Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 2  |  Page : 378-386

Pattern of risk factors and management strategies in patients with acute coronary syndrome


1 Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Cardiology, National Heart Institute, Giza, Egypt

Date of Submission06-Nov-2016
Date of Acceptance29-Jan-2017
Date of Web Publication27-Aug-2018

Correspondence Address:
Ahmed N Taha Hussein
Department of Cardiology, National Heart Institute, Faisal, Giza
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_602_16

Rights and Permissions
  Abstract 


Objective
The aim of the study was to assess the pattern of risk factors of acute coronary syndrome (ACS) in patients with coronary artery disease (CAD) in different age groups and sex categories.
Background
ACS refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction to presentations found in non-ST-segment elevation myocardial infarction or in unstable angina.
Patient and methods
This is a prospective, observational, noncontrolled study including 200 patients with ACS who were admitted at As-Salam International Hospital from August 2015 to March 2016. The patients were classified into four groups according to age: patients younger than 45 years, patients between 45 and 55 years, patients between 55 and 64 years, and patients aged 65 years or older. Further, a comparison was made between male and female patients.
Results
There was a significant difference between the studied groups as regards the prevalence of diabetes mellitus (DM), hypertension (HTN), and cigarette smoking, with no significant difference as regards positive family history of premature CAD. There was significant difference between male and female patients as regards the prevalence of DM, HTN, and cigarette smoking, with no significant difference as regards positive family history of premature CAD, dyslipidemia, and lipid profile.
Conclusion
The youngest patients had a higher incidence of smoking, were mostly male, had a positive family history of premature CAD, a low BMI, and had a poor lipid profile compared with other groups. In contrast, they had a lower incidence of other risk factors as diabetes, HTN, and low high-density lipoprotein values. The oldest patients (group 4) had the lowest incidence of some risk factor as DM, HTN, smoking, total cholesterol (TCh), low low-density lipoprotein levels, waist circumference, and BMI, which gave rise to the suspicion that age alone is an important risk factor for CAD. Female patients had a higher incidence of HTN, dyslipidemia, high levels of BMI, and atherogenic lipid profile compared with male patients. In contrast, they had a lower incidence of DM, positive family history of premature CAD, and smoking.

Keywords: acute coronary syndrome, Egyptian, risk factors


How to cite this article:
Reda AA, Mina MB, Taha Hussein AN. Pattern of risk factors and management strategies in patients with acute coronary syndrome. Menoufia Med J 2018;31:378-86

How to cite this URL:
Reda AA, Mina MB, Taha Hussein AN. Pattern of risk factors and management strategies in patients with acute coronary syndrome. Menoufia Med J [serial online] 2018 [cited 2018 Dec 11];31:378-86. Available from: http://www.mmj.eg.net/text.asp?2018/31/2/378/239750




  Introduction Top


Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non-ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina (UA). In terms of pathology, ACS is almost always associated with rupture of an atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery [1].

In some instances, however, stable coronary artery disease (CAD) may result in ACS in the absence of plaque rupture and thrombosis, when physiologic stress (e.g., trauma, blood loss, anemia, infection, and tachyarrhythmia) increases demands on the heart. The diagnosis of acute myocardial infarction in this setting requires a finding of the typical rise and fall of biochemical markers of myocardial necrosis in addition to at least one of the following:

  1. Ischemic symptoms
  2. Development of pathologic Q waves
  3. Ischemic ST-segment changes on ECG or in the setting of a coronary intervention [2].


Risk factors such as age, cigarette smoking, high blood pressure, elevated levels of low-density lipoprotein (LDL) cholesterol, low levels of high-density lipoprotein (HDL) cholesterol, family history of premature coronary heart disease (CHD), and high fasting plasma glucose levels are epidemiologically strongly associated with CHD, even though the precise mechanism by which they promote atherosclerosis and predispose a person to CHD is not fully understood.

Aim

The aim of this work was to study the pattern of different risk factors such as age, sex, and family history of premature CHD, diabetes mellitus (DM), hypertension (HTN), smoking, dyslipidemia, obesity, and metabolic syndrome in patients with ACS of different age groups and sex who were admitted to As-Salam International Hospital.


  Patients and Methods Top


The study was approved from the ethical committee of faculty of medicine menoufia university and the patients gave an informed consent. This is a prospective, observational, noncontrolled study including 200 patients with ACS who were admitted at As-Salam International Hospital from August 2015 to March 2016. The patients were classified into four groups according to age: group 1 patients were less than 45 years old, group 2 patients were between 45 and 55 years old, group 3 patients were between 55 and 64 years old, and group 4 patients were 65 years or older. Finally, a comparison was made between male and female patients.

Inclusion criteria

All patients admitted to As-Salam International Hospital with ACS without age limitation were eligible for participation in this study.

Exclusion criteria

Patients with rheumatic heart disease, those with ACS complicated with early in-hospital death, and finally patients with known dilated cardiomyopathy were excluded.

Methods

All patients were subjected to full history taking, full general examination, and cardiac examination (heart sounds, murmurs, and additional sounds).

All patients underwent an ECG, echocardiography, and laboratory investigation in the form of complete blood picture, renal function tests, liver function tests, and lipid profile evaluation:

Serum cholesterol and triglycerides (TGs) were determined by enzymatic colorimetric test, using kits supplied by SPINREACT, Spain [3].

Serum HDL-cholesterol was determined by the colorimetric method using a Human Kit supplied by Spinreact (Ctra. Sta. Coloma, 7, 17176 St. Esteve de Bas, GIRONA - Spain) [3].

LDL-cholesterol was estimated by Friedwald's formula [4].

Statistical analysis

Data were collected, tabulated, and statistically analyzed using SPSS, 19.0, for Windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for Windows (MedCalc Software BVBA, Ostend, Belgium).

The Pearson's correlation coefficient was computed and evaluated as follows:

  1. P-value less than 0.05 was considered mildly statistically significant
  2. P-value less than 0.001 was considered highly statistically significant
  3. P-value greater than 0.05 was considered statistically nonsignificant.



  Results Top


In the study population, 150 (81%) patients were male and 50 (19%) were female. In terms of the relation between sex and age in the studied groups this difference was statistically nonsignificant (P > 0.05).

There was a significant difference between all studied groups as regards the prevalence of DM, HTN, and cigarette smoking. There was no significant difference between age groups as regards positive family history of premature CAD [Table 1].
Table 1: Comparison between study groups as regards personal data and risk factors

Click here to view


The mean value of TCh in the whole group was 195.76 ± 44.99 mg/dl. This difference was statistically highly significant (P < 0.05). The mean value of TGs in the whole group was 172.49 ± 92.36 mg/dl. This difference was statistically significant (P < 0.05). The mean value of HDL in the study population was 51.60 ± 14.91 mg/dl. This difference was statistically nonsignificant (P > 0.05). The mean value of LDL-cholesterol in the study population was 130.97 ± 49.01 mg/dl. This difference was statistically significant (P < 0.05) [Table 2].
Table 2: Comparison between study groups as regards lipid profile

Click here to view


The mean value of waist circumference was 96.46 ± 7.24 cm in group 1 and it decreased to 95.60 ± 6.35 cm in group 2, to 96.23 ± 7.21 cm in group 3, and to 95.05 ± 7.56 cm in group 4. This difference was statistically nonsignificant (P > 0.05). The mean value of BMI was 28.59 ± 1.56 in group 1, which increased to 29.71 ± 1.74 in group 2, to 31.14 ± 2.22 in group 4, and decreased to 29.21 ± 2.08 in group 3. This difference was statistically highly significant (P < 0.01) [Table 3].
Table 3: Comparison between study groups as regards anthropometric measures

Click here to view


The incidence of STEMI was highest in group 1 at 30%, and it decreased to 20% in group 3, to 10% in group 4, and to 8.6% in group 2. This difference was statistically significant (P < 0.05). The incidence of NSTEMI/UA was lowest in group 1 at 70%, and it increased to 81.4% in group 3, to 90.0% in group 4, and to 91.4% in group 2. This difference was statistically significant (P < 0.05) [Table 4].
Table 4: Comparison between study groups as regards patients' presentation

Click here to view


Sex difference

Overall, 22.8% of male patients had a positive family history compared with only 17.6% of female patients. This difference was statistically nonsignificant (P > 0.05).

An overall 56.9% of female patients had a history of HTN, compared with only 53.7% of male patients. This difference was statistically significant (P < 0.05).

Among female patients, 33.3% had DM, compared with 39.6% of male patients. This difference was statistically significant (P < 0.05).

Overall, 17.6% of female patients had dyslipidemia, compared with 37.6% of male patients. This difference was statistically nonsignificant (P > 0.05).

In all, 65.8% of male patients were current smokers, compared with only 3.9% of female patients, and the difference in smoking prevalence with sex was statistically highly significant (P < 0.001) [Table 5].
Table 5: Comparison between male and female patients as regards personal data and risk factors

Click here to view


For lipid profile comparison between male and female patients, women had higher values of TCh (195.98 ± 50.64 mg/dl in women vs. 195.68 ± 43.07 mg/dl in men), higher values of HDL-cholesterol (54.18 ± 12.43 mg/dl in women vs. 50.72 ± 15.61 mg/dl in men), higher values of LDL-cholesterol (132.69 ± 42.85 mg/dl in women vs. 130.38 ± 51.06 mg/dl in men), and higher values of TGs (178.41 ± 90.79 mg/dl in women vs. 170.46 ± 93.10 mg/dl in men), but these differences were statistically nonsignificant (P > 0.05) [Table 6].
Table 6: Comparison between male and female patients as regards lipid profile

Click here to view


The mean waist circumference in women was 85.83 ± 4.06 and that in men was 99.30 ± 3.55. This difference was statistically highly significant (P < 0.001).

The mean BMI of women was 30.16 ± 2.60 and that of men was 29.90 ± 1.98. The difference was statistically nonsignificant (P > 0.05) [Table 7].
Table 7: Comparison between male and female patients as regards anthropometric measures

Click here to view


The incidence of increased TCh above 200 mg/dl was more in nondiabetic patients (41.1%) than in diabetic patients (40.8%), whereas the incidence of increased LDL was higher in diabetic patients (73.7%) than in nondiabetic patients (63.7%). These differences were statistically nonsignificant (P > 0.05).

The incidence of increased TGs above 150 mg/dl was higher in diabetic patients (57.9%) than in nondiabetic patients (44.4%). The incidence of decreased HDL was higher in diabetic patients (27.6%) than in nondiabetic patients (18.5%).

The incidence of central obesity was higher in diabetic patients (88.2%) than in nondiabetic patients (85.5%) but the differences in the above-mentioned parameters with diabetes were statistically nonsignificant (P > 0.05).

The incidence of obesity was higher in diabetic patients (52.6%) than in nondiabetic patients (49.2%). This difference was statistically nonsignificant (P > 0.05) [Table 8].
Table 8: Comparison between diabetic and nondiabetic patients as regards the incidence of abnormal lipid profile and anthropometric measures

Click here to view


The incidence of increased TCh was higher in hypertensive patients (41.3%) than in nonhypertensive patients (40.7%). The incidence of increased LDL was also higher in hypertensive patients (68.8%) than in nonhypertensive patients (65.9%). The incidence of decreased HDL was higher in hypertensive patients (22.9%) than in nonhypertensive patients (20.9%) and the incidence of increased TGs was also higher in hypertensive patients (54.1%) than in nonhypertensive patients (44.0%). However, these differences were statistically nonsignificant (P > 0.05).

The incidence of central obesity was higher in hypertensive patients (88.1%) than in nonhypertensive patients (84.6%). The incidence of obesity was also higher in hypertensive patients (55.0%) than in non hypertensive patients (45.1%). These differences were statistically significant (P ≤ 0.05) [Table 9] and [Figure 1] and [Figure 2].
Table 9: Comparison between hypertensive and nonhypertensive patients as regards the incidence of abnormal lipid profile and anthropometric measures

Click here to view
Figure 1: Suggested algorithm for triaging patients with chest pain. ACS, acute coronary syndrome.

Click here to view
Figure 2: Risk factors of acute coronary syndrome. BP, blood pressure; CAD, coronary artery disease; CRP, C-reactive protein; LDL, low-density lipoprotein; BNP, brain natriuretic peptide.

Click here to view



  Discussion Top


ACS refers to a spectrum of clinical presentations ranging from those for STEMI to presentations found in NSTEMI or in UA. It is almost always associated with rupture of an atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery [1].

Age may be the only major risk factor that does not cause CHD by directly promoting atherosclerosis. Thus, increased age increases the risk for developing more severe CHD [3].

In this study we tried to look for the pattern of risk factors in Egyptian ACS patients to be able to handle this burden.

The concept of risk factors is a major advancement for developing strategies for preventing CHD.

As expected, our study revealed that the youngest age group (<45 years) had fewer risk factors compared with other groups as they showed the lowest incidence of DM, HTN, and obesity and they had a better lipid profile compared with the other groups. However, they showed a higher incidence of positive family history, higher incidence of current smoking, low HDL value, and being male. Similar findings were found by Haque et al. [4]. In their study, out of 64 patients in a military hospital (CMH Dhaka) the highest presentation was STEMI (about 61%). In addition, there was a high prevalence of smoking and positive family history compared with other risk factors.

The oldest age group (>65 years) showed an increase in the incidence of risk factors that increase with age (such as incidence of DM, HTN, obesity, increased waist circumference, abnormal lipid profile, and male sex). Similar findings were reported by Duc Cong and Dung [5]. They found a higher prevalence of DM, HTN, and obesity in the oldest patients compared with other groups.

The incidence of STEMI was higher in the youngest age group, decreasing as age advanced, whereas the incidence of UA/NSTEMI was higher in the older age groups, with the highest prevalence in group 2 (about 90%). Similar findings were reported in the CREATE registry, which found about 60% of patients with STEMI [6].

With regard to sex distribution, 75% of our study population was male and only 25% was female (male: female ratio of 3:1), showing a clear male preponderance. Shah et al. [7] reported a similar ratio of 3.5:1 and Jafar et al. [8] a ratio of 3.9:1, suggesting that it is predominantly a disease afflicting men. However, this ratio changes after menopause, when the risk increases rapidly in women to equal that of men. This may be due to loss of the cardioprotective properties of estrogen [9].

Positive family history (either of premature CAD or sudden death) was not high, as only 21.5% of our study population had a positive family history. But this risk factor was an important one in the younger age group as 46.7% of patients less than 45 years old revealed a positive family history; however, this percentage decreased with age. A similar result was found by Tahvildari et al. [10] (15%), although Ranjith et al. [11] found a higher prevalence of positive family history (54%).

About 50% of our study population consisted of current cigarette smokers. The incidence of smoking was higher among the younger age groups, but the rate decreased with age. A similar finding was reported by Ranjith et al. [11], in whose study 60% of young adult patients were current smokers. In addition, Singh et al. [12] studied 200 patients and found 65% of the study population to be current smokers. In contrast, Ali et al. [13] found only 35% of the study population to be smokers.

Other than advanced age, smoking remains the single most important risk factor for CAD. According to the 2010 surgeon general's report, cigarette smoking is the leading preventable cause of death and disease.

For DM our study population revealed that 38% of patients had DM (known by past history of DM or in-hospital laboratory findings). The incidence of DM as a risk factor was lowest in the younger age group (16.7% of patients).

The incidence of DM increased with age, except in the oldest group, but the figure was still higher than that in the youngest one.

Similar results were found by Singh et al. [12], in whose study the prevalence of DM was 46%.

Another important finding was that the prevalence of DM in ACS patients was higher than its prevalence in developed countries, as found by Rosengren et al. [14] in the Euroheart ACS survey, who found an incidence of DM in ACS patients of 23%.

The incidence of DM was also almost similar to those Pakistani patients in whom the overall prevalence of history of DM in ACS patients was 39.8%, as reported by Khan et al. [15].

A diabetic patient has risk for heart disease or stroke that is likely to be at least two-fold that of someone who does not have diabetes. People with diabetes also tend to develop heart disease or have stroke at an earlier age compared with other people. Some studies suggest that middle-aged patients with type 2 diabetes have a probability of suffering a heart attack that is as high as that of someone without diabetes who has already suffered one heart attack [16].

With regard to HTN, we found that 54.5% of our study population had a past history of HTN but the incidence was low in the younger age group and that incidence increased with age but declined again in the oldest group. These results were similar to those of Rosengren et al. [14] in the Euroheart ACS survey, who found an overall prevalence of HTN of 48%. The incidence was lowest in the youngest group and it increased with age but decreased again in the oldest two age groups [14]. The incidence of HTN was also almost similar to those of Pakistani patients in whom the overall prevalence of history of HTN in ACS patients was 53%, as reported by Khan et al. [15].

The results of our study were higher than those of Singh et al. [12], which showed that the prevalence of HTN was 33% This was the same finding as that of Ranjith et al. [11], in whose study 45% of patients were hypertensive.

Both studies showed a higher prevalence of HTN among Pakistani and South African patients, but the incidence was still lower than that in our study.

Elevated blood pressure is a major risk factor for CAD, heart failure, cardiovascular diseases, peripheral arterial disease, renal failure, atrial fibrillation, and total mortality, as well as loss of cognitive function and increased incidence of dementia.

With regard to lipid profile, the youngest age group (<45 years) had the highest proportion of patients with increased TCh (50%) and LDL (90%), and the highest proportion of patients with increased TGs (63.3%) was in the oldest group (>65 years), followed by the youngest group (<45 years = 63.1%). Decreased HDL was high in the entire study population, with no significant difference among the age groups. The results were similar to those of Rosengren et al. [14], who saw the highest level in the younger age group and a decline in proportion as age advanced.

Dyslipidemia is recognized as a prominent risk factor for cardiovascular disease [17]. Current guidelines focus on lowering LDL-cholesterol with a statin in both primary and secondary intervention settings [16],[17]. This approach is supported by extensive evidence from large, prospective studies. In a recent meta-analysis of 14 statin studies including 90 056 patients, lowering LDL-cholesterol by 39 mg/dl (1 mmol/l) was associated with about one-fifth reduction in the 5-year incidence of major cardiovascular events [18]. However, the residual risk for vascular events remained high; 14.1% of statin-treated patients compared with 17.8% of control patients experienced vascular events representing a residual relative risk of 79%. Although high-dose statin therapy may provide some incremental benefit of between 10 and 20% [18], statin-treated patients remain at high residual risk for future cardiovascular events.

With regard to BMI, the mean BMI was 28.59 ± 1.56 for the whole study population and the mean value increased with age except in the oldest group, which showed a decrease. Yagi et al. [19] found that the mean BMI was 23.9 ± 3.4 kg/m 2, which was lower than that in our study. With regard to obesity (defined as BMI of 30 or more) as a risk factor it was noted that 50.5% of the whole study population was obese. The youngest age group (<45 years) showed the lowest proportion of patients with obesity compared with the oldest group (>65 years), whereas the middle groups (45–55 and 55–65 years) had the highest proportion of obesity; thus, obesity was prominent in the middle-aged groups than in the other two extreme groups.

In contrast to our study, Rosengren et al. [14] found that obesity declined from 23.4% in the youngest group to 12.8% in the oldest group, but there was a difference between the two studies as in the study by Rosengren et al. [14] the youngest group was younger than 55 years old.

Obesity is associated with elevated vascular risk in population studies. In addition, this condition has been associated with glucose intolerance, insulin resistance, HTN, physical inactivity, and dyslipidemia [20],[21].

With regard to sex-related difference the prevalence of HTN and dyslipidemia among women was statistically significantly higher than the prevalence of HTN and dyslipidemia among men. Also, the proportion of diabetic men was statistically significantly higher than the proportion of diabetic women. Also the proportion of male smokers was statistically significantly higher than the proportion of female smokers.

Also the mean TCh, LDL, HDL, TGs, BMI, and waist circumference was higher in women than in men. Rosengren et al. [14] found the prevalence of dyslipidemia to be higher in women than in men among patients older than 55 years, whereas it was lower in younger age group (<55 years). As we had about 58.5% of women in age groups older than 55 years, all parameters of the lipid profile are more atherogenic in women than in men. Rosengren et al. [14] also found that the percent of HTN and DM was higher in women than in men in all age groups.

From the above data it can be noted that women presenting with ACS have a wide range of risk factors such as higher incidence of HTN and DM and a more atherogenic lipid profile.


  Conclusion Top


The youngest patients had the highest incidence of smoking, a higher proportion of men, a positive family history of premature CAD, a low BMI, and a poor lipid profile compared with others. In contrast, they had a lower incidence of other risk factors as diabetes, HTN, and low HDL.

The older patients had a higher incidence of diabetes, HTN, positive family history of premature CAD, and better lipid profile compared with the youngest patients. In contrast, the oldest patients had the lowest incidence of DM, HTN, smoking, TCh, low LDL levels, waist circumference, and BMI, which gave rise to the suspicion that age alone is an important risk factor for CAD.

STEMI presentation was higher in the youngest patients, whereas UA/NSTEMI was higher among the oldest patients.

The incidence of in-hospital complications and mortality was higher among the oldest patients.

There was no significant difference in the prevalence of risk factors for CAD between diabetic and nondiabetic patients and the same was seen for hypertensive and nonhypertensive patients.

Women had a higher incidence of HTN, dyslipidemia, high levels of BMI, and better atherogenic lipid profile compared with men. In contrast, they had a lower incidence of DM, positive family history of premature CAD, and smoking and a higher incidence of UA/NSTEMI compared with men, who had a higher incidence of STEMI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
David L, Shirani J, Kalyanasundaram A. Acute coronary syndrome. Available at: Emedicine.medscape.com/article/1910735-overview. [Last accessed on 2017 March 09].  Back to cited text no. 1
    
2.
Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined – a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000 36:959–969.  Back to cited text no. 2
    
3.
Jousilahti P1, Vartiainen E, Tuomilehto J, Puska P. Sex, age, cardiovascular risk factors, and coronary heart disease: a prospective follow-up study of 14,786 middle-aged men and women in Finland. Circulation 1999; 99:1165–1172.  Back to cited text no. 3
    
4.
Haque AFMS, Siddiqui AR, Rahman SMM, Iqbal SA, Fatema NN, Khan Z. Acute coronary syndrome in the young – risk factors and angiographic pattern. Cardiovascular Journal 2010; 2(2):175–78.  Back to cited text no. 4
    
5.
Duc Cong N, Dung HT. The risk factors of acute coronary syndrome in patients over 65 years old at Thong Nhat Hospital of Ho Chi Minh City, Vietnam. J Atheroscler Thromb 2014; 21 (Suppl 1): S36–S41.  Back to cited text no. 5
    
6.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE). Lancet 2008; 371:1435–1442.  Back to cited text no. 6
    
7.
Shah SS, Noor L, Shah SH, Shahsawar, Din SU, Awan ZA, Hafizullaht M. Myocardial infarction in young versus older adults: clinical characteristics and angiographic features. J Ayub Med Coll Abbottabad 2010; 22:187–190.  Back to cited text no. 7
    
8.
Jafar TH, Qadri Z, Chaturvedi N. Coronary artery disease epidemic in Pakistan: more electrocardiographic evidence of ischaemia in women than in men. Heart 2008; 94:408–413.  Back to cited text no. 8
    
9.
Rosengren A, Spetz CL, Köster M, Hammar N, Alfredsson L, Rosén M. Sex differences in survival after myocardial infarction in Sweden; data from the Swedish National Acute Myocardial Infarction Register. Eur Heart J 2001; 22:314–322.  Back to cited text no. 9
    
10.
Hatmi ZN, Tahvildari S, Gafarzadeh Motlag A Sabouri Kashani A. Prevalence of coronary artery disease risk factors in Iran: a population based survey. BMC Cardiovasc Disord 2007; 7:32.  Back to cited text no. 10
    
11.
Ranjith N, Pegoraro RJ, Zaah MG. Risk factors associated with acute coronary syndromes in South African Asian Indian patients. J Clin Exp Cardiol 2011; 2:163.  Back to cited text no. 11
    
12.
Singh PS, Singh G, Singh SK. Clinical profile and risk factors in acute coronary syndrome. J Indian Acad Clin Med 2013; 14:130–132.  Back to cited text no. 12
    
13.
Ali N, Hadi A, Zeb S, Jan H. Risk factors in acute coronary syndrome in patients less than 40 years. Rawal Med J 2015 40:158–161.  Back to cited text no. 13
    
14.
Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, Hasdai D. Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey. Eur Heart J 2006; 27:789–795.  Back to cited text no. 14
    
15.
Khan HU, Khan MU, Noor MM, Hayat U, Alam MA. Coronary artery disease pattern: a comparison among different age groups. J Ayub Med Coll Abbottabad 2014; 26:466–469.  Back to cited text no. 15
    
16.
Brunzell JD, Davidson M, Furberg CD, Goldberg RB, Howard BV, Stein JH, et al. American Diabetes Association; American College of Cardiology Foundation Lipoprotein management in patients with cardiometabolic risk: consensus statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care 2008; 31:811–822.  Back to cited text no. 16
    
17.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III) final report. Circulation 2002; 106:106–421.  Back to cited text no. 17
    
18.
Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C. et al. Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins. Lancet 2005; 366:1267–1278.  Back to cited text no. 18
    
19.
Yagi H, Komukai K, Hashimoto K, Kawai M, Ogawa T, Anzawa R, Minai K. Difference in risk factors between acute coronary syndrome and stable angina pectoris in the Japanese: smoking as a crucial risk factor of acute coronary syndrome. J Cardiol 2010; 55: 345–353.  Back to cited text no. 19
    
20.
Rexrode KM, Carey VJ, Hennekens CH, Walters EE, Colditz GA, Stampfer MJ, Willett WC, Manson JE. Abdominal adiposity and coronary heart disease in women. JAMA 1998; 280:1843–1848.  Back to cited text no. 20
    
21.
Bacha F, Edmundowicz D, Sutton-Tyrell K, SoJung Lee, Tfayli H, Arslanian SA. Coronary artery calcification in obese youth: what are the phenotypic and metabolic determinants? Diabetes Care 2014; 37:2632–2639.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed440    
    Printed60    
    Emailed0    
    PDF Downloaded73    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]