LMC journal Vol. 2.indd 89 Clinical profi le of pa ents with acute coronary syndrome in Lumbini Medical College and Teaching Hospital: A prospec ve study Che ri BK, Paudel MS, Dhungana SP and Shamsuddin Lumbini Medical College and Teaching Hospital (LMCTH), Palpa, Nepal Corresponding author: Dr. Bishal KC, Department of Internal Medicine, Lumbini Medical College and Teaching Hospital, Palpa, Nepal; e-mail: bishalk@gmail.com ABSTRACTS Background: The clinical profi le among pa ents with acute coronary syndromes (ACS) is not well studied in this western part of Nepal where Lumbini Medical College and Teaching Hospital (LMCTH) is situated. Cardiovascular disease is now the most common non communicable disease killing thousands of people worldwide. The trend of incidence is increasing in the developing countries including Nepal. Objec ve: To obtain the clinical profi le of pa ent presen ng with ACS in LMCTH. Material and Method: This is a prospec ve study carried out in LMCTH in the department of Internal Medicine April 14, 2013 to October 14, 2013. Pa ents were diagnosed to have ACS based on their clinical fi ndings, Electrocardiogram (ECG) and Troponin test. Those with non-cardiac chest pain were excluded. A detail history and all the data pertaining to the pa ent were noted analyzed in a systema c way. Results: A total of 40 pa ents with ACS presented during the study period in LMCTH. The mean age of presenta on was 67±18 years. Thirty out of those cons tute male (75%). Six pa ents (15%) died during the study period. Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with le sided chest pain, 4(10%) presented with acute shortness of breath. Four (10%) pa ent presented in the state of cardiogenic shock and 2 (5%) presented with the Ventricular tachycardia (VT) as their complica on. 6 (15%) had unstable angina (UA), 14 (35%) had Non ST eleva on Myocardial Infarc on (NSTEMI) and 20 (50%) had ST eleva on Myocardial Infarc on (STEMI). Of the total 20 (50%) pa ent who had STEMI, only four of them underwent thrombolysis. Anterior wall MI was the most common wall involved. Circadian varia on study showed peak incidence of acute coronary syndrome during the early morning hours. Mean dura on of symptoms before presenta on to the hospital facility was 4 days. Mean hospital stay was 5±2 days. Conclusion: Cardiovascular disease is common in this Western part of Nepal. STEMI was the commonest presenta on and the incidence was more among the male and the elderly pa ents. Keywords: Acute coronary syndrome, S T eleva on myocardial infarc on, Ventricular tachycardia INTRODUCTION Pa ents with ischemic heart disease (IHD) presents with two main spectrum, stable angina in which the pa ent has chronic coronary artery disease and those who with acute coronary syndrome consis ng of pa ents with ST eleva on Myocardial infarc on (STEMI), unstable angina (UA) and Non-ST-segment eleva on MI (NSTEMI).1 Due to the advances in medical sciences of various invasive and non-invasive therapeu c strategies the mortality related ACS has signifi cantly reduced in the developed world over the past 2 decades.2-7 The prevalence of coronary artery disease is related to various modifi able and non-modifi able risk factors such as gender, age and ethnicity. The cardiovascular disease has become a major health burden in developing countries which is on the verge of epidemic.8 PATIENTS AND METHODS The study was conducted prospec vely for six months in the department of Internal Medicine from April 14, 2013 to October 14, 2013. Those cases with proven non- cardiac chest pain were excluded from the study. The cases were grouped into those presented with STEMI and those presented with NSTEMI and UA. Cases of chest pain/ discomfort with eleva on of ST segment in ECG leads/ presumed new onset le bundle branch block in ECG were categorized as STEMI. Cases of angina at rest without ST segment eleva on were categorized as NSTEMI if their cardiac Troponin T (Trop I) was posi ve and as UA if their Trop I was nega ve. The baseline clinical characteris cs analyzed were the age, gender, hypertension (blood pressure > 140/90 mm Hg and/ or those already taking treatment for hypertension), diabetes mellitus (fas ng blood glucose >126 mg/dL and/or postprandial blood glucose >200 mg/dL and those who were on treatment for diabetes mellitus), dyslipidemia (cholesterol >190 mg/dL and/or triglycerides >200 mg/dL), smoking status, dura on of chest pain before hospitaliza on, me of occurrence of Original Article L M Coll J 2013; 1(2): 89-92 90 Journal of Lumbini Medical College the ACS, clinical course in the hospital, the mean dura on of hospital stay and complica ons related to the ACS and its treatment. In cases with STEMI, the details of the area of myocardium infarcted, the associated mechanical complica ons and conduc on abnormali es, further, a record was made whether thromboly c therapy was received or not. The cause of death was also studied. RESULTS A total of 40 pa ents with acute coronary syndrome (ACS) presented during the study period in LMCTH. The mean age of presenta on was 67±18 years. Thirty pa ents were males (75%). Six (15%) pa ents died during the study period. A comparison of the clinical characteris cs of the pa ents with ACS is shown in the table 1. Pa ents presented with various symptoms in the hospital. Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with le sided chest pain, 4(10%) presented with acute shortness of breath. Four (10%) pa ent presented in the state of cardiogenic shock and 2 (5%) presented with the Ventricular tachycardia (VT). The pa ent presented with cardiogenic shock and VT died. Table 1: The baseline characteris cs among males and females with ACS Variables Total n (%) 40 (100) Male n (%) 30 (75) Female n (%) 10 (25) P value Mean age 67.85 65.13 76 <0.001 Mean dura on before hospitaliza on 4days 4.44days 2.6 days <0.001 Symptoms before hospitaliza on <6hrs 7-12 hrs >24hrs 14 (35) 2 (5) 24 (60) 10 (33.33) 2 (6.66) 18 (60) 4 (40) 0 6 (60) <0.001 --- <0.001 Smoking history 26 (65) 20 (66.66) 6 (60) <0.001 Hypertension 22 (55) 14 (46.66) 8 (80) <0.001 Diabetes 8 (20) 8 (26.66) 0 ---- Thrombolysis 4 (10) 4 (13.33) 0 ---- Of the total 20 (50%) pa ent who had STEMI, only four of them underwent thrombolysis. Rest was not thrombolysed because of the late presenta on and the complica on they had which contraindicated thrombolysis. ACS was most common in anterior wall and inferior wall than any others wall (fi g 2). Eighteen pa ents (45%) had anterior wall involvement, 14(35%) had inferior wall, 6(15%) had extensive wall involvement. All six mortali es were from involvement of anterior wall. The me of onset of chest pain among pa ents with STEMI showing the circadian varia on of cardiac events is depicted in Figure 3. Mean dura on of symptoms before presenta on to the hospital facility was 4 days. Mean hospital stay was 5±2 days. Fig 1. Categories of pa ents with ACS Fig 2. Involved wall in pa ents with ACS Fig 3. Circadian varia on of cardiac events no ced among pa ents with ACS DISCUSSION Lumbini Medical College with its 700 bed teaching hospital has emerged as a ter ary referral center for the hospitals in Western Nepal and diff erent health facili es of peripheries. There are few data regarding the acute coronary syndrome from this part of Nepal. So this study was done to know the spectrum of acute coronary syndrome as they present in hospital and their clinical profi le. 91 BK Chettri et al Cardiovascular disease is on the rise in the developing country which has become a burden.8 Even in the developed countries, despite of eff orts of reducing the major risk factors like cigare e smoking and sedentary lifestyle, the cardiovascular disease remain the major cause of morbidity and mortality due to increase popula on of elderly popula on and absolute increases in obesity and diabetes.9 There has been rise in the incidence of coronary artery disease in the Asian popula on.10-12 Of the total 40 pa ents who were diagnosed with ACS by the clinical, ECG and laboratory parameters, 50% had STEMI, 35% had NSTEMI and, 15% had unstable angina. This study also showed a higher propor on of STEMI cases among pa ents with ACS as observed in the CREATE registry.13 The mean age of presenta on was 67±18 years. The mean age of pa ent presen ng with STEMI was 67±14 years, which is comparable to observa ons of CREATE registry13 and study done by Teoh M et al.14 Though we observed an in-hospital mortality rate of 15% that was much higher than the mortality rate observed among ACS cases in the CREATE registry (5.6%), it was comparable to the mortality rates among pa ents, not undergoing coronary interven ons, observed by other.15 Higher in-hospital mortality rate among our STEMI cases compared to the mortality rate observed among cases from the CREATE registry 13 (30% vs. 8.6%) may be related to the higher number of elderly pa ents in our study. There was a male preponderance was observed in this study was comparable to another series reported from North India,16 CREATE registry 13 and study done by Teoh M et al.15 Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with le sided chest pain, 4(10%) presented with acute shortness of breath. Study done by Patel et al17 also showed similar fi ndings of higher rate classic chest pain among the pa ent with ACS. Of the total 20 (50%) pa ent who had STEMI, only four of them underwent thrombolysis which was due to late presenta on in the hospital facility or due to the complica on. The mean dura on of symptoms before hospitaliza on was 4 days which is diff erent from the western18 and indian13, 19 studies which shows increasing trends towards the earlier presenta on. This is mainly due to the lack of educa on, lack of health awareness, remote loca ons and lack of transporta on system and inaccessible health facility. Circadian variation of incidence of acute coronary syndrome, with an early morning peaking of events, were observed in our study which is similar to western studies and in a recent study 20 reported from Singapore and from Indian studies recently conducted by Gopal et al.21 Signifi cantly higher numbers of pa ent with ACS in our study had risk factors like hypertension, diabetes and cigare e smoking as observed in other studies.18, 19 CONCLUSION Acute coronary syndrome is common in this Western part of the country. The main limita on of this study was the short dura on and the small sample size. Further larger prospec ve studies with large sample size are required to verify the fi ndings of this study. REFERENCE 1. Christopher P.C, Eugene B. Unstable Angina and Non-ST- Segment Eleva on Myocardial Infarc on. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL (editors). Harrison's Principle of Internal medicine 18th edi on. USA: McGraw-Hill Companies Inc; 2012.p.2015. 2. Fox KA. Management of acute coronary syndromes: an update. Heart 2004; 90: 698-706. 3. White HD, Barbash GI, Califf RM et al. Age and outcome with contemporary thromboly c therapy. Results from the GUSTO-I trial. Global U liza on of Streptokinase and TPA for Occluded coronary arteries trial. Circula on 1996; 94: 1826-33. 4. Fassa AA, Urban P, Radovanovic D et al. AMIS Plus Inves gators. Trends in reperfusion therapy of ST segment eleva on myocardial infarc on in Switzerland: six year results from a na onwide registry. Heart 2005; 91: 882-88. 5. Patel MR, Chen AY, Roe MT et al. A comparison of acute coronary syndrome care at academic and nonacademic hospitals. Am J Med 2007; 120: 40-6. 6. Watkins S, Thiemann D, Coresh J, Powe N, Folsom AR, Rosamond W. Fourteen-year (1987 to 2000) trends in the a ack rates of, therapy for, and mortality from non-ST- eleva on acute coronary syndromes in four United States communi es. Am J Cardiol 2005; 96: 1349-55. 7. de Winter RJ, Windhausen F, Cornel JH et al. Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Inves gators. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353: 1095-104. 8. Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circula on 1998; 97; 596-601. 9. Iqbal J, Keith A.A. Fox: Epidemiological trends in acute coronary syndromes: understanding the past to predict and improve the future. Arch Med Sci 2010; 6, 1A: S 3-S 14. 10. Mc Keigue P M, Miller G J, Marmot M G. Coronary heart disease in South Asians overseas: a review. J Clin Epidemiol 1989; 42(7): 597-609. 11. Cappuccio FP, Barbato A, Kerry SM. Hypertension, diabetes and cardiovascular risk in ethnic minori es in the UK. Br J Diabetes Vasc Dis 2003; 3286-93. 12. Patel KCR, Bhopal RS. The epidemic of coronary heart disease in South Asian populations: causes and consequences. Warley, UK: South Asian Health Founda on, 2004. 92 Journal of Lumbini Medical College 13. Xavier D, Pais P, Devereaux PJ et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet 2008; 371(9622): 1435-42. 14. Molly T, Susan L, Michael R, Richard GM, Simon D. Acute coronary syndromes and their presenta on in Asian and Caucasian pa ents in Britain. Heart 2007; 93(2): 183-8. 15. Monteiro P. Portuguese Registry on Acute Coronary Syndromes. Impact of early coronary artery bypass gra in an unselected acute coronary syndrome pa ent popula on. Circula on 2006; 114(1 Suppl): I467-72. 16. Holay MP, Janbandhu A, Javahirani A, Pandharipande MS, Suryawanshi SD. Clinical profi le of acute myocardial infarc on in elderly (prospec ve study). J Assoc Physicians India 2007; 55: 188-92. 17. P a t e l H , R o s e n g r e n A , E k m a n I . S y m p t o m s in acute coronary syndromes: does sex make a diff erence? Am Heart J. 2004; 148(1): 27-33. 18. Steg AG, Goldberg RJ, Gore JM et al. GRACE Inves gators. Baseline characteris cs, management prac ces and in- hospital outcomes of pa ents hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). Am J Cardiol 2002; 90: 358- 63. 19. Jose VJ, Gupta SN. Mortality and morbidity of acute ST segment eleva on myocardial infarc on in the current era. Indian Heart J 2004; 56: 210-14. 20. Bhalla A, Sachdev A, Lehl SS, Singh R, D’Cruz S. Ageing and circadian varia on in cardiovascular events. Singapore Med J 2006; 47(4): 305-8. 21. Gopal M, Boopathy N, Venkatesan R, Jagannathan V. Circadian varia on in acute coronary syndromes. Web med central CARDIOLOGY 2010;1(9):WMC00533