Background: The clinical profile among patients 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. Objective: To obtain the clinical profile of patient presenting with ACS in LMCTH. Material and Method: This is a prospective study carried out in LMCTH in the department of Internal Medicine April 14, 2013 to October 14, 2013. Patients were diagnosed to have ACS based on their clinical findings, Electrocardiogram (ECG) and Troponin test. Those with non-cardiac chest pain were excluded. A detail history and all the data pertaining to the patient were noted analyzed in a systematic way. Results: A total of 40 patients with ACS presented during the study period in LMCTH. The mean age of presentation was 67±18 years. Thirty out of those constitute male (75%). Six patients (15%) died during the study period. Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with left sided chest pain, 4(10%) presented with acute shortness of breath. Four (10%) patient presented in the state of cardiogenic shock and 2 (5%) presented with the Ventricular tachycardia (VT) as their complication. 6 (15%) had unstable angina (UA), 14 (35%) had Non ST elevation Myocardial Infarction (NSTEMI) and 20 (50%) had ST elevation Myocardial Infarction (STEMI). Of the total 20 (50%) patient who had STEMI, only four of them underwent thrombolysis. Anterior wall MI was the most common wall involved. Circadian variation study showed peak incidence of acute coronary syndrome during the early morning hours.  Mean duration of symptoms before presentation 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 presentation and the incidence was more among the male and the elderly patients

., Shamsuddin

Chhetri, Bishal Karki

Dhungana, Sahadev Prashad

Paudel, Mukesh Sharma

Journal of Lumbini Medical College

English

Bishal Karki Chhetri

Mukesh Sharma Paudel

Sahadev Prashad Dhungana

Shamsuddin .

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Clinical profile of patients with acute coronary syndrome in Lumbini Medical College and Teaching Hospital: A prospective study

Background: The clinical profile among patients 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. Objective: To obtain the clinical profile of patient presenting with ACS in LMCTH. Material and Method: This is a prospective study carried out in LMCTH in the department of Internal Medicine April 14, 2013 to October 14, 2013. Patients were diagnosed to have ACS based on their clinical findings, Electrocardiogram (ECG) and Troponin test. Those with non-cardiac chest pain were excluded. A detail history and all the data pertaining to the patient were noted analyzed in a systematic way. Results: A total of 40 patients with ACS presented during the study period in LMCTH. The mean age of presentation was 67Â±18 years. Thirty out of those constitute male (75%). Six patients (15%) died during the study period. Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with left sided chest pain, 4(10%) presented with acute shortness of breath. Four (10%) patient presented in the state of cardiogenic shock and 2 (5%) presented with the Ventricular tachycardia (VT) as their complication. 6 (15%) had unstable angina (UA), 14 (35%) had Non ST elevation Myocardial Infarction (NSTEMI) and 20 (50%) had ST elevation Myocardial Infarction (STEMI). Of the total 20 (50%) patient who had STEMI, only four of them underwent thrombolysis. Anterior wall MI was the most common wall involved. Circadian variation study showed peak incidence of acute coronary syndrome during the early morning hours. Â Mean duration of symptoms before presentation to the hospital facility was 4 days. Mean hospital stay was 5Â±2 days. Conclusion: Cardiovascular disease is common in this Western part of Nepal. STEMI was the commonest presentation and the incidence was more among the male and the elderly patients

Journal of Lumbini Medical College (JLMC)

89Clinical profi le of paƟ ents with acute coronary syndrome in Lumbini Medical College and Teaching Hospital: A prospecƟ ve studyCheƩ ri BK, Paudel MS, Dhungana SP and ShamsuddinLumbini Medical College and Teaching Hospital (LMCTH), Palpa, NepalCorresponding author: Dr. Bishal KC, Department of Internal Medicine, Lumbini Medical College and Teaching Hospital, Palpa, Nepal; e-mail: bishalk@gmail.comABSTRACTSBackground: The clinical profi le among paƟ 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. ObjecƟ ve: To obtain the clinical profi le of paƟ ent presenƟ ng with ACS in LMCTH. Material and Method: This is a prospecƟ ve study carried out in LMCTH in the department of Internal Medicine April 14, 2013 to October 14, 2013. PaƟ 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 paƟ ent were noted analyzed in a systemaƟ c way. Results: A total of 40 paƟ ents with ACS presented during the study period in LMCTH. The mean age of presentaƟ on was 67±18 years. Thirty out of those consƟ tute male (75%). Six paƟ ents (15%) died during the study period. Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with leŌ  sided chest pain, 4(10%) presented with acute shortness of breath. Four (10%) paƟ ent presented in the state of cardiogenic shock and 2 (5%) presented with the Ventricular tachycardia (VT) as their complicaƟ on. 6 (15%) had unstable angina (UA), 14 (35%) had Non ST elevaƟ on Myocardial InfarcƟ on (NSTEMI) and 20 (50%) had ST elevaƟ on Myocardial InfarcƟ on (STEMI). Of the total 20 (50%) paƟ ent who had STEMI, only four of them underwent thrombolysis. Anterior wall MI was the most common wall involved. Circadian variaƟ on study showed peak incidence of acute coronary syndrome during the early morning hours.  Mean duraƟ on of symptoms before presentaƟ 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 presentaƟ on and the incidence was more among the male and the elderly paƟ ents.Keywords: Acute coronary syndrome, S T elevaƟ on myocardial infarcƟ on, Ventricular tachycardiaINTRODUCTIONPaƟ ents with ischemic heart disease (IHD) presents with two main spectrum, stable angina in which the paƟ ent has chronic coronary artery disease and those who with acute coronary syndrome consisƟ ng of paƟ ents with ST elevaƟ on Myocardial infarcƟ on (STEMI), unstable angina (UA) and Non-ST-segment elevaƟ on MI (NSTEMI).1Due to the advances in medical sciences of various invasive and non-invasive therapeuƟ c strategies the mortality related ACS has signifi cantly reduced in the developed world over the past 2 decades.2-7The 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.8PATIENTS AND METHODSThe study was conducted prospecƟ 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 elevaƟ on of ST segment in ECG leads/ presumed new onset leŌ  bundle branch block in ECG were categorized as STEMI. Cases of angina at rest without ST segment elevaƟ on were categorized as NSTEMI if their cardiac Troponin T (Trop I) was posiƟ ve and as UA if their Trop I was negaƟ ve.The baseline clinical characterisƟ cs analyzed were the age, gender, hypertension (blood pressure > 140/90 mm Hg and/ or those already taking treatment for hypertension), diabetes mellitus (fasƟ 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, duraƟ on of chest pain before hospitalizaƟ on, Ɵ me of occurrence of Original Article L M Coll J 2013; 1(2): 89-9290Journal of Lumbini Medical Collegethe ACS, clinical course in the hospital, the mean duraƟ on of hospital stay and complicaƟ ons related to the ACS and its treatment. In cases with STEMI, the details of the area of myocardium infarcted, the associated mechanical complicaƟ ons and conducƟ on abnormaliƟ es, further, a record was made whether thrombolyƟ c therapy was received or not. The cause of death was also studied.RESULTSA total of 40 paƟ ents with acute coronary syndrome (ACS) presented during the study period in LMCTH. The mean age of presentaƟ on was 67±18 years. Thirty paƟ ents were males (75%). Six (15%) paƟ ents died during the study period. A comparison of the clinical characterisƟ cs of the paƟ ents with ACS is shown in the table 1. PaƟ ents presented with various symptoms in the hospital. Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with leŌ  sided chest pain, 4(10%) presented with acute shortness of breath. Four (10%) paƟ ent presented in the state of cardiogenic shock and 2 (5%) presented with the Ventricular tachycardia (VT). The paƟ ent  presented with cardiogenic shock and VT died. Table 1: The baseline characterisƟ cs among males and females with ACSVariablesTotal n (%)40 (100)Male n (%)30 (75)Female n (%)10 (25)P valueMean age 67.85 65.13 76 <0.001Mean duraƟ on before hospitalizaƟ on4days 4.44days 2.6 days <0.001Symptoms  before hospitalizaƟ on                  <6hrs 7-12 hrs >24hrs 14 (35)2 (5)24 (60)10 (33.33)2 (6.66)18 (60)4 (40)06 (60)<0.001---<0.001Smoking history 26 (65) 20 (66.66) 6 (60) <0.001Hypertension 22 (55) 14 (46.66) 8 (80) <0.001Diabetes 8 (20) 8 (26.66) 0 ----Thrombolysis 4 (10) 4 (13.33) 0 ----Of the total 20 (50%) paƟ ent who had STEMI, only four of them underwent thrombolysis. Rest was not thrombolysed because of the late presentaƟ on and the complicaƟ on they had which contraindicated thrombolysis.ACS was most common in anterior wall and inferior wall than any others wall (fi g 2).Eighteen paƟ ents (45%) had anterior wall involvement, 14(35%) had inferior wall, 6(15%) had extensive wall involvement. All six mortaliƟ es were from involvement of anterior wall.The Ɵ me of onset of chest pain among paƟ ents with STEMI showing the circadian variaƟ on of cardiac events is depicted in Figure 3. Mean duraƟ on of symptoms before presentaƟ on to the hospital facility was 4 days. Mean hospital stay was 5±2 days. Fig 1. Categories of paƟ ents with ACSFig 2. Involved wall in paƟ ents with ACSFig 3. Circadian variaƟ on of cardiac events noƟ ced among paƟ ents with ACSDISCUSSIONLumbini Medical College with its 700 bed teaching hospital has emerged as a terƟ ary referral center for the hospitals in Western Nepal and diff erent health faciliƟ 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.91BK Chettri et alCardiovascular 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 cigareƩ e smoking and sedentary lifestyle, the cardiovascular disease remain the major cause of morbidity and mortality due to increase populaƟ on of elderly populaƟ on and absolute increases in obesity and diabetes.9 There has been rise in the incidence of coronary artery disease in the Asian populaƟ on.10-12Of the total 40 paƟ 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 proporƟ on of STEMI cases among paƟ ents with ACS as observed in the CREATE registry.13The mean age of presentaƟ on was 67±18 years. The mean age of paƟ ent presenƟ ng with STEMI was 67±14 years, which is comparable to observaƟ ons of CREATE registry13 and study done by Teoh M et al.14Though 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 paƟ ents, not undergoing coronary intervenƟ 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 paƟ 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.15Seventeen (42.5%) presented with central chest pain, 13(32.5%) presented with leŌ  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 paƟ ent with ACS.Of the total 20 (50%) paƟ ent who had STEMI, only four of them underwent thrombolysis which was due to late presentaƟ on in the hospital facility or due to the complicaƟ on. The mean duraƟ on of symptoms before hospitalizaƟ on was 4 days which is diff erent from the western18 and indian13, 19 studies which shows increasing trends towards the earlier presentaƟ on. This is mainly due to the lack of educaƟ on, lack of health awareness, remote locaƟ ons and lack of transportaƟ 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.21Signifi cantly higher numbers of paƟ ent with ACS in our study had risk factors like hypertension, diabetes and cigareƩ e smoking as observed in other studies.18, 19CONCLUSION Acute coronary syndrome is common in this Western part of the country. The main limitaƟ on of this study was the short duraƟ on and the small sample size. Further larger prospecƟ ve studies with large sample size are required to verify the fi ndings of this study.REFERENCE1. Christopher P.C, Eugene B. Unstable Angina and Non-ST-Segment ElevaƟ on Myocardial InfarcƟ on. In: Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL (editors). Harrison's Principle of Internal medicine 18th ediƟ 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 thrombolyƟ c therapy. Results from the GUSTO-I trial. Global UƟ lizaƟ on of Streptokinase and TPA for Occluded coronary arteries trial. CirculaƟ on 1996; 94: 1826-33.4. Fassa AA, Urban P, Radovanovic D et al. AMIS Plus InvesƟ gators. Trends in reperfusion therapy of ST segment elevaƟ on myocardial infarcƟ on in Switzerland: six year results from a naƟ 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 aƩ ack rates of, therapy for, and mortality from non-ST-elevaƟ on acute coronary syndromes in four United States communiƟ 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) InvesƟ 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. CirculaƟ 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 minoriƟ 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 FoundaƟ on, 2004.92Journal of Lumbini Medical College13. 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 presentaƟ on in Asian and Caucasian paƟ ents in Britain. Heart 2007; 93(2): 183-8.15. Monteiro P. Portuguese Registry on Acute Coronary Syndromes. Impact of early coronary artery bypass graŌ  in an unselected acute coronary syndrome paƟ ent populaƟ on. CirculaƟ on 2006; 114(1 Suppl): I467-72.16. Holay MP, Janbandhu A, Javahirani A, Pandharipande MS, Suryawanshi SD. Clinical profi le of acute myocardial infarcƟ on in elderly (prospecƟ ve study). J Assoc Physicians India 2007; 55: 188-92.17. Pate l  H ,  Ro s e n g re n  A ,  E k m a n  I .  Sy m p to 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 InvesƟ gators. Baseline characterisƟ cs, management pracƟ ces and in-hospital outcomes of paƟ 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 elevaƟ on myocardial infarcƟ 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 variaƟ on in cardiovascular events. Singapore Med J 2006; 47(4): 305-8.21. Gopal M, Boopathy N, Venkatesan R, Jagannathan V. Circadian variaƟ on in acute coronary syndromes. Web med central CARDIOLOGY 2010;1(9):WMC00533

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Clinical profile of patients with acute coronary syndrome in Lumbini Medical College and Teaching Hospital: A prospective study

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Journal of Lumbini Medical College (JLMC)