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O ri gi nal A rticle
Clinical Characteristics, Angiographic Profile
and in Hospital Mortality in Acute Coronary
Syndrome Patients in South Indian Population
Rajni Sharma, Shivkumar Bhairappa, SR Prasad1, Cholenahally Nanjappa Manjunath
Departments of Cardiology and 1Cardiac Anaesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru,
Karnataka, India

ABSTRACT
Aims: The aim was to study the clinical profile, risk factors prevalence, angiographic distribution, and severity of
coronary artery stenosis in acute coronary syndrome (ACS) patients of South Indian population. Materials and
Methods: A total of 1562 patients of ACS were analyzed for various risk factors, angiographic pattern and severity of
coronary heart disease, complications and in hospital mortality at Sri Jayadeva Institute of Cardiovascular Research
and Sciences, Bengaluru, Karnataka, India. Results: Mean age of presentation was 54.71 ± 19.90 years. Majority were
male 1242 (79.5%) and rest were females. Most patients had ST elevation myocardial infarction (STEMI) 995 (63.7%)
followed by unstable angina (UA) 390 (25%) and non-STEMI (NSTEMI) 177 (11.3%). Risk factors; smoking was present
in 770 (49.3%), hypertension in 628 (40.2%), diabetes in 578 (37%), and obesity in (29.64%) patients. Angiography was
done in 1443 (92.38%) patients. left anterior descending was most commonly involved, left main (LM) coronary
artery was least common with near similar frequency of right coronary artery and left circumflex involvement
among all three groups of ACS patients. Single-vessel disease was present in 168 (45.28%) UA, 94 (56.29%) NSTEMI
and 468 (51.71%) STEMI patients. Double-vessel disease was present in 67 (18.08%) UA, 25 (14.97%) NSTEMI and 172
(19.01%) STEMI patients. Triple vessel disease was present in 28 (7.55%) UA, 16 (9.58%) NSTEMI, 72 (7.95%) STEMI
patients. LM disease was present in 12 (3.23%) UA, 2 (1.19%) NSTEMI and 9 (0.99%) STEMI patients. Complications;
ventricular septal rupture occurred in 3 (0.2%), free wall rupture in 2 (0.1%), cardiogenic shock in 45 (2.9%), severe
mitral regurgitation in 3 (0.2%), complete heart block in 11 (0.7%) patients. Total 124 (7.9%) patients died in hospital
after 2.1 ± 1.85 days of admission. Conclusion: STEMI was most common presentation. ACS occurred a decade
earlier in comparison to Western population. Smoking was most prevalent risk factor. Diabetic patients had more
of multivessel disease. Complications and in hospital mortality was higher in females and elderly population.

Key words: Acute coronary syndrome, coronary angiogram, non-ST elevation myocardial infarction, ST elevation myocardial
infarction, unstable angina

INTRODUCTION
Coronary artery disease (CAD) is leading cause of mortality
Address for correspondence: worldwide[1] and by the year 2020, will be first in the leading
Dr. Rajni Sharma, causes of disability.[2] While the death rates have been declining
Sri Jayadeva Institute of Cardiovascular Sciences and Research, for the past three decades in the west, these rates are rising in
Jaya Nagar, 9th Block, Bannergahtta Road,
India. In the last three decades, the prevalence of CAD has
Bengaluru - 560 069, Karnataka, India.
E-mail: rajaksehgal@gmail.com increased from 1.1% to about 7.5% in the urban population
and from 2.1% to 3.7% in the rural population.[3] CAD tends
Access this article online to occur at a younger age in Indians, with more extensive
Quick Response Code:
Website: angiographic involvement[4] contributed genetic, metabolic,
conventional and nonconventional risk factors. [5,6] The
www.heartindia.net
objective of this study was to represents the clinical profile,
DOI: prevalence of risk factors and distribution of coronary artery
stenosis in acute coronary syndrome (ACS) patients of South
10.4103/2321-449x.140228
Indian population.

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Sharma, et al.: Angiographic profile in acute coronary syndrome patients

MATERIALS AND METHODS RESULTS

One thousand five hundred and sixty-two consecutive patients Among 1562 ACS patients majority were male 1242 (79.5%)
presented to Sri Jayadeva Institute of Cardiovascular Research and 320 (20.5%) were female. The mean age of presentation
and Sciences, Bengaluru, Karnataka, India with first episode for male was 53.28 ± 11.54 and for female was 60.23 ± 17.67
of ACS were analyzed. The clinical presentations of patient (P = 0.001). Most common presentation in ACS was STEMI
were categorized as unstable angina (UA), non-ST elevated with 995 (63.7%) patients followed by UA 390 (25%) and
myocardial infarction (NSTEMI) and STEMI according to NSTEMI 177 (11.3%). Baseline characteristics are mentioned
American College of Cardiology/American Heart Association in Table 1.
(ACC/AHA) definitions and treated as per ACC/AHA
recommendations.[7,8] Patients with concomitant valvular heart Risk factor analysis
disease or cardiomyopathy were excluded from this study. A total of 578/1562 (37%) patients were diabetic and 628/1562
(40.2%) patients were hypertensive. Smoking was most prevalent
The following data were included for analysis: Age and gender risk factor seen in 770/1562 (49.30%) patients. Active smoking
and CAD risk factor profile, comprised of current cigarette/ in our study was noticed only in male, that is, 770 (62%) of
bidi smoking history, dyslipidemia was defined as the presence
total male (1242) patients. Women were rather tobacco chewers.
of any of the following: Patients on lipid lowering drugs or total
Dyslipidemia was present in 593/1562 (37.96%) patients. Obesity
cholesterol >240 mg/dl, triglycerides (TG) >150 mg/dl, low-
in 463/1562 (29.64%) patients and family history of CAD was
density lipoprotein >130 mg/dl, and high-density lipoproteins
significant in 152/1562 (9.73%) patients.
(HDL) <50 mg/dl for female and <40 mg/dl for male. Diabetes
mellitus symptoms of diabetes and plasma glucose concentration
≥200 mg/dl (11.1 mmol/L), or fasting blood sugar ≥126 mg/dl Table 1: Baseline characteristics
(7.0 mmol/L) or 2-hp ≥200 mg/dl (11.1 mmol/L), hypertension Various parameters Baseline values
(systolic blood pressure ≥140 and/or diastolic ≥90 mmHg and/ Age (years) 54.70±19.90
or on anti-hypertensive treatment), family history of CAD (first Male (n and %) 1242 (79.5)
degree relatives before the age of 55 years in men and 65 years in Female (n and %) 320 (20.5)
women), obesity was defined using the body mass index (BMI) with Risk factors (%)
Diabetes (n) 578 (37)
a value >30. BMI was calculated using Quetlet’s formula (weight in
Hypertension (n) 628 (40.2)
kg/height in m2). Clinical manifestations, left ventricular ejection
Smoking (n) 770 (49.30)
fraction, hematologic indices, coronary angiographic findings, and
Obesity 463 (29.64)
treatment strategy were reported. Selective coronary angiogram Family history 152 (9.7)
was done using standard technique within 48 h of admission Fluid lipid profile (mg/dl)
unless patient is hemodynamically unstable or with deranged renal Total cholesterol 170.69±60.758
parameters. Expert opinion on coronary angiography was taken HDL 38.39±8.401
by two cardiologist. Significant CAD was defined as a diameter LDL 107.49±38.15
stenosis >50% in each major epicardial artery. Normal vessels were Triglyceride 153.17±94.366
defined as the complete absence of any disease in the left main Total cholesterol/HDL 5.29±1.559
coronary artery (LMCA), left anterior descending (LAD), right Hb (g %) 14.10±2.193
coronary artery (RCA), and left circumflex (LCX) as well as in Serum creatinine (mg %) 1.01±1.307
their main branches (diagonal, obtuse marginal, ramus intermedius, Cardiac enzymes
posterior descending artery, and posterolateral branch). Patients UA
were classified as having single-vessel disease (SVD), double-vessel CPK (median, mg/dl) 107.50
CPK-MB 23
disease (DVD) or triple vessel disease (TVD) accordingly.
TropT (ng/dl) 0.04
MI (NSTEMI and STEMI)
Statistical analysis CPK (median, mg/dl) 282
The results were reported as mean ± standard deviation for CPK-MB 41
the quantitative variables and percentages for the categorical TropT (ng/dl) 0.52
variables. The groups were compared using the Student’s t-test Ejection fraction (median, %)
for the continuous variables and the Chi-square test for the UA/NSTEMI 55
dichotomous variables. P < 0.05 were considered as statistically STEMI 46
significant. All the statistical analyses were carried out via HDL: High-density lipoprotein, LDL: Low-density lipoprotein, Hb: Hemoglobin,
CPK: Creatine phosphokinase, TropT: Troponin T, MI: Myocardial infarction,
Statistical Package for Social Sciences version 20 (SPSS, IL, NSTEMI: Non-ST elevation myocardial infarction, STEMI: ST elevation myocardial
Chicago Inc., USA). infarction, UA: Unstable angina, MB: Myocardial band

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Sharma, et al.: Angiographic profile in acute coronary syndrome patients

Angiographic profile one male and one female. Severe mitral regurgitation was seen
Most common coronary artery to be involved was LAD followed in 3 (0.2%) patients, two were female and one patient was
by near similar frequencies of RCA and LCX involvement with male. Cardiogenic shock was seen in total 45 (2.9%) patients,
least common involvement of LMCA in all three groups (UA, 11/320 (3.44%) were female and 34/1242 (2.73%) were male.
NSTEMI and STEMI). Table 2 among UA patients SVD was Eleven (0.7%) patients had complete heart block, 3 (0.2%)
seen in 168 (45.28%) patients, DVD in 67 (18.06%) patients, were female and 8 (0.5%) were male. Ventricular tachycardia
TVD in 28 (7.55%) patients, LM disease in 12 (3.23%) patients occurred in 8 (0.5%) patients, three were female and five were
and normal vessels or nonsignificant lesion seen in 96 (25.88%) male patients. Pulmonary edema occurred in total 37 (2.4%)
patients out of 371 patients. In NSTEMI SVD was present in patients, 14 (4.37%)/320 were female and 23/1242 (1.85%)
94 (56.29%), DVD in 25 (14.97%), TVD in 16 (9.58%), LM were male patients.
in 2 (1.19%) and normal vessel or nonsignificant lesion seen
in 30 (17.97%) out of 167 patients. In STEMI, SVD was seen in Mortality data
468 (51.71%), DVD in 172 (19.01%), TVD in 72 (7.95%), LM Among 1562 ACS patients 124 (7.9%) patients died in hospital
in 9 (0.99%) and normal vessel or nonsignificant lesions seen in after 2.18 ± 1.85 days of admission. Mortality was more in
184 (20.34%) out of 905 patients [Table 3]. elderly population with mean age of 61.14 ± 12.33 years in
comparison to patients discharged from hospital having mean
Single-vessel disease was present in 127 (46.02%) of female age of 54.14 ± 20.32 years (P < 0.001). Mortality was more in
patients whereas 603 (51.67%) of male patients (P < 0.001). female patients 44/320 (13.75%), whereas in men mortality
DVD was present in 44 (15.94%) female patients in comparison occurred in 80/1242 (6.44%) patients with P < 0.01. The mean
to 220 (18.85%) male patients. TVD was seen in 27 (9.78%) age of mortality in female was higher 62.18 ± 11.9 years in
female patients but in 89 (7.62%) male patients. LMCA disease comparison to male 60.70 ± 12.56 years (P > 0.05). In hospital
was seen in 3 (1.09%) female patients whereas in 20 (1.71%) mortality occurred in 43/578 (7.44%) diabetic patients whereas
male patients (P > 0.05). Normal or mild disease was present in 81/984 (8.23%) nondiabetic patients (P > 0.05). In diabetics
in 75 (27.17%) of female patients compared with 235 (20.15%) mean age of mortality was 61.19 ± 11.80 years in comparison
of male patients (P < 0.01). Diabetic patients had trend toward to 61.30 ± 13.4 years in nondiabetics (P > 0.05).
multivessel disease in comparison to nondiabetic patients. DVD
was seen in 113 (21.08%) of diabetic patients, whereas in 151 DISCUSSION
(16.65%) of nondiabetic patients. TVD was present in 52 (9.70%)
diabetic patients, but in 64 (7.06%) nondiabetic patients. LMCA Epidemiological studies have revealed that the prevalence
disease was present in 9 (1.68%) diabetic patients in comparison of CAD is increasing along with the rising prevalence of
to 14 (1.54%) nondiabetic patients (P > 0.05). conventional risk factors for CAD in India. Present health
transition from predominance of infections to the preponderance
Complication of acute coronary of cardiovascular disorders, such as hypertension, diabetes, and
syndrome CAD is now responsible for 53% of all deaths.[6, 6,9] Indians have
Three (0.2%) patients had ventricular septal rupture (VSR) and one of the highest rates of heart disease in the world. The disease
all three were female. Two (0.1%) patients had free wall rupture, also tends to be more aggressive and manifests at a younger

Table 2: In ACS patients various pattern of coronary artery involvement

ACS groups Total patients Coronary Coronary artery involvement
angiogram done LAD LCX RCA LM
UA (number and %) 390 (25) 371 239 (64.42) 111 (29.92) 133 (35.85) 22 (5.93)
NSTEMI (number and %) 177 (11.3) 167 119 (71.26) 54 (32.34) 50 (29.94) 5 (2.99)
STEMI (number and %) 995 (63.7) 905 644 (71.16) 271 (29.94) 361 (39.88) 24 (2.65)
Total (number and %) 1562 (100) 1443 (92.38)
ACS: Acute coronary syndrome, LAD: Left anterior descending, LCX: Left circumflex, RCA: Right coronary artery, LM: Left main, NSTEMI: Non-ST elevation myocardial
infarction, STEMI: ST elevation myocardial infarction, UA: Unstable angina

Table 3: Distribution of coronary vessels involvement in ACS patients

ACS Normal n (%) Nonsignificant n (%) SVD n (%) DVD n (%) TVD n (%) LM n (%)
UA 59 (15.90) 37 (9.97) 168 (45.28) 67 (18.6) 28 (7.55) 12 (3.23)
NSTEMI 19 (11.40) 11 (6.60) 94 (56.29) 25 (14.97) 16 (9.58) 2 (1.19)
STEMI 88 (9.72) 94 (10.6) 468 (51.71) 172 (19.01) 72 (7.95) 9 (0.99)
ACS: Acute coronary syndrome, UA: Unstable angina, NSTEMI: Non-ST elevation myocardial infarction, STEMI: ST elevation myocardial infarction, SVD: Single-vessel disease,
DVD: Double-vessel disease, TVD: Triple vessel disease, LM: Left main

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Sharma, et al.: Angiographic profile in acute coronary syndrome patients

age.[10] However, in our study, the mean age of presentation was ACS in middle-aged men and combination with smoking, the risk
54.70 ± 19.90 years comparable to other studies done in India, of coronary events increases by 5.5 times.[19] Obesity has become an
that is, CREATE registry (56 ± 13 years) and Jose and Gupta epidemic and rapidly growing public health hazard. Central obesity
study (57 ± 12 years) but lower than the western population as (visceral fat) corresponding to increased waist circumference is an
in COURAGE trial 62 ± 5 years conducted in USA, study by important component of the insulin resistance-hyperinsulinemia
Hochman et al.[11] (69 years), and Chang et al. (73 years).[12] The syndrome, and has been found to be more frequent in persons of
skewed gender distribution males 79.5% versus females 20.5% Indian origin. Whereas no significant correlation could be found
of the study population can be attributed to the gender bias and between the levels of lipid parameters and the severity of CAD
atypical presentation, which is also a feature in INTERHEART on angiography. Others have also reported similar findings in
study and its South Asian cohort (overall male, 76% and South their study except that they reported a relationship between the
Asian cohort, 85%).[13] MI without previous angina pectoris is C/HDL-cholesterol (HDL-C) ratio and the severity of CAD.[19]
more common in younger patients with CAD[14,15] as seen in Hughes et al. showed an increased relative risk of MI directly with
our study, the mean age of STEMI patients was 53.38 ± 11.53 TG and inversely with HDL-C levels in Asian Indians.[20]
years compared with UA patients (57.85 ± 14.34 years). Studies
on histopathology has shown that those plaques would have Single-vessel involvement was most prevalent in all groups of ACS
been more lipid containing with relative lack of acellular scar including UA/NSTEMI and STEMI, followed by double-vessel
tissue and present for a shorter period of time or developed and triple vessel similar to Kumar et al. study and Tewari et al.[16,21]
more quickly than plaques seen in older patients. These plaques SVD was also most commonly involved in male as well as female
are more unstable and likely to rupture, attributing for having patients followed by DVD, and TVD with statistical significance,
more of STEMI at younger age than chronic stable angina.[16] similar to Kumar et al. and Tewari et al. study from north India.
The most common presentation among ACS patients is STEMI Left main disease did not show statistical significant difference in
in comparison to UA or NSTEMI. Our study showed that view of diabetes or gender distribution. UA was more commonly
the prevalence of diabetics was 37%, which is higher than the associated with normal coronaries (15.6%) compared to NSTEMI
reported prevalence in other nations (INTERHEART study) (11.4%) and STEMI (9.72%). In UA group many patients may
but near to other Indian studies (CREATE, Jose and Gupta).[6,17] have been over diagnosed, false positive as ACS especially in
Indians natives now constitute the largest population of diabetics females. Angiographically the absolutely normal vessels were
in the world. The number of diabetics in India is projected to present in 9.42% cases of STEMI have been attributed to complete
surpass 57.2 million by 2025.[5] The relatively high prevalence recanalization whether spontaneous or postthrombolysis.[22]
of DVD (21.08%) and TVD (9.70%) in diabetic patients when
compared with nondiabetics (16.65%) and (7.06%) respectively Complications occurred more commonly in female patients and
along with a similar mean age confirms the role of diabetes as a elderly population as VSR, cardiogenic shock, free wall rupture
chronic risk factor in CAD. Others have also reported diabetes to and pulmonary edema as explained by other studies as well.[23,24]
be a predictor of presence of multivessel disease.[16] Hypertension In hospital mortality was also significantly higher in female
is another conventional risk factor implicated in CAD. In our patients. Diabetes did not influence the short term outcome and
study 40.2% patients were hypertensive. The prevalence of in hospital mortality in our studies. Recently, studies has shown
hypertension in South Asian cohort of INTERHEART study that yet diabetes prevalence is on increase but all complications
(31.1%) is comparatively lower than in our study but near to in diabetic patients is toward downhill course, maximum fall is
other Indian studies.[6,17] The higher prevalence of diabetes seen in acute MI and mortality.[25]
and hypertension in this region could be explained by the
comparatively higher development and increasing epidemic of The study limitations include the noninclusion of factors
CAD.[18] like detailed dietary habits, exercise frequency and alcohol
consumption, as the primary aim was to study the clinical
Tobacco smoking is a known modifiable risk factor for CAD. correlation with angiographic profile of the first event of
In our study, 49.3% patients were smoker. Patients who were ACS patients. The waist hip ratio, which is better marker for
smoking had more commonly STEMI compared with UA/ measurement of obesity, was not used in our study. In mortality
NSTEMI. In our study, 560/770 (72.73%) of smoker patients group, only five patients could undergo angiogram because of
had STEMI comparable to other studies.[19] The prevalence of unstable condition, which restricted us in commenting on how
obese patients was 29.64% which is less than the prevalence seen CAD severity influenced the mortality group.
in South Asian cohort of INTERHEART study (44.2%). May be
obesity prevalence has turned out low in study because of using CONCLUSION
BMI as marker of obesity instead of waist: Hip ratio used in
INTERHEART study population. Lakka et al. in their study have Acute coronary syndrome occurs 5-10 years earlier in Indian
reported that abdominal obesity is an independent risk factor for population compared to western population. Higher prevalence

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Sharma, et al.: Angiographic profile in acute coronary syndrome patients

of diabetes and hypertension in Indian subcontinent. Overall before age 36: Risk factor and arteriographic analysis. Am J Cardiol
1982;49:1600-3.
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