Patients with acute coronary syndrome with special reference to diabetes

mellitus
DR. AMRENDRA KUMAR SINGH1
DR. RAVI VISHNU PRASAD 2
INTRODUCTION
Ischemic heart disease (IHD) is a condition in which there is a inadequate supply of blood and oxygen
to a portion of the myocardium; it typically occurs when there is an imbalance between myocardial
oxygen supply and demand. Patients with ischemic heart disease (IHD) who most commonly present
with stable angina and with acute coronary syndrome1.
Acute coronary syndrome which further separated into:-
 Acute myocardial infarctionwith ST segment elevation
 Acute myocardial infarction without ST segment elevation (NSTEMI)
 Unstable angina2.
Coronary artery disease (CAD) is the leading cause of death worldwide currently and together with
diabetes, it poses a serious health threat, particularly in Indian population
Risk factor includes abnormal cholesterols with elevated level of LDL- cholesterol and reduced level
of HDL-cholesterol, hypertension, cigarette smoking, Diabetes mellitus, male gender, post-
menopausal
. .
1. M.B.B.S, M.D. (MEDICINE), Senior Resident Department of Cardiology, I.G.I.M.S. - Patna
2. M.D. , DM (CARDIOLOGY), Associate Professor Department of Cardiology, I.G.I.M.S. - Patna

state, advanced age, sedentary life style, obesity and a positive family history of premature
cardiovascular disease.
Diabetes mellitus is one of the major risk factor for acute coronary syndrome. Population with DM2
have a 2-3 times increase risk of cardiovascular disease than nondiabetics, and about 70% die from
macro vascular complications, especially ischemic heart disease and cerebrovascular disease.
Approximately 20% of DM2 sufferers have vascular complications at the time of diagnosis.
AIMS AND OBJECTIVES
To interrogate and to assess the patients presented with acute coronary syndrome, for the presence
of conventional risk factors with special eye on diabetes.
MATERIALS AND METHOD
The present study was carried out in department of Cardiology IGIMS, Patna, on 65 patients of acute
coronary syndrome of both sex age more then 18 years were selected based on serial ECG changes
and Cardiac biomarkers then stratified accordingly into ST elevation MI, non ST elevation MI and
unstable angina. It is small scale retrospective study. Informed and written consent was taken from
family members of all these.
Inclusion Criteria
 Age ≥18 yrs.
 Patients with chest pain having ECG change & increased cardiac biomarkers.
Exclusion Criteria
 Patients with non cardiac chest pain
 without significant ECG changes
 without elevated cardiac biomarkers,
 Having previous ECG showing persistent elevated ST elevation.
INVESTIGATION
 Complete hemogram, blood sugar, urea, creatinine, lipid profile, routine examination of urine
 Chest x-ray
 Cardiac enzymes
 Electrocardiogram
 Echocardiography
 Coronary angiography
RESULTS:
Table number 1: Age distribution among study population
Age group (Years) Age distribution among study
population
≤30 2
31-40 3
41-50 10
51-60 20
61-70 19
71-80 8
>80 3
Mean age among our study population was found to be 59.03 Years.
Table number 2: Distribtuion of BMI among study population
BMI DM Non DM
<25 16 17
25-30 26 4
>30 1 1

Table number 3: Distribution of lifestyle among study population

Lifestyle Patients distribution
Active 3
Sedentary 62

Table number 4: Distribution of Socioeconomic status among study population

Socioeconomic status Status among study population
Upper 3
Middle 56
Lower 6

Table number 5: Distribution of smoking among study population

Smoking DM Non DM Total
Yes 30 17 47
No 13 5 18

Table number 6: Distribution of blood pressure among study population

hypertension Distribution of blood pressure among study
population
Yes 47
No 18
Table number 7: Distribution of blood pressure among study population
Duration of blood Distribution of blood pressure duration
pressure in years among study population
<5 9
5-10 21
11-15 8
16-20 7
21-25 1
>25 1

Table number 8: Distribution of diabetes mellitus among study population

Diabetes mellitus Distribution of diabetes mellitus among study
population
Yes 43
No 22

Table number 9: Distribution diabetes among study population

Durtion in years Duration of diabetes among study
population
<5 14
3-10 17
11-15 7
16-20 4
>20 1

Table number10: Distribution of ACS among study population

Clinical subtype DM Non DM
ST elevation MI 29 13
Non ST elevation MI 4 4
Unstable angina 10 5
Total 43 22

Table number11: Distribution of dyslipidemia among study population

Dyslipidemia DM Non DM
Present 36 3
Absent 7 19
Total 43 22

Table number12: Distribution of pattern of coronary artery involvement among study

population
CAD pattern DM Non DM
 SVD 15 9
DVD 17 10
TVD 2 3
Normal 7 0
Total 43 22
Not done in two patients
DISCUSSION
Total number of patients of acute coronary syndrome in this study was 65. Distribution pattern of
different clinical subtype of acute coronary syndrome were demonstrate as ST elevation MI
constitute 65% of total population followed by unstable angina 23% and non ST elevation MI 12%. All
patients with ST elevation and non ST elevation MI showed positive qualitative Troponin T test and
increased levels of CPK and CPK-MB.
Incidence of ACS increases as the age increases as shown by increased incidence of ACS in 5 th and 6th
decade. Mean age among our study population was found to be 59.03 Years. While mean age in
CREATE study was 57.5 years3
The obesity among our study population was found to be low (3%) and majority were with BMI below
25kg/m2 (51%). In study done by Diercks DB, roe MT, Mulgund J,Pollack CV, Kirk JD Jr.et al. found that
most (70.5%) of the CRUSADE patients were classified as obese or overweight (Overweight BMI 25-
29.9 and obesity BMI≥30.0) they present with co-morbid conditions like diabetes mellitus,
hypertension and hyperlipidemia4
In our study populationas the maximum patients was old age and retired they were having sedentary
life style compared to active life style with 95% and 5% respectively. Whereas in study done by Singh
RB,Sharma JP,Rastogi, V, Raghuvanshi RS,Moshiri M, Verma SP, et al. (1997) found that sedentary life
style was significantly higher in urban population compared to the rural subjects 5
Socioeconomic status in our study population was found to be maximum number of middle class
then lower followed by upper class as 56%, 9% and 5% respectively. In CREATE study most (52.5%)
patients were from lower-middle socioeconomic status6
There were 72% smokers and 28% were non smokers in our study population.
Among study population we found that 72% are hypertensive and remaining 28% are non
hypertensive, among hypertensive patients 9 patients were having hypertension for <5 years, 21
number of patients were having it for 5-10 years, 8 patients having hypertension for 11-15 years and
7 patients were having hypertension for about 16-20 years.
When we compared our population for the presence of diabetes mellitus we found that 66% are
diabetic and 34% were non diabetic, among diabetic patients 14 patients had diabetes for <5 years,
17 patient had diabetes for 5-10 years and 7 patient had same for 11-15 years.
Among diabetes mellitus group of patients 68% were ST elevation MI,23% unstable angina and 9%
were non ST elevation MI versus in non diabetic population STEMI was 48% Unstable angina 37% and
Non ST elevation MI was 15%. As evident from number 24 diabetes mellitus increases the risk of
STEMI. Among diabetic population 84% were having dyslipidemia compared to 16% nonDyslipidemic
and among nondiabetic population 14% were Dyslipidemic compared to 85% nondyslipidemic.
Coronary angiography done on patient for the localization of lesion, among diabetic study population
sowed 35% with single vessel disease which include single vessel diffuse lesion, 39% patient with
double vessel disease, 5% patient with triple vessel disease and 21% patient with normal coronary
angiogram, so it indicates that diabetic patients can have ACS even in presence of normal coronary
artery which might be because of micro-vascular angina. In patients who suffered MI despite normal
coronary angiogram, smoking and diabetes are major risk factor 7. When we compared this
distribution with non diabetic study population it revealed that 41% are with single vessel disease,
45% with double vessel disease and 14% are with triple vessel disease.
CONCLUSION
1. Majority of patients of ACS are with STEMI (65%)
2. Commonest risk factor in our population was hypertension (72%) and smoking (72%) followed
by dyslipidemia (68%), diabetes mellitus (66%) and obesity (46%)
3. STEMI was the commonest pattern of ACS in our diabetic population also (68%)
4. Presence of diabetes increases risk of dyslipidemia.
REFERENCE
1. Longo DL, Fauci AS, kasper DL, hauser SL, Jameson JL, Loscalzo J, et al., eds. Harrison's
principles of internal Medicine. 20th ed. New York: McGraw Hill Education; 2018:1850
2. Longo DL, Fauci AS, Kasper DL, hauser SL, Jameson JL, Loscalzo J, et al. Acute coronary
syndrome. In: Longo DL, Fauci AS,Kasper DL, Hauser SL, Jameson JL, Loscalzo J, et al., eds.
 Harrison's Principles of internal Medicine. 18th ed. New York: MCGraw Hill Education;
2012:2015
3. Xavier D. Treatment and outcomes of acute coronary syndromes in India (CREATE): a
prospective analysis of registry data. Lancet.2008;371:1435-42
4. Diercks DB, roe MT, Mulgund J, Pollack CV Jr, Kirk JD, Gibler WB, et al. the obesity paradox in
non-ST-segment elevation acute coronary syndromes: results from the can rapid risk
stratification of unstable angina patients suppress adverse outcomes with early
implementation of the American College of Cardiology/American Heart Association guidelines
Quality improvement initiative. Am Heart j. 2006;152(1):140-8.
5. Singh RB, Sharma JP, Rastogi V, Raghuvanshi RS, Moshiri M, Verma SP, et al. prevalence of
coronary artery disease and coronary risk factors in rural and urban populations of orth india.
Eur Heart J. 1997;18(11):1728-35
6. Gupta R. Lifestyle risk factors in Acute Coronary heart disease prevalence in Indian men. J
Assoc physicians india. 1996 Oct;44(10):689-93
7. Clinical profile & Risk Factors in Acute Coronary Syndrome: P. yadav, D. joseph, P. Sakhi, R.K.
Jha, J. Gupta. National journal of Community Medicine 2010, Vol. 1, issue 2.