CY, Chia KS, Hughes K, Ling SL. Ethnic differences among Chinese, Malay and Indian patients with type 2 diabetes mellitus in Singapore. Singapore Med J 2004;45:154-60.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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