Prevalence, treatments and outcomes of coronary artery disease in Indians: A systematic review

Updates in the Management of Coronary Artery Disease: A Review Article

Coronary artery disease (CAD) remains a significant health challenge, imposing substantial burdens on individuals and healthcare systems worldwide. CAD's impact stems from artery narrowing and blockage, leading to severe complications like heart attacks and heart failure. Collaborative efforts by researchers, professionals, and governments have fostered advancements in comprehending and managing this cardiovascular ailment. Evolving CAD management embraces modern diagnostics, cutting-edge pharmaceuticals, invasive procedures, lifestyle modifications, and cardiac rehabilitation. This comprehensive approach aims to amplify outcomes and elevate the quality of life for CAD-affected individuals. This review delves into innovative treatments, pivotal breakthroughs, and recent trends in clinical practices that collectively shape CAD management. The exploration encompasses novel diagnostic technologies enabling early detection and risk assessment. Moreover, it investigates recent breakthroughs in medications that profoundly impact platelet disorders, lipid reduction, and angina. Precision medicine's role in tailoring treatment strategies based on patient characteristics is thoroughly examined. Advances in invasive procedures, like percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), have revolutionised coronary revascularisation, substantially improved long-term outcomes, and reduced restenosis rates. The increasing significance of lifestyle changes and cardiac rehabilitation in CAD management, augmenting treatment options and patient recovery, are meticulously scrutinized. While these strides are pivotal, research continues to chart new paths in CAD management, from innovative drugs to collaborative multidisciplinary care models. Staying attuned to the latest advancements and embracing a patient-centric approach can collectively reduce CAD's impact and facilitate the lives of those grappling with this chronic cardiovascular disorder.

Linking Metallic Micronutrients and Toxic Xenobiotics to Atherosclerosis and Fatty Liver Disease-Postmortem ICP-MS Analysis of Selected Human Tissues

Dyslipidaemia is a disorder of the lipid metabolism, caused mainly by poor eating habits. The most severe consequence of an inappropriate diet is the development of atherosclerosis and hepatic steatosis. It is generally believed that a change in nutrition, and increased physical activity can eliminate these health problems. The contemporary research and therapies used to treat dyslipidemia mainly focus on lowering the triglyceride and cholesterol levels. However, disturbances in trace element homeostasis or the accumulation of toxic elements can also affect physiological processes, and be involved in the development of metabolically mediated diseases. The present study aimed to determine the mineral profiles of liver and brain tissues collected at autopsy (n = 39) in groups of people with hepatic steatosis (n = 5), atherosclerosis (n = 9), hepatic steatosis, and atherosclerosis (n = 16), and others without the selected disorders (n = 9). Concentrations of 51 elements were analysed via inductively coupled plasma mass spectrometry (ICP-MS) after the initial wet mineralisation of the samples with nitric acid. The results obtained allow us to conclude that the hepatic steatosis group suffers from a deficiency of important trace elements, such as copper, zinc, and molybdenum (p < 0.05), whereas the group with atherosclerosis is characterised by elevated levels of cadmium in the liver tissue (p = 0.01). Analysing the mean values of the element concentrations measured in 11 brain areas, statistically significant higher levels of calcium and copper (p < 0.001) were found in the atherosclerosis group, compared to the hepatic steatosis group, confirming the involvement of these elements in the pathogenesis of atherosclerosis. In addition, an accumulation of cadmium, lead, titanium, and strontium in the brain tissue was observed in the atherosclerosis group. While the accumulation of individual elements differs in different parts of the brain, the differences in the cadmium content (p < 0.05) between the study groups apply to the whole brain, except for the nucleus accumbens septi area, where a statistically significant titanium accumulation occurs in the atherosclerosis and steatosis groups, compared to the others (p < 0.05). In addition, the disruption of elemental homeostasis in the brain of a single case with bipolar disorder, and a case with hip replacement was observed. Our results confirm the involvement of chemical elements in the pathogenesis of selected metabolic diseases, and the need for further studies in larger populations.

Channel Intensity and Edge-Based Estimation of Heart Rate via Smartphone Recordings

Smartphones, today, come equipped with a wide variety of sensors and high-speed processors that can capture, process, store, and communicate different types of data. Coupled with their ubiquity in recent years, these devices show potential as practical and portable healthcare monitors that are both cost-effective and accessible. To this end, this study focuses on examining the feasibility of smartphones in estimating the heart rate (HR), using video recordings of the users’ fingerprints. The proposed methodology involves two-stage processing that combines channel-intensity-based approaches (Channel-Intensity mode/Counter method) and a novel technique that relies on the spatial and temporal position of the recorded fingerprint edges (Edge-Detection mode). The dataset used here included 32 fingerprint video recordings taken from 6 subjects, using the rear camera of 2 smartphone models. Each video clip was first validated to determine whether it was suitable for Channel-Intensity mode or Edge-Detection mode, followed by further processing and heart rate estimation in the selected mode. The relative accuracy for recordings via the Edge-Detection mode was 93.04%, with a standard error of estimates (SEE) of 6.55 and Pearson’s correlation r > 0.91, while the Channel-Intensity mode showed a relative accuracy of 92.75%, with an SEE of 5.95 and a Pearson’s correlation r > 0.95. Further statistical analysis was also carried out using Pearson’s correlation test and the Bland–Altman method to verify the statistical significance of the results. The results thus show that the proposed methodology, through smartphones, is a potential alternative to existing technologies for monitoring a person’s heart rate.

Prevalence and associated factors of cardiovascular diseases among men and women aged 45 years and above: Analysis of the longitudinal ageing study in India, 2017-2019

OBJECTIVE

Epidemiological studies on the prevalence and associated factors of cardiovascular diseases (CVDs) representative of all states of India among middle-aged and elderly are not much reported. The present study estimates the prevalence and associated factors of cardiovascular diseases across Indian states among men and women aged ≥45 years.

METHODS

We used data from the Longitudinal Ageing Study in India wave 1 (2017-2019), which included a final analytical sample size of 56,935 adults and their spouses aged 45 years and above. We estimated CVDs prevalence for sociodemographic and behavioural variables, and multivariable logistic regression was used to assess the association between behavioural factors and CVDs in both men and women.

RESULTS

The prevalence of CVDs was 5.2% among adults ≥45 years (women: 4.6%; men: 5.9%), hypertension was 46.7% (women:48.9%; men:44%). Men and women have a similar prevalence of diabetes (11.9%) and cholesterol (2.3%). Prevalence of physical inactivity was 30.3% (women:27%; men:34.1%). Hypertension (adjusted odds ratio; aOR women:2.60, 95% CI: 2.08-3.25, men:1.88, 95% CI 1.54-2.29), hypercholesterolemia (aOR women:1.70; 95% CI 1.07-2.69, men 3.55; 95% CI 2.66-4.74), diabetes (aOR women:2.53; 95% CI 1.83-3.51, men:1.77 95% CI 1.44-2.17), obesity, physical inactivity, and smoking in men were significantly associated with CVDs.

CONCLUSION

The prevalence of CVDs and lifestyle risk factors among middle-aged and elderly poses severe concerns regarding noncommunicable disease (NCD) healthcare services provided in a lower-middle-income country like India. The key to preventing CVDs is controlling hypertension, diabetes, hypercholesterolemia, and increasing physical activity among adults aged ≥45 years.

Nicorandil, Novel Potassium Adenosine Triphosphate Channel (K+ ATP) Opener in Ischemia With Non-Obstructive Coronary Arteries (INOCA) and Atherosclerotic Cardiovascular Disease (ASCVD): Delphi Consensus Statement

BACKGROUND

Coronary artery disease (CAD) is a significant health concern today that has assumed epidemic proportions worldwide and in India.

OBJECTIVE

The pathobiology of CAD or ischemia with non-obstructive coronary arteries disease (INOCA) in most cases involves coronary microvascular dysfunction (CMD) that often requires personalized pheno-approach based on the risk stratification and diagnostic yield, especially in patients with recurrent angina episodes. Chronic therapy with anti-anginal is often fraught with challenges of unipolar action, tolerance, and oxidative stress that precludes consistent benefits in clinical cases of CMD represented by microvascular angina (MVA). To further elucidate the clinical role and relevance of long-term vasodilator therapy, including nicorandil, a Knowledge, Attitude, and Perception (KAP) survey was planned to be conducted.

METHODS

Based on responses to the KAP survey questionnaire, Delphi-mediated graded recommendations were developed by a specialist panel as per Agency of Health Care and Quality Systems (AHRQ) criteria.

RESULTS

Management of INOCA with MVA requires a multidisciplinary approach involving non- or invasive procedures that may be relevant for persistent or refractory angina before instituting symptomatic and long-term use of nicorandil for beta-blocker intolerant and associated clinical phenotypes.

CONCLUSION

The analyses provide a real-life approach to the management of INOCA and angina non-obstructive coronary artery disease (ANOCA) with underlying CMD that may be relevant in outpatient settings in India.

Risk factors for premature coronary artery disease (PCAD) in adults: a systematic review protocol

PCAD possesses a public health challenge resulting in years of productive life lost and an escalating burden on health systems. Objective of this review is to compare modifiable and non-modifiable risk factors for PCAD compared to those without PCAD. This review will include all comparative observational studies conducted in adults aged >18 years with confirmed diagnosis of PCAD (on angiography) compared to those without PCAD. Databases to be searched include; PubMed, CINAHL, Embase, Web of Science, and grey literature (Google Scholar). All identified studies will be screened for title and abstract and full-text against the inclusion criteria on Covidence software. Data relevant to exposures and outcomes will be extracted from all included studies. All studies selected for data extraction will be critically appraised for methodological quality. Meta-analysis using random-effects model will be performed using Review Manager 5.3. Effect sizes for categorical risk factors will be expressed as odds ratios with 95% confidence intervals. For risk factors measured in continuous form, mean difference (if units are consistent) otherwise standardized mean difference (if units are different across studies) will be reported. Heterogeneity between studies will be assessed using I 2 test statistics. GRADE will be used to assess the certainty of the findings. Systematic review registration number:PROSPERO Registration # CRD42020173216.

Epidemiology and the Magnitude of Coronary Artery Disease and Acute Coronary Syndrome: A Narrative Review

BACKGROUND

Coronary Artery Disease (CAD) is the foremost single cause of mortality and loss of Disability Adjusted Life Years (DALYs) globally. A large percentage of this burden is found in low and middle income countries. This accounts for nearly 7 million deaths and 129 million DALYs annually and is a huge global economic burden.

OBJECTIVE

To review epidemiological data of coronary artery disease and acute coronary syndrome in low, middle and high income countries.

METHODS

Keyword searches of Medline, ISI, IBSS and Google Scholar databases. Manual search of other relevant journals and reference lists of primary articles.

RESULTS

Review of the results of studies reveals the absolute global and regional trends of the CAD and the importance and contribution of CAD for global health. Data demonstrates which region or countries have the highest and lowest age-standardized DALY rates and what factors might explain these patterns. Results also show differences among the determinants of CAD, government policies, clinical practice and public health measures across the various regions of world.

CONCLUSION

CAD mortality and prevalence vary among countries. Estimation of the true prevalence of CAD in the population is complex. A significant number of countries have not provided data, the estimation of the exact figures for epidemiological data is a barrier. The incidence of CAD continues to fall in developed countries over the last few decades and this may be due to both effective treatment of the acute phase and improved primary and secondary preventive measures. Developing countries show considerable variability in the incidence of CAD. The globalization of the Western diet and increased sedentary lifestyle will have a dramatic influence on the progressive increase in the incidence of CAD in these countries.

Compliance to secondary prevention strategies for coronary artery disease: a hospital-based cross-sectional survey from Ernakulam, South India

OBJECTIVES

The primary objective of the study was to report the compliance to secondary prevention strategies for coronary artery disease (CAD), such as smoking cessation, weight management, low-density lipoprotein (LDL) cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy from a resource-limited setting.

DESIGN

Analytical cross-sectional survey with data collection using questionnaire administered by study personnel.

SETTING

Institutional-two tertiary care hospitals and two cardiology clinics.

PARTICIPANTS

Patients in the age group of 30-80 years with documented CAD with a minimum of 1 year and a maximum of 6 years of follow-up after diagnosis.

MAIN OUTCOME MEASURES

The main outcome measures were the prevalence of individual compliance to secondary prevention strategies for CAD such as smoking cessation, weight management, LDL cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy. The secondary outcomes were the association of secondary prevention strategies with age, sex, domicile, socioeconomic status, insurance and type of treatment.

RESULTS

We recruited a total of 1206 patients among whom 879 (72.9%) were males. The median age of patients was 62 (14) years. The compliance to smoking cessation was 93.86% (95% CI 91.66% to 96.06%), ideal body mass index was 63.76% (95% CI 61.05% to 66.47%), blood pressure control was 65.11% (95% CI 62.42% to 67.80%), LDL compliance was 36.50% (95% CI 33.18% to 39.82%), diabetes control was 51.23% (95% CI 46.10% to 56.36%) and adequate physical activity was 39.22% (95% CI 36.46% to 41.98%)respectively. Reported compliance for cardiovascular drugs therapy was 96% for antiplatelets, 89.4% for statins, 68.2% for beta blockers, 37.7% for renin angiotensin aldosterone system blockers, 81.28% for oral hypoglycaemic agents and 22% for insulin therapy.

CONCLUSION

Compliance to secondary prevention strategies for CAD in resource limited settings are moderate. This needs further improvement for better outcomes related to CAD in future.

Optimal Profile Limits for Maternal Mortality Rates (MMR) Influenced by Haemorrhage and Unsafe Abortion in South Sudan

Maternal mortality rate (MMR) is one of the main worldwide public health challenges. Presently, the high levels of MMR are a common problem in the world public health and especially, in developing countries. Half of these maternal deaths occur in Sub-Saharan Africa where little or nothing progress has been made. South Sudan is one of the developing countries which has the highest MMR. Thus, this paper deploys statistical analysis to identify the significant physiological causes of MMR in South Sudan. Prediction models based on Poisson Regression are then developed to predict MMR in terms of the significant physiological causes. Coefficients of determination and variance inflation factor are deployed to assess the influence of the individual causes on MMR. Efficacy of the models is assessed by analyzing their prediction errors. The paper for the first time has used optimization procedures to develop yearly lower and upper profile limits for MMR. Hemorrhaging and unsafe abortion are used to achieve UN 2030 lower and upper MMR targets. The statistical analysis indicates that reducing haemorrhaging by 1.91% per year would reduce MMR by 1.91% (95% CI (42.85–52.53)), reducing unsafe abortion by 0.49% per year would reduce MMR by 0.49% (95% CI (11.06–13.56)). The results indicate that the most influential predictors of MMR are; hemorrhaging (38%), sepsis (11.5%), obstructed labour (11.5%), unsafe abortion (10%), and indirect causes such as anaemia, malaria, and HIV/AIDs virus (29%). The results also show that to obtain the UN recommended MMR levels of minimum 21 and maximum 42 by 2030, the Government and other stakeholders should simultaneously, reduce haemorrhaging from the current value of 62 to 33.38 and 16.69, reduce unsafe abortion from the current value of 16 to 8.62 and 4.31. Thirty years of data is used to develop the optimal reduced Poisson Model based on hemorrhaging and unsafe abortion. The model with R² of 92.68% can predict MMR with mean error of −0.42329 and SE-mean of 0.02268. The yearly optimal level of hemorrhage, unsafe abortion, and MMR can aid the government and other stakeholders on resources allocation to reduce the risk of maternal death.

Pathology of atherosclerotic coronary artery disease in the young Indian population

Atherosclerotic coronary artery disease (CAD) is of great concern in young adults because of its potential to cause great incapacitation. This arena of cardiology has gained importance in South Asian countries, particularly India due to increased prevalence that is related to traditional risk factors, altered life styles and inherent risk factors. In this study, we sought to evaluate, at autopsy, the pathology of atherosclerotic CAD in young patients with ischemic heart disease (IHD). A 10-year retrospective autopsy-based study was carried out in a large tertiary-care centre and patients aged ≤45 years with IHD were selected. Out of 545 autopsied cases of IHD, 95 patients (17.4%) were young. Among these 95 patients, 84 (88.4%) had IHD related to atherosclerotic CAD; the youngest patient was 18 years old. Predictably there was sole involvement of left anterior descending artery and the presence of fibrous plaques. Irrespective of the plaque morphology, the commonest complication was thrombosis produced by plaque erosion seen in 36.9% of patients. Acute coronary insufficiency was noted in 52 patients (61.9%), while healed infarctions were surprisingly noted in 28 patients (33.3%). Screening for IHD in the young population may help to improve prognosis by detecting subclinical disease, although more studies are necessary to establish reference limits for this young population. Additional research must also focus on treatment concerns that are specific to young patients.

Epidemiology of confirmed coronary heart disease among population older than 60 years in rural central India-A community-based cross-sectional study

Background

Three-fifths of total deaths in India are attributed to noncommunicable diseases, and coronary heart disease (CHD) is one of the dominant causes. There are only few studies available in India to find confirmed CHD by pragmatic approach. This study aims to find prevalence of confirmed CHD and its risk factors in rural community of central India.

Materials and methods

This was a community-based cross-sectional study during 2013–2014 involving adults ≥60 years from 13 villages in rural central India. We screened CHD on the basis of history and standard 12-lead ECG. Apart from the past documentation of CHD, we diagnosed confirmed CHD in symptomatic patients or with resting ECG changes by means of echocardiography, exercise ECG test or coronary angiography whenever needed.

Results

We screened 1190 of 1415 individuals ≥60 years for CHD. Five hundred eighty were men and 610 were women. Diagnosis of CHD was confirmed in 61 individuals (29 men and 32 women). The prevalence of CHD in individuals older than 60 years was 51.3 per 1000 population. Hypertension was the only independent risk factor associated with CHD, whereas association of diabetes mellitus, obesity, socioeconomic status and smoking with CHD was not significant.

Conclusion

Prevalence of confirmed CHD has increased in agrarian rural community in central India, which requires further studies to find out causative factors.

Do ANGPTL-4 and galectin-3 reflect the severity of coronary artery disease?

BACKGROUND

Coronary artery disease (CAD) is one of the leading causes of mortality and morbidity worldwide. We thereby sought to investigate whether the biomarkers, angiopoietin-like 4 (ANGPTL-4) and galectin-3, reflect the severity of CAD.

METHODS

Patients were screened based on inclusion/exclusion criteria and written informed consent was obtained from the patients. Serum ANGPTL-4 and galectin-3 was quantified using enzyme-linked immunosorbent assay (ELISA) and correlated with the Global Registry of Acute Coronary Events (GRACE) and GENSINI score using Spearman's rank correlation coefficient and multivariate analysis.

RESULTS

A total of 226 patients consisting of ST-segment elevation myocardial infarction (STEMI), non-STEMI/unstable angina (USA), chronic stable angina (CSA) and normal controls (NCs) participated in the study. ANGPTL-4 and galectin-3 were significantly higher in CAD than the NC group. ANGPTL-4 showed significant negative correlation with GRACE score in acute coronary syndrome (ACS) ( r = -0.211, p = 0.03) patients. ANGPTL-4 showed significant positive correlation with serum creatinine ( r = 0.304, p = 0.056) and body mass index (BMI) ( r = 0.424, p = 0.009) in CSA patients. A modest positive correlation was observed between the serum galectin-3 levels and GRACE score ( r = 0.187, p = 0.055) in ACS patients. However, on multivariate analysis the positive correlation relationship between ANGPTL-4 and galectin-3 with the severity of CAD was not sustained.

CONCLUSION

In conclusion, ANGPTL-4 and galectin-3 do not appear to have a promising role for assessing the severity of CAD. Nevertheless these biomarkers do warrant further exploration in improving the management of CAD.

Prevalence and control of cardiovascular risk factors in stable coronary artery outpatients in India compared with the rest of the world: An analysis from international CLARIFY registry

OBJECTIVES

We describe the clinical characteristics, prevalence and control of coronary artery disease (CAD) risk factors of the Indian cohort enrolled in the CLARIFY registry and compare them with data from rest of the world (ROW).

METHODS

CLARIFY is an international, prospective, observational, longitudinal cohort study in stable CAD outpatients. The baseline data of Indian cohort (n=709) were compared to ROW (n=31994).

RESULTS

The CLARIFY India patients were significantly younger than the ROW (59.6±10.9 vs 64.3±10.4). Indian patients were more likely than those in ROW to have diabetes (42.9% vs 28.8%) and angina (27.8% vs 21.9%). Mean heart rate was significantly greater in Indians measured by either palpatory method (76.1±10.4 vs 68.0±10.5) or ECG (74.9±12.9 vs 67.0±11.3). The use of aspirin (85.6% vs 87.8%), β-blockers (69.4% vs 75.4%), and lipid-lowering agents (90% vs 92.4%) was lower in India. A significantly greater proportion of patients in India exhibited low HDL cholesterol (41.6% vs 31.2%), and heart rate ≥70bpm (82.2% vs 48.5%). The risk factors control was poor in India with heart rate goal of ≤60bpm achieved in 2.5%; HbA1c <7% in 9.9%; and HbA1c <6.5% in 4.6% patients.

CONCLUSION

The CLARIFY registry demonstrates a high prevalence and poor control of cardiovascular risk factors in Indian patients. Systematic efforts to improve risk factor control are required.

Depression and Anxiety following Coronary Artery Bypass Graft: Current Indian Scenario

Epidemiological studies have shown a high prevalence of coronary artery disease among the Indian Population. Due to increasing availability and affordability of tertiary care in many parts of India, carefully selected patients undergo coronary artery bypass surgery to improve cardiac function. However, the procedure is commonly associated with depression and anxiety which can adversely affect overall prognosis. The objective of this review is to highlight early identifiable symptoms of depression and anxiety following coronary artery bypass graft (CABG) in Indian context so as to facilitate prompt intervention for better outcome. The current review was able to establish firm evidence in support of screening for depression and anxiety following CABG. Management of depression and anxiety following CABG is briefly reviewed.

Cardiovascular health awareness and the effect of an educational intervention on school-aged children in a rural district of India

BACKGROUND AND OBJECTIVES

India is the second most populous country in the world and two-thirds of its population is less than 35 years old. This survey was conducted to assess the level of health awareness of cardiovascular disease in adolescent school-aged children 14-16 years old, with the goal of establishing school-based health education and development of heart-healthy lifestyle practices.

METHODS

A school-based survey was conducted in the rural district of West Midnapore, India between June and July of 2014. This involved a pre-evaluation of cardiovascular disease (CVD) health awareness, a short presentation on CVD, and a post-evaluation of CVD health awareness.

RESULTS

A total of 2995 students (48% response rate) from 20 schools participated in the survey. The mean age of the students in the study sample was 14.7 years, 46% were male, 53% were in the 9th grade, and the rest were in the 10th grade. After assessing students' awareness in six domains with 20 multiple-choice questions with a maximum score of 100, the mean pre-test score was 41.1 (SD±10.5) and the mean post-test score was 48.1 (SD±16.9) (p<0.001).

CONCLUSIONS

Awareness of CVD and its risk factors was far from optimal among the adolescent school-aged children in this study. A school-based educational program may help improve awareness of CVD and reduce the future disease burden in the community. The results of this study may be useful in formulating a nationwide school health program to deal with the emerging epidemic of CVD in countries such as India.

Correlation between mimecan expression and coronary artery stenosis in patients with coronary heart disease

OBJECTIVE

This study aimed to investigate the correlation between coronary artery stenosis and Mimecan expression in patients with coronary heart disease (CHD).

METHODS

Seventy eight patients with CHD and 80 controls without vascular lesions were recruited into present study. CHD patients were divided into one-vessel CHD subgroup, 2-vessel CHD subgroup and multivessel CHD subgroup. ELISA was performed to detect the expressions of serum Mimecan and nuclear factor kappaB (NF-κB).

RESULTS

When compared with control group, the expressions of serum mimecan gene and NF-κB significantly increased in CHD groups (P < 0.05); When compared with one-vessel and two-vessel CHD subgroups, the expressions of serum mimecan and NF-κB significantly increased in multivessel CHD subgroup (P < 0.05), significant difference was observed among three subgroups (P < 0.05). The expressions of serum mimecan and NF-κB were positively related to the severity of coronary lesions (rmimecan=0.79, rNF-κB=0.83, P < 0.05).

CONCLUSION

Increased expressions of serum mimecan and NF-κB in CHD patients are related to cardiac insufficiency, which may be ascribed to the binding of NF-κB to mimecan gene.