229J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 229–234 Original Clinico-Angiographic Profiles and In-Hospital Outcomes of non-ST Segment Elevation Myocardial Infarction in Kurdistan Region of Iraq Ameen M Mohammad1*, Haval A Issa2, Saad Y Saeed3 1Department of Internal Medicine, College of Medicine, Duhok University, Duhok, Iraq. 2Duhok Heart Center, Azadi Teaching Hospital, Duhok, Iraq. 3Department of Community Medicine, College of Medicine, University of Duhok, Iraq. *Correspondence to: Ameen M Mohammad (E-mail: doctoramb@yahoo.com ) (Submitted: 10 May 2022 – Revised version received: 24 May 2022 – Accepted: 21 June 2022 – Published online: 26 August 2022) Abstract Objectives: This work aimed to study the clinical, angiographic profiles and in-hospital outcomes of NSTEMI cases in Duhok, Iraq. Methods: This prospective study involved 283 patients with NSTEMI who were admitted to Azadi teaching hospital/Azadi heart center in Duhok, Kurdistan region of Iraq, between 2021 and 2022. The patient’s demographic variables, major cardiovascular risk factors (smoking, hypertension, diabetes mellitus, hyperlipidemia and family history of coronary artery disease), clinical presentation, past history of myocardial infarction/previous percutaneous coronary intervention (PCI) and drug history were collected. The GRACE risk score was calculated for each patient. Patients were followed up regarding the management strategies (whether conservative or invasive approach), and in-hospital complications and outcomes. Results: The mean GRACE score was 142 ± 26. 70% of cases underwent coronary angiography/angioplasty, with a mean time to the coronary intervention of 8 days. 17% of the sample had developed different cardiovascular complications, with heart failure being the most common. The mortality rate was 7.4%. Conclusion: The study demonstrated higher complications and mortality rates, especially among patients with higher GRACE scores, compared to rates found in most available studies, particularly in western countries. This finding could be secondary to a suboptimal coronary intervention for NSTEMI in terms of time to intervention and the proportion of patients who underwent it. Keywords: Non-ST elevated myocardial infarction, acute coronary syndrome, coronary intervention in NSTEMI ISSN 2413-0516 Introduction Acute myocardial infarction remains the leading cause of death worldwide, including in Iraq.1-3 However, despite the rate of ST-elevation myocardial infarction decreasing, the incidence of non-ST-elevation myocardial infarction (NSTEMI) is increasing.4 This is believed to be due to many reasons, including the ageing of the population with a greater prevalence of diabetes and chronic kidney disease; and exten- sive use of troponin assays with higher sensitivity for myocar- dial injury, which move the diagnosis from unstable angina to NSTEMI.5-7 The risk stratification for cases with NSTEMI can be obtained from several prognostic scores like the TIMI (Throm- bolysis in Myocardial Infarction) and GRACE (Global Reg- istry of Acute Coronary Events) scores.8,9 TIMI and GRACE scores can be determined from the patient’s clinical character- istics, electrocardiographic and laboratory investigations per- formed on admission. They are satisfactorily simple and practical for risk assessments over a wide range of patients with NSTE-ACS.10 The fundamental step in the management of patients with NSTEMI is the initial assessment of hemodynamic and elec- trical stability, and calculation of the patient’s overall risk to assist in treatment guidance.11-13 There are two management strategies in NSTEMI; either an early invasive strategy with coronary angiography/revascularization (either PCI/coronary artery bypass grafting (CABG) as needed) or a conservative approach with medical therapy initially.14,15 Regardless of which strategy is applied, both demand proper use of risk assessment and medications.16,17 Being the NSTEMI has not been studied well in our region and Iraq, we aimed in this reg- istry to look at the clinical, angiographic, management and in-hospital outcomes of NSTEMI patients in Duhok, Iraq. Methods In this prospective study, we enrolled cases of NSTEMI admitted at Azadi teaching hospital/Azadi heart center in Duhok, Kurdistan Region of Iraq, between 2021 and 2022. All recruited cases, both men and women, were followed up during the period of in-hospital stay. The following data of cases were collected: patient’s demographic variables, clinical presentations, major cardio- vascular risk factors (smoking, hypertension, diabetes mel- litus, hyperlipidemia and family history of coronary artery disease (CAD)), past history of myocardial infarction/pre- vious PCI and drug history. The GRACE risk score was calcu- lated for each patient. The patients were followed up during hospitalization with subsequent documentation of in-hospital major adverse cardiac events, namely heart failure, life-threat- ening arrhythmias, ischemic stroke and cardiac death. For patients who underwent coronary angiography, time to intervention was documented, and the results of cor- onary angiography/angioplasty were collected and classified according to lesion significance, the number of coronary vessels involved, and the recommended management pro- tocol; whether medical, PCI or CABG was addressed. Ethical Approval The study was approved by the research ethics committee of Kurdistan Higher Council of Medical Specialties. All patients enrolled in the study provided written informed consent. Statistical Analysis Collected data were entered into Microsoft Excel, and then transferred to SPSS version 26 for statistical analysis. mailto:doctoramb@yahoo.com 230 J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 229–234 Clinico-Angiographic Profiles and In-Hospital Outcomes of NSTEMI Original A.M. Mohammad et al. Frequency tables, range, mean and standard deviation (SD) were used to describe the data. Association between categor- ical data were analyzed by Chi-square test, while differences in means were analyzed by unpaired t-test. P values less than 0.05 were considered statistically significant. Results A total of 283 patients (191 males, 92 females) with a clinical diagnosis of NSTEMI were enrolled in the study with a mean age of 60.3 ± 12.8 years. Males were affected more than females. The common presenting symptom was ischemic chest pain. The cardiovascular risk factors were clustered, particularly hypertension and smoking. About 70% of cases were newly diagnosed with CAD. The mean GRACE score was 142 ± 26. 70% of patients underwent coronary angiography/angioplasty. 17% of the sample had developed different cardiovascular complications. The mor- tality rate was 7.4%, as shown in Table 1. The data from patients who underwent coronary inter- vention showed that (17.4%) had no significant coronary lesions. And the cases had undergone coronary angiography/ intervention within a mean of 8 days after admission. Many of them received stents (65.1%), as shown in Table 2. The comparison between conservative and intervention groups showed that the young cases underwent intervention significantly more than elderly (P < 0.001). Both genders received similar rates of intervention. The coronary intervention was done more frequently for cases with higher GRACE scores compared to cases with lower grace scores (P < 0.001). Generally, the incidence of cardiovas- cular complications and mortality rate were higher among the conservative group (P < 0.006 and P < 0.001), respectively, as shown in Table 3. The characteristics of patients in relation to GRACE scores revealed that the younger ages had lower GRACE scores than older ages (P < 0.001). Males made up the majority of the lower GRACE scores compared to the females (P < 0.001). Those cases presented with nonspecific presentations had higher GRACE scores. Almost all cardiovascular risk factors were significantly associated with higher rates of GRACE scores (P-values were significant for all except for hyperlipi- demia). Furthermore, those cases with a positive history of prior MI/PCI had higher GRACE scores than cases without such past history (P-values were significant). The higher the GRACE scores, the greater the cardiovascular complications and mortality rates (P values of <0.001 for each), as shown in Table 4. The characteristics of the intervention group based on GRACE scores demonstrated that extensive coronary lesions were significantly seen among GRACE scores of higher than 140 with a highly significant P-value <0.001. Regarding time to intervention and treatment modalities, there were no sig- nificant differences between the two groups of GRACE scores with (P values of 0.936 and 0.309) respectively, as shown in Table 5. Discussion The study was conducted to assess NSTEMI patient’s charac- teristics, management strategy, complications and in-hospital outcomes. The mean age of presentation was comparable to Table 1. Characteristics of all the patients Characteristics No. (283) % Age (years) 25–44 28 9.9 45–64 155 54.8 65–90 100 35.3 Range; Mean ± SD 25–90; 60.3 ± 12.8 Gender Male 191 67.5 Female 92 32.5 Main presentation Chest pain 220 77.7 Dyspnea 46 16.3 Other 17 6.0 Cardiovascular risk factors Hypertension 140 49.5 DM 110 38.9 Hyperlipidemia 56 19.8 Smoking 132 46.6 Family history 20 7.1 Past medical history Previous PCI 48 17.0 Previous MI 36 12.7 Drug history Aspirin 107 37.8 ACE/ARB 89 31.4 Statin 103 36.4 Beta-blocker 38 13.4 Others 50 17.7 GRACE score (range; Mean ± SD) 81–218; 142.2 ± 26.3 Management Conservative 88 31.1 Intervention 195 68.9 Complications Heart failure 23 8.1 Arrhythmias 8 2.8 Heart failure + arrhythmias 14 4.9 Heart failure + stroke 1 0.4 Arrhythmias + stroke 1 0.4 No complication 236 83.4 Survival Alive 262 92.6 Dead 21 7.4 Total 283 100.0 other studies from Iraq, including Mohammad et al.,17 but was younger compared with western countries’ age presentation of NSTEMI.18-20 The female percentage in our study was 32.5%, which was higher than Kinsara et al. from Saudi Arabia21 and was com- parable to Abdelmoneim et al. from Egypt.22 Regarding clin- ical presentation, chest pain was the predominant symptom. However, females tend to present more with dyspnea than males, and this was comparable to other Iraqi23 and Saudi Arabian trends.21 231J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 229–234 A.M. Mohammad et al. Original Clinico-Angiographic Profiles and In-Hospital Outcomes of NSTEMI Table 2. Characteristics of the intervention group Characteristics No. % Angiographic findings Single vessel 80 41.0 Double vessels 48 24.6 Triple vessels 33 16.9 No significant lesion 34 17.4 Time to intervention in days (range; Mean ± SD) 1–21; 8.3 ± 4.2 Treatment Stenting 127 65.1 CABG 30 15.4 Medical 38 19.5 Total 195 100.0 Table 3. Characteristics of the conservative group vs the intervention group Characteristics Management P-value*Conservative Intervention No. % No. % Age (years) 25–44 2 2.3 26 13.3 <0.00145–64 35 39.8 120 61.5 65–90 51 58.0 49 25.1 Gender Male 58 65.9 133 68.2 0.703 Female 30 34.1 62 31.8 Main presentation Chest pain 56 63.6 164 84.1 <0.001Dyspnea 26 29.5 20 10.3 Other 6 6.8 11 5.6 Hypertension 57 64.8 83 42.6 0.001 DM 35 39.8 75 38.5 0.834 Hyperlipidemia 20 22.7 36 18.5 0.404 Smoking 36 40.9 96 49.2 0.194 Family history 4 4.5 16 8.2 0.266 Previous PCI 15 17.0 33 16.9 0.980 Previous MI 11 12.5 25 12.8 0.940 Aspirin 34 38.6 73 37.4 0.847 ACE/ARB 35 39.8 54 27.7 0.043 Statin 33 37.5 70 35.9 0.795 Beta blocker 16 18.2 22 11.3 0.115 Others 17 19.3 33 16.9 0.625 Grace score <140 25 28.4 107 54.9 <0.001 ≥140 63 71.6 88 45.1 Complications Heart failure 5 5.7 18 9.2 0.006 Arrhythmias 4 4.5 4 2.1 Heart failure + arrhythmias 9 10.2 5 2.6 Stroke 2 2.3 0 0.0 No complication 68 77.3 168 86.2 Survival Alive 69 78.4 193 99.0 <0.001 Dead 19 21.6 2 1.0 Total 88 100.0 195 100.0 *Based on Chi-square test. Studying the cardiovascular risk factors for the cases, hypertension was the commonest risk factor, followed by smoking in the current study, this comes in agreement with Mohammad et al.,17 but in the Mrsic et al. study from Bosnia, smoking was the commonest risk factor followed by hyperten- sion.24 Generally, the traditional cardiovascular risk factors are clustering with the increasing incidence among Iraqi patients with CAD.25 The management strategy applied in the current study showed that about 70% of cases were managed by an invasive interventional approach, and 30% were managed conserva- tively. However, the medical guidelines recommend a routine invasive strategy for almost all patients with NSTEMI within a limited time to improve the composite ischemic outcomes.16,26 https://pubmed.ncbi.nlm.nih.gov/?term=Mrsic%20D%5BAuthor%5D 232 J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 229–234 Clinico-Angiographic Profiles and In-Hospital Outcomes of NSTEMI Original A.M. Mohammad et al. In terms of major adverse cardiovascular events and com- plications, we found that 17% of cases developed complica- tions during the hospital stay. The most common one was heart failure, followed by arrhythmias. Its rates were compa- rable to the study by Dakhil et al.27 and was higher than the study by Butt et al.28 Regarding NSTEMI mortality, the study demonstrated that the mortality rate was 7.4%. This rate was almost similar to a study by Hamid et al. from Iraq (7.7%),29 but was higher than the GRACE registry (5%)30 and Yusuf et al. (3.3%).31 In assessing the coronary lesions cases in the intervention group; 17.4% had no significant coronary lesions. This was higher than the rate mentioned in a study by Cortell et al. (13%),32 and lower than the rate revealed in Mohammad et al. study (22.4%).33 The mean time to intervention was 8 days in the study. It was much longer than the mean times to intervention in most other studies like Milasinovic et al. (Time to coronary angiography varied from 0.5 to 24 h in the early and from Table 4. Characteristics of all cases (n = 283), based on Grace score Characteristics Grace score P-value*<140 ≥140 No. % No. % Age (years) 25–44 28 21.2 0 0.0 <0.00145–64 98 74.2 57 37.7 65–90 6 4.5 94 62.3 Gender Male 106 80.3 85 56.3 <0.001 Female 26 19.7 66 43.7 Main presentation Chest pain 113 85.6 107 70.9 0.006Dyspnea 16 12.1 30 19.9 Other 3 2.3 14 9.3 Hypertension 48 36.4 92 60.9 <0.001 DM 35 26.5 75 49.7 <0.001 Hyperlipidemia 23 17.4 33 21.9 0.351 Smoking 73 55.3 59 39.1 0.006 Family history 16 12.1 4 2.6 0.002 Previous PCI 16 12.1 32 21.2 0.043 Previous MI 8 6.1 28 18.5 0.002 Aspirin 38 28.8 69 45.7 0.003 ACE/ARB 28 21.2 61 40.4 0.001 Statin 37 28.0 66 43.7 0.006 Beta blocker 16 12.1 22 14.6 0.547 Others 13 9.8 37 24.5 0.001 Complications Heart failure 2 1.5 21 13.9 <0.001 Arrhythmias 2 1.5 6 4.0 Heart failure + arrhythmias 2 1.5 12 7.9 Stroke 0 0.0 2 1.3 No complication 126 95.5 110 72.8 Survival Alive 131 99.2 131 86.8 <0.001 Dead 1 0.8 20 13.2 Total 132 100.0 151 100.0 *Based on Chi-square test. 20.5 to 86 h in the delayed group).34 This means that despite the rate of interventional approach for cases in our study, the time to intervention was significantly late and inconsistence with the recommended guidelines. In regards to treatment modalities for cases underwent intervention in this study, 65% were treated by PCI and stenting, which was higher than the percentage found in a study from United States by B. Case et al. (53%).35 Never- theless, the CABG rates were similar in both studies (15.4% vs 15.1%). In comparisons between conservative and intervention groups, the study showed that the younger age groups had a significantly higher rate of intervention than the elderly group (P < 0.001). This was comparable to Dakhil et al.27 Those with higher GRACE scores received more intervention than cases with lower GRACE scores (P < 0.001). This was comparable to other studies, including Martinez et al. in Spain.36 Almost all cardiovascular risk factors in this study were associated significantly with higher rates of GRACE scores https://pubmed.ncbi.nlm.nih.gov/?term=Dakhil%20ZA%5BAuthor%5D https://pubmed.ncbi.nlm.nih.gov/?term=Milasinovic+D&cauthor_id=25966439 https://pubmed.ncbi.nlm.nih.gov/?term=Dakhil%20ZA%5BAuthor%5D 233J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 229–234 A.M. Mohammad et al. Original Clinico-Angiographic Profiles and In-Hospital Outcomes of NSTEMI Table 5. Characteristics of the intervention group (n = 195), based on grace score Characteristics Grace score P-value<140 ≥140 No. % No. % Angiographic findings Single vessel 55 51.4 25 28.4 <0.001* Double vessels 18 16.8 30 34.1 Triple vessels 10 9.3 23 26.1 No significant lesion 24 22.4 10 11.4 Time to intervention in days (range; Mean ± SD) 1–20; 8.3 ± 4.7 1–21; 8.3 ± 3.4 0.936** Treatment Stenting 67 62.6 60 68.2 0.309*CABG 15 14.0 15 17.0 Medical 25 23.4 13 14.8 Total 107 100.0 88 100.0 *Based on Chi-square test. **Based on unpaired t-test. (P values were significant for all except for hyperlipidemia). This was in concordance with a study by Hall et al. in the UK, which showed that all cardiovascular risk factors were signifi- cantly correlated to higher GRACE scores (including hyper- lipidemia).37 Meanwhile, a study by Cakar et al. in Turkey showed a statistically significant relation between hyperten- sion (but not smoking/diabetes) and high GRACE scores.38 Patients with a past history of MI/PCI had higher GRACE scores (P-value was significant). This was comparable to Hall et al.37 On the other hand, the extensive coronary lesions were significantly associated with GRACE scores of higher than 140. Such finding was also seen by Butt et al. and Rahmani et al.28,39 The cardiovascular complications and death rates were also higher among GRACE scores of ≥ 140 with P values (<0.001 for each). These findings were almost similar to rates found by Dakhil et al.27 and Kumar et al.40 Conclusion The coronary intervention for NSTEMI cases was suboptimal in our area, both in the time to intervention and the percentage of cases undergoing intervention. This might explain the higher mortality and adverse outcomes in this study compared to available data. It is worthy to say that the guideline-directed immediate and early invasive strategy in indicated NSTEMI cases and the revision of the current local NSTEMI manage- ment protocol might improve the outcomes of the cases in our countries. Conflict of Interests Nothing to declare. Financial Support None. Acknowledgments We thank all the staff of Cath lab and cardiology department in Azadi heart center/Azadi teaching hospital for their cooper- ation in conducting this study.  References 1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. 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This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. https://doi.org/10.22317/jcms.v8i4.1249