|Year : 2019 | Volume
| Issue : 1 | Page : 28-32
Profile of patients undergoing coronary angiography at tertiary care center in Northeast India
Gopinath Narayanaswamy, Silpa Kshetrimayum, Hidangmayum Dwijaraj Sharma, Konsam Biona Devi, Nang Neeta Manpang, Dhanaraj Singh Chongtham
Department of General Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||14-Oct-2019|
Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Background: Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Increased age, male sex, diabetes-mellitus, hypertension, smoking, and dyslipidemia are important risk factors of CAD. Diagnostic coronary angiography (CAG) and subsequent angioplasty is the mainstay of management in CAD.
Objectives: The objective of the study is (1) To study the clinical and echocardiographic profile among patients undergoing CAG. (2) To analyze the angiographic findings with respect to CAD risk factors.
Methods: A observational cross-sectional study of 100 patients who underwent CAG at Tertiary Care Teaching Hospital, Imphal, from October 2015 to September 2017 were studied. Detailed history and echocardiographic findings were obtained. Angiographic findings were studied with respect to various risk factors. Data were analyzed using SPSS (version 21) and Chi-square test.
Results: Single vessel disease was the most common angiographic abnormality (71%). Left anterior descending artery was the most common artery involved, followed by the right coronary artery and left circumflex artery, respectively. Elderly patients (>60 years) and males had more severe form of CAD. Triple vessel disease (TVD) was more common in diabetic patients than nondiabetics (16.7% >5.7%, P = 0.153). Hypertensives had less severe disease when compared to nonhypertensives. Smoking had no effect on the severity of disease. All patients with TVD had regional wall motion abnormality, and severe systolic dysfunction was present in 33.3% of them.
Conclusions: Increased age, male sex, and patients with diabetes mellitus were predisposed to develop more severe CAD. Smoking, hypertension, and dyslipidemia had no effect on severity or pattern of artery involvement.
Keywords: Coronary angiography, double vessel disease, echocardiography, single vessel disease, triple vessel disease
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2019 [cited 2020 Jan 19];33:28-32. Available from: http://www.jmedsoc.org/text.asp?2019/33/1/28/269101
| Introduction|| |
Coronary angiography (CAG) is defined as the radiographic visualization of the coronary vessels after injection of radiopaque contrast media. The purpose of CAG is to define the coronary anatomy and the degree of luminal obstruction of coronary arteries. It is most commonly used to determine the presence and extent of obstructive coronary artery disease (CAD) and to assess the feasibility and appropriateness of various forms of therapy such as revascularization by percutaneous or surgical interventions.
CAD is one of the leading causes of mortality and morbidity. Various studies conducted worldwide have shown the universal association of CAD and its traditional risk factors such as age, male sex, diabetes mellitus, hypertension, dyslipidemia, and smoking. However, the effect of these risk factors on the severity of CAD, as assessed by angiography in terms of number of vessels involved and extent of artery lumen occlusion is yet to be identified. Even though some studies, have shed some light on the above discussion, further studies are required for effective prevention and management of CAD.
To the best of our knowledge, there is no available data of the patients undergoing CAG in Northeast India. This study was conducted to study the clinical, echocardiographic and angiographic profile of patients undergoing CAG at Tertiary Care Teaching Hospital, Imphal, and also to compare the findings among patients with and without CAD risk factors.
| Methods|| |
The present study was conducted in 100 patients, who underwent CAG at tertiary care teaching hospital, Department of Medicine, Imphal, over a period of 24 months from October 2015 to September 2017. Patients with indications for CAG according to ACC/AHA 1999 guidelines were included in the study.
Patients were explained about the procedure and purpose of the study. Written informed consent was taken from all the subjects. Clinical history, physical examination, and biochemical profile of subjects were recorded.
Transthoracic echocardiography was done for all patients with the help of two dimensional, M-mode and pulsed wave Doppler using SONACE X8 machine to document left ventricular (LV) ejection fraction (EF) percentage and regional wall motion abnormalities (RWMAs). The LV systolic dysfunction was graded as mild (EF - 35%–55%) and severe (EF - <35%). Angiography was done at hospital CATH laboratory using PHILIPS ALLURA XPER FD10 equipment. Angiographic findings were documented as vessels affected, severity of occlusion, and number and type of lesions present. Accordingly, patients were divided into the following groups: normal study, single vessel disease (SVD), double vessel disease (DVD), triple vessel disease (TVD), and left main stem disease (LMSD). The severity of lesion occlusion was classified as follows: Grade (1): <50% of occlusion, Grade (2): 51%–75%, Grade (3): 76%–99%, and Grade (4): Total occlusion. These findings were analyzed in relation to the presence or absence of CAD risk factors.
The data obtained from the study were analyzed using descriptive statistics (means, proportions, percentages, and standard deviations) and Chi-square test. IBM SPSS Statistics for Windows, Version 21.0. (IBM Corp., Armonk, NY). was used to analyze the data. P <0.05 was considered statistically significant. Prior permission was taken from the Research Ethics Board.
| Results|| |
CAG was done in CATH laboratory for 100 patients in the study period. In our study, 85% were males and 15% females. The mean age of presentation was 58.58 ± 10.69 years (males – 58.48 ± 7.59 and females – 59.13 ± 11.18). About 53% of subjects belonged to 41–60 years age group, while 5% were below 40 years and remaining 42% were above 60 years of age. Among them, 71% were diagnosed as SVD, 20% as DVD and 9% as TVD. In the middle age group, patients (40–60 years) 74% had SVD, 22.22% had DVD, and 3.7% had TVD. Whereas in elderly (>60 years) 64.28% had SVD, 19.06% had DVD, and 16.66% had TVD as shown in [Table 1].
|Table 1: The distribution of coronary artery disease patients according to angiographic diagnosis among different age groups|
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The most common clinical presentation was typical angina, seen in 73% of patients, while 19% complained of atypical angina and only 8% of patients had other angina equivalent symptoms.
About 71% of the patients had Grade 3 severity of occlusive lesions, and 10% were found to have total occlusion as shown in [Table 2].
In SVD patients, left anterior descending artery (LAD) was the most common artery to be involved, seen in 44 (62%) patients, followed by right coronary artery (RCA) in 23 (32%) and left circumflex artery (LCX) in 4 (6%). Tubular was the most common type of lesion, encountered in 30 (42.25%) patients, diffuse in 22 (31%), discrete in 7 (9.85%), plaque in 2 (2.81%), thrombosis in 4 (5.63%), cutoff in 3 (4.22%), and sluggish flow in 3 (4.22%) of the patients.
As shown in [Table 3], the incidence of SVD and DVD was high in females when compared to males (SVD: 73.3% >70.6%, DVD: 26.7% >18.8% respectively), but TVD was more common in males compared to females (10.6% >0%). Assessing severity of occlusion of lesions, males had a higher incidence of Grade 3 and total occlusive lesions when compared to females (Grade 3: 71.8% >66.7%, total occlusion: 10.6% >6.7% respectively). However, these findings were not statistically significant (P = 0.369).
|Table 3: Distribution of artery involvement and severity of occlusion among male and female patients|
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Thirty (30%) patients were diabetics, 34 (34%) were hypertensive and only 8 (8%) had dyslipidemia. Smoking history was obtained from 32% of patients. Smoking history was common among males (36.5%) when compared to females (6.7%) and was statistically significant (P = 0.023).
[Table 4] compares the angiographic findings among patients with and without diabetes. DVD incidence was higher in nondiabetic patients, whereas that of TVD (16.7% >5.7%) was higher in the diabetic group. Neither finding was statistically significant (P = 0.153). Grade 3 severity of occlusive lesions was found in 83.3% of diabetics and 65.7% of nondiabetics, but total occluding lesion was present more in nondiabetics when compared to diabetics (11.4% >6.7% respectively) but it was statistically not significant (P = 0.259).
[Table 5] compares the angiographic findings among hypertensive and nonhypertensive patients. Incidence of SVD and DVD were comparable in both groups (73% >69.7% and 20.6% >19.7%, respectively). The incidence of TVD was more in nonhypertensive patients (10.6% >5.9%), but was statistically not significant (P = 0.737). Nonhypertensives had comparatively more severe number of lesions when compared to hypertensive group (Grade 3: 75.8% >61.8%, total occlusion: 10.6% >8.8%, respectively), but was statistically not significant (P = 0.077).
[Table 6] compares the angiographic findings among smokers and nonsmokers. Incidences of SVD, DVD, and TVD were comparable in the two groups. Grade 3 lesion was seen more frequently in smokers when compared to nonsmokers, and total occlusion lesion was more common in nonsmokers, but it was statistically not significant (P = 0.069).
[Table 7] shows echocardiography findings. About 59% of them had normal systolic function, 33% had mild, and 8% had severe systolic dysfunction. RWMA was seen in 37% of the patients. Among TVD patients, 33.3% (n = 3) of patients had severe LV systolic dysfunction and was statistically significant (P = 0.000). Whereas, among DVD and SVD only 20% (n = 4) and 1.4% (n = 1) respectively had severe LV systolic dysfunction. RWMA was seen in all patients of TVD, but only 22.5% (n = 16) of SVD and 60% (n = 12) of DVD patients had RWMA.
|Table 7: Echocardiographic findings among patients who underwent angiography|
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| Discussion|| |
In the present study, the prevalence of traditional CAD risk factors was 34% – hypertension, 30% – diabetes mellitus and 8% – dyslipidemia. Smoking history was provided by 32% (31 males and 1 female) of the population. Similar findings were noted in studies conducted by Larifla et al. and Nadeem et al. who examined the traditional risk factors of patients with established CAD. In our study, the population from Northeast India, hypertension and diabetes was more prevalent when compared to dyslipidemia which may be because of different dietary habits and lifestyle.
Typical angina was the most common clinical presentation. Our findings suggest that at least one-quarter of CAD patients present with symptoms other than typical angina, urging clinicians to have a strong clinical suspicion of CAD among patients presenting otherwise.
SVD was the most common abnormality in our study (71% of patients). The incidence of DVD was 20% and TVD was 9%. Considering the severity of lumen occlusion majority (71% of patients) had Grade 3 lesions and 10% had total occlusive lesions. However, in studies conducted by Larifla et al. and Shah et al., incidence of DVD and TVD, i.e. more severe form of disease was more when compared to our study. Lower incidence of DVD and TVD in our study, can be explained by regional differences in terms of lifestyle, physical activity, and dietary habits of Northeast India, which might be protective in the development of severe form of CAD.
The incidence of TVD, severe form of CAD is more in patients above 60 years when compared to 40–60 years of group patients (16.66% >3.7%), but DVD incidence was comparable between the two groups. Similar results were also published in a study by Veeranna et al., that patients with obstructive CAD were likely to be older when compared with patients of nonobstructive CAD. Above results show that elderly age is a nonmodifiable risk factor for developing more severe form of CAD.
The incidence of TVD was higher in males than in females (10% >0%). However, the incidence of SVD and DVD were comparable between both sexes. Signifying the fact that male sex predisposes to more severe form of CAD. Similar results were seen in the study conducted by Larifla et al., which showed male sex had more frequent multivessel involvement (71.6% >63.1%). Another study by Veeranna et al., showed that male sex was an independent predictor of obstructive CAD (>70% stenosis in at least one coronary artery territory). In our study, even though male sex predisposed to TVD, extent of vessel occlusion (Grade 3 and total occlusion) was more among females.
The incidence of TVD was more among diabetics than nondiabetics (16.7% >5.7% respectively). However, incidence of SVD was comparable between the two groups. Grade 3 occlusive lesions were more prevalent in diabetics (83.3%) when compared to nondiabetics (65.7%). However, total occluding lesions were common in latter group (11.4%) than in former group (6.7%). Patients with diabetes have a high risk of developing TVD and Grade 3 occlusive lesions, which indicates severe form of CAD. Diabetics have a predisposition to develop discrete type of lesions. A study conducted by Zand Parsa et al. also showed similar results, as above in which multivessel involvement was more in diabetics than in nondiabetics (89.1% >61%). Another study conducted by Larifla et al., showed that compared to nondiabetic patients, diabetics had more frequent multivessel disease and high burden of lesions.
The incidence of TVD was almost twice in nonhypertensive group than in hypertensive group (10.6% >5.9%). Grade 3 occlusive and total occlusive lesions were more frequent in nonhypertensive group than in hypertensive group. In our study, hypertension history did not have much effect on the severity of angiographic findings and was a negative predictor of developing severe CAD. Similarly, Larifla et al., study showed that hypertension was not associated with angiographic severity in CAD patients. The prevalence of hypertension among patients with or without multivessel disease was comparable (76.1% >75.6%) and not statistically significant. Contradicting our findings, Parsa et al. found that the incidence of multivessel disease was slightly higher in hypertensive patients than nonhypertensives (74.4% >64%), but was statistically not significant. Further studies with more sample size are required in Northeast India, to assess effect of hypertension on angiographic profile.
In our study, incidence of SVD, DVD, and TVD did not very much, when compared between smokers and nonsmokers. Grade 3 lesions were more in smokers (87.5% >63.2%), but total occlusive lesions were more in nonsmokers (13.2% >3.1%). Similar findings were observed in a study conducted by Zand Parsa et al., incidence of multivessel disease was more in nonsmokers than in smokers (69.1% >63.5%), but it was statistically not significant. Larifla et al. showed that smoking was not associated with angiographic severity in CAD patients. However, in a study conducted by Veeranna et al. smoking was found to be a predictor of CAD. Above observations suggest that, even though smoking is an important modifiable risk factor of CAD, it is not associated with the severity of the disease. The prevalence of dyslipidemia among our study population was only 8%. Significant differences in angiographic findings among patients with and without dyslipidemia were not found.
Echocardiography was done for all patients who underwent angiography. About 33% of patients had mild systolic dysfunction and 8% had severe systolic dysfunction. 37% of patients had significant RWMA. The incidence of severe LV dysfunction among TVD patients (33.3%) was significantly higher when compared to DVD (20%) and SVD (1.4%). All patients of TVD had RWMA, whereas it was present in 60% of DVD and 22.5% of SVD patients. Severe LV systolic dysfunction and RWMA were more evident among patients of TVD; therefore, the assessment of severity in CAD patients by angiography and echocardiography are comparable.
| Conclusions|| |
Diabetes, hypertension, and smoking were the most prevalent modifiable risk factors, present in about one-third of the study population. SVD was the most common angiographic abnormality, which was followed by double and TVD. LAD was the most common culprit vessel in the majority of patients, followed by RCA and LCX. Echocardiographic and angiographic findings were comparable in assessing the severity of CAD.
Comparative analysis of our study showed elderly age, male sex, and diabetes mellitus patients were predisposed to develop more severe CAD assessed in terms of number of vessels involved and extent of lumen occlusion. Whereas smoking, hypertension, and dyslipidemia did not have much effect on severity or pattern of artery involvement in the same study population.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]