- Email: [email protected]
Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome
G Model
JICC-384; No. of Pages 4 Journal of Indian College of Cardiology xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Indian College of Cardiology journal homepage: www.elsevier.com/locate/jicc
Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome Tamer M. Mustafa, Mohammad M. Al-Daydamony * Cardiology Department, Faculty of Medicine, Zagazig University, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 October 2016 Accepted 29 November 2016 Available online xxx
Background: Coronary artery disease (CAD) is a major health problem around the world. Acute coronary syndrome (ACS) is a serious and life threatening presentation of CAD. Metabolic syndrome (MetS) is a major risk factor for CAD. Objectives: To study the impact of MetS on angiographic severity in Egyptian ACS patients. Methods: The study included 100 patients admitted to coronary care unit of Zagazig University Hospital by ACS, among them 50 patients had Mets. All patients had undergone history taking and clinical examination, ECG, echocardiography, laboratory tests, and coronary angiography with measuring of Gensini score. Results: Patients with metabolic syndrome were significantly younger (p = 0.003). Body mass index, waist circumference, systolic, and diastolic blood pressures, fasting blood glucose, hemoglobin A1c, and serum triglycerides were significantly higher, and HDL-cholesterol was significantly lower in metabolic syndrome patients (p < 0.00001 for each). Incidence of left main coronary artery disease and threevessel disease were significantly higher in metabolic syndrome patients (p = 0.027, and 0.0211 respectively). Gensini score was significantly higher in metabolic syndrome patients (p = 0.0007). There was a significant positive correlation between Gensini score and waist circumference (r = 0.345, p = 0.0004), hemoglobin A1c (r = 0.297, p = 0.0027), and systolic blood pressure (r = 0.253, p = 0.012). Conclusion: Acute coronary syndrome patients when associated with metabolic syndrome tend to have more extensive coronary artery disease. ß 2016 Indian College of Cardiology. All rights reserved.
Keywords: Metabolic syndrome Coronary artery disease Coronary angiography Gensini score
1. Introduction Coronary artery disease (CAD) is a major worldwide heath problem,1 and this problem is even more pronounced in developing countries.2 Among the different forms of CAD, acute coronary syndrome (ACS) represents one of the severest, most important, and life threatening presentation.3 Metabolic syndrome (MetS) represents a group of cardiovascular risk factors. This group includes elevated blood pressure (BP), hyperglycemia, central obesity, elevated triglyceride (TG) levels, and decreased high-density lipoprotein cholesterol (HDL-C).4 Metabolic syndrome represents a major health problem as all components of MetS are well defined risk factors for developing of cardiovascular diseases (CVD). Also, patients with MetS are at higher risk of morbidity and mortality from CVD.4
* Corresponding author. E-mail address: [email protected] (M.M. Al-Daydamony).
Previous researchers have found a relation between different components of MetS and the angiographic severity of CAD in the western countries,5 in India,6 in Korea7 as well as in Turkey.8 However, no data are available about this relation in Egypt, a country with different and variable lifestyle patterns, food habits, urbanization, and socioeconomic and cultural factors. So, we aimed to study the impact of MetS on angiographic severity in Egyptian ACS patients. 2. Patients and methods Our study was cross-sectional study; we included 100 ACS patients who were presented to the Coronary Care Unit of the Cardiology Department, Zagazig University during the period from June 2015 to June 2016. The inclusion criteria met were first episode of ACS and age 18 years. The diagnosis of ACS was made in the presence of serial increase of cardiac biomarkers, associated with typical ECG changes and/or typical symptoms, as defined by the ACC/AHA guidelines.9 Patients with ST-segment elevation or new, left bundle
http://dx.doi.org/10.1016/j.jicc.2016.11.072 1561-8811/ß 2016 Indian College of Cardiology. All rights reserved.
Please cite this article in press as: Mustafa TM, Al-Daydamony MM. Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome, J Indian Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2016.11.072
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branch block on the admission ECG were diagnosed with STsegment elevation myocardial infarction (STEMI).9 Patients without STEMI were categorized as having non-ST-segment elevation ACS (NSTEACS).10 We excluded the patients with prior CAD or who underwent coronary revascularization. Also the patients with advanced liver or kidney disease, neoplasm, acute infections, or any contraindication for coronary angiography9,10 were excluded from our study. According to the presence of MetS, patients were classified into two groups: Group I: Included fifty patients with Mets. Group II: Included fifty patients without Mets. MetS was diagnosed if the patient had three of the five items of MetS according to the harmonized definition of MetS provided by the World heart Federation and the International Association for the Study of Obesity11 (Table 1). Central obesity was defined according to the cutoff values of waist circumference and associated cardiovascular risk in Egyptians.12 Therefore, we defined central obesity as waist circumference was 93.5 cm men and 92 cm for women. An informed written consent was obtained from every patient, and we did the following for all patients: 1) Full history taking and thorough clinical examination with emphasis on: - Body weight and height. - Waist circumference: measured using an inelastic tape, taken after expiration at the level of mid-distance between the bottom of the rib cage and the top of the iliac crest.12 2) Complete standard 12-leads electrocardiography. 3) Laboratory testing: the following laboratory test were done to all patients: - Cardiac biomarkers: creatine kinase (CK), CK-MB, and Troponin I. - Fasting serum lipids: with measuring of cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-C), and highdensity lipoprotein cholesterol (HDL-C). - Fasting and 2 h postprandial blood glucose level and hemoglobin A1c level.
Table 1 Clinical and laboratory data. MetS (n = 50) Age (years) Sex Male Female Clinical presentation: - STEMI - NSTEACS Waist circumference (cm) Body mass index (kg/m2) Heart rate (beat/min) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Fasting blood glucose (mg/dl) Hemoglobin A1c (%) Triglycerides (mg/dl) HDL-C (mg/dl)
No MetS (n = 50)
p
47.5 8.72
52.9 9.11
0.003
28 (56%) 22 (44%)
35 (70%) 15 (30%)
0.147
18 (36%) 32 (64%) 100.4 12.51 34.8 6.32 75.3 11.54 133.2 18.33 87.3 11.62 158 24.1 8.15 1.91 163 25.4 41.2 8.21
22 (44%) 28 (56%) 85.8 11.26 23.8 4.51 72.1 12.81 116.1 10.54
<0.00001 <0.00001 0.192 <0.00001
78.2 7.23
<0.00001
87.1 9.4
<0.00001
5.23 1.22 118 14.2 53.1 7.5
0.414
<0.00001 <0.00001 <0.00001
Data are expressed as mean SD or number (%). HDL-C = high density lipoprotein cholesterol. STEMI = ST-segment elevation myocardial infarction. NSTEACS = non-STsegment elevation acute coronary syndrome.
4) Coronary angiography: coronary angiography was done to all patients. The coronary artery system was visually estimated by an expert angiographer who was unaware of patients’ clinical data. The coronary artery narrowing expressed as percentage of luminal diameter stenosis. Lesions with 70% narrowing in major epicardial artery or 50% narrowing in the left main coronary artery were considered significant angiographic stenosis.13 Gensini score was calculated for every patient to assess the angiographic severity. In this score, give points to every lesion according to the percentage of stenosis multiplied by the importance of the diseased artery. Accordingly, we give 1 for 25% stenosis, 2 for 50%, 4 for 75%, 8 for 90%, 16 for 99% and 32 for total occlusion. The score is then multiplied by a factor according to the site of the lesion.14 All data were analyzed using the SPSS for Windows (Version 20.0; Armonk, NY, USA: IBM Corp.) package program. Differences between patients’ groups were analyzed using chi-square test and Student’s t-test. Correlations between different variables were investigated by Pearson correlation analysis. A p value <0.05 was regarded as being statistically significant. The study protocol had been approved by the Institutional Review Board of the Faculty of Medicine, Zagazig University.
3. Results Regarding clinical and laboratory findings and as shown in Table 1, there was no significant difference between the two groups regarding sex, duration or heart rate. Patients with Mets were significantly younger in age (p = 0.003). Waist circumference, body mass index, systolic blood pressure, diastolic blood pressure, fasting blood glucose, hemoglobin A1c, and serum triglycerides level were significantly higher in patients with MetS (p < 0.00001 for each), while serum HDL-C level was significantly lower in patients with MetS (p < 0.00001). Regarding findings of coronary angiography and as shown in Table 2, among patients with MetS, there were significantly more patients with left main coronary artery (LMCA) disease (14% versus 2%, p = 0.027), and more patients with three-vessel disease (22% versus 6%, p = 0.0211). Gensini score was significantly higher in patients with MetS (30.1 13.11 versus 21.4 9.21, p = 0.0002). As shown in Fig. 1, there was a significant positive correlation between waist circumference and Gensini score (r = 0.345, p = 0.0004). As shown in Fig. 2, there was a significant positive correlation between hemoglobin A1c level and Gensini score (r = 0.295, p = 0.0027). As shown in Fig. 3, there was a significant positive correlation between systolic blood pressure and Gensini score (r = 0.253, p = 0.012). Table 2 Coronary angiography results. MetS (n = 50) Diseased vessel: - LMCA 7 (14%) - LAD 40 (80%) - LCX 33 (66%) - RCA 23 (46%) Number of diseased vessels: - Single vessel 14 (28%) - Two vessels 25 (50%) - Three vessels 11 (22%) Gensini score 30.1 13.11
No MetS (n = 50)
p
1 33 29 20
(2%) (66%) (58%) (40%)
0.027 0.115 0.41 0.545
21 (42%) 26 (52%) 3 (6%) 21.4 9.21
0.142 0.841 0.0211 0.0002
Data are expressed as mean SD or number (%). LMCA = left main coronary artery, LAD = left anterior descending, LCX = left circumflex, RCA = right coronary artery.
Please cite this article in press as: Mustafa TM, Al-Daydamony MM. Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome, J Indian Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2016.11.072
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JICC-384; No. of Pages 4 T.M. Mustafa, M.M. Al-Daydamony / Journal of Indian College of Cardiology xxx (2016) xxx–xxx
Fig. 1. Correlation between Gensini score and waist circumference.
Fig. 2. Correlation between Gensini score and hemoglobin A1c level.
4. Discussion In our study, we have found that patients with Mets had more extensive CAD as shown by increased incidence of three-vessel disease and LMCA disease as well as increased mean Gensini score among patients with MetS. Also we have found significant positive correlations between Gensini score and different components of MetS like waist circumference, hemoglobin A1c level, and systolic blood pressure. Metabolic syndrome represents a great challenge to health providers in the 21st century. If the trend MetS continues to increase by the same present rate, the premature deaths and morbidities caused by it will adversely affect the social and financial burden in developing and developed countries as well.6 Metabolic syndrome is a major health problem in Egypt. Incidence of Mets among Egyptian population is about 7.4% among adolescents between 10 and 18 years15 and reaches 55% in middleage and elderly Egyptians.16
3
Metabolic syndrome is well known risk of developing CAD and was found to be an independent predictor of angiographically significant CAD lesions.17 Zidi and his colleagues have reported that MetS score correlates with the angiographic severity of CAD. They have also found that the predictive ability for CAD was stronger with high fasting blood glucose and high triglycerides and associated low HDL-C and high blood pressure.17 In our study, we found higher incidence of LMCA disease and multi-vessel disease, and higher Gensini score in patients with MetS. These results were concordant to those found by Kim et al.18 We also found a significant correlation between Gensini score and all of waist circumference, hemoglobin A1c, and systolic blood pressure. In concordance with our results, Kim and his colleagues have reported similar correlations between Gensini score and some components of MetS which were blood pressure (systolic and diastolic), fasting blood glucose, and HDL-C level.19 The exact mechanisms by which MetS increases CAD risk have not been fully elucidated, but given the clear associations between the two. It probably directly influences atherosclerotic plaque development and progression as well as its instability.6 Variable mechanisms have been proposed to explain the proven link between MetS and atherosclerosis among which are the vascular effects of advanced glycation end products (AGEs), pernicious effects of circulating free fatty acids (FFAs), increased systemic inflammation, and endothelial vasomotor dysfunction.20 Endothelial vasomotor dysfunction, which was found to have a major role in the development of vascular disease in patients with MetS, is associated with adverse CVD outcomes. The mechanisms that contribute in the process of endothelial dysfunction include abnormal nitric oxide release and function, increased angiotensin II and endothelin levels, reduced prostacyclin activity, and impaired endothelial fibrinolytic capacity.21 Insulin resistance and central obesity are essential components of MetS.22 Obesity as a predictor of cardiovascular events is related to many cardiovascular risk factors which are also components of MetS.23 Visceral adipose tissue has been shown to be an active endocrine organ from which several bioactive derivatives are secreted including proinflammatory and prothrombotic adipokines, and protective adiponectin.24 The accumulation of visceral fat results in increased production of proinflammatory adipokines and decreased production of adiponectin which is associated with individual components of MetS such as insulin resistance, hypertension, and dyslipidemia.25 Eventually, these abnormalities could lead to atherosclerosis and cardiovascular events.26 Our study was concordant with other studies in different parts of the world and we have shown that patients with MetS do not only have an increased risk of developing CAD but also tend to have more severe and extensive degree of it and this fact is well applied on Egyptian population as on other nationalities. 5. Conclusion Egyptian patients with ACS, when associated with Mets, tend to have more severe and severe angiographic CAD manifested by increased incidence of multi-vessel CAD and LMCA disease as well as higher mean Gensini score when compared with patients without MetS. 6. Study limitations
Fig. 3. Correlation between Gensini score and systolic blood pressure.
Actually, our study had several limitations as the relatively small number of patients, being cross-sectional study and being a single center study. In addition to these limitations, an important limitation is the study population as we only included patients with ACS in whom we always expect to find a flow limiting
Please cite this article in press as: Mustafa TM, Al-Daydamony MM. Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome, J Indian Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2016.11.072
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lesion(s) in their coronary angiogram, so we cannot search for incidence of angiographically significant CAD. Other important limitation as we used Gensini scoring system for assessing CAD severity which depends only on degree of luminal stenosis and site of lesion, so, lesion complexity and plaque vulnerability could not be analyzed in the present study. However, angiographic assessment of coronary stenosis is a clinically useful and widely accepted method for risk stratification in CAD patients. Conflict of interest The authors declare that there is no conflict of interest. References 1. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367:1747–1757. 2. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middle-income countries. Curr Probl Cardiol. 2010;35:72–115. 3. Salvagno GL, Pavan C. Prognostic biomarkers in acute coronary syndrome. Ann Transl Med. 2016;4:258. 4. Zimmet P, Magliano D, Matsuzawa Y, Alberti G, Shaw J. The metabolic syndrome: a global public health problem and a new definition. J Atheroscler Thromb. 2005; 12:295–300. 5. Solymoss BC, Bourassa MG, Campeau L, et al. Effect of increasing metabolic syndrome score on atherosclerotic risk profile and coronary artery disease angiographic severity. Am J Cardiol. 2004;93:159–164. 6. Sinha SK, Goel A, Madaan A, et al. Prevalence of metabolic syndrome and its clinical and angiographic profile in patients with naive acute coronary syndrome in north Indian population. J Clin Med Res. 2016;8:667–673. 7. Yoon SE, Ahn SG, Kim JY, et al. Differential relationship between metabolic syndrome score and severity of coronary atherosclerosis as assessed by angiography in a non-diabetic and diabetic Korean population. J Korean Med Sci. 2011;26: 900–905. 8. Aykan A&cd, Gu¨l I˙dt., Kalaycıog˘lu E, et al. Is metabolic syndrome related with coronary artery disease severity and complexity: an observational study about IDF and AHA/NHLBI metabolic syndrome definitions. Cardiol J. 2014;21:245–251. 9. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425. 10. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344–e426.
11. Alberti KG, Eckel RH, Grundy SM, et al. International Diabetes Federation Task Force on Epidemiology and Prevention; Hational Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; International Association for the Study of Obesity. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009;120:1640–1645. 12. Ibrahim MM, Elamragy AA, Girgis H, Nour MA. Cut off values of waist circumference and associated cardiovascular risk in Egyptians. BMC Cardiovasc Disord. 2011;11:53. 13. Powell D, Moxey CF. Diagnostic catheterization. In: Watson S, Gorski KA, eds. In: Invasive Cardiology: A Manual for Cath Lab Personnel 3rd ed. Sudbury, MA, USA: Jones & Bartlett Learning; 2011:143–162. 14. Gensini GG. A more meaningful scoring system for determining the severity of coronary heart disease. Am J Cardiol. 1983;51:606. 15. Aboul Ella NA, Shehab DI, Ismail MA, Maksoud AA. Prevalence of metabolic syndrome and insulin resistance among Egyptian adolescents 10–18 years of age. J Clin Lipidol. 2010;4:185–195. 16. Abd Elaziz KM, Gabal MS, Aldafrawy OA, Abou Seif HA, Allam MF. Prevalence of metabolic syndrome and cardiovascular risk factors among voluntary screened middle-aged and elderly Egyptians. J Public Health (Oxf). 2015;37:612–617. 17. Zidi W, Allal-Elasmi M, Zayani Y, et al. Metabolic syndrome, independent predictor for coronary artery disease. Clin Lab. 2015;61:1545–1552. 18. Kim JY, Choi EY, Mun HS, et al. Usefulness of metabolic syndrome score in the prediction of angiographic coronary artery disease severity according to the presence of diabetes mellitus: relation with inflammatory markers and adipokines. Cardiovasc Diabetol. 2013;12:140. http://dx.doi.org/10.1186/1475-2840-12-140. 19. Kim JY, Mun HS, Lee BK, et al. Impact of metabolic syndrome and its individual components on the presence and severity of angiographic coronary artery disease. Yonsei Med J. 2010;51:676–682. 20. Jain P, Lahiri A. Metabolic syndrome: an evolving threat in the genesis of coronary artery disease. J Cardiometab Syndr. 2007;2:190–197. 21. Van Guilder GP, Hoetzer GL, Greiner JJ, Stauffer BL, DeSouza CA. Metabolic syndrome and endothelial fibrinolytic capacity in obese adults. Am J Physiol Regul Integr Comp Physiol. 2008;294:R39–R44. 22. Mottillo S, Filion KB, Genest J, et al. The metabolic syndrome and cardiovascular risk a systematic review and meta-analysis. J Am Coll Cardiol. 2010;56:1113–1132. 23. Yusuf S, Hawken S, Ounpuu S, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366: 1640–1649. 24. Hutley L, Prins JB. Fat as an endocrine organ: relationship to the metabolic syndrome. Am J Med Sci. 2005;330:280–289. 25. Espinola-Klein C, Gori T, Blankenberg S, Munzel T. Inflammatory markers and cardiovascular risk in the metabolic syndrome. Front Biosci (Landmark Ed). 2011; 16:1663–1674. 26. Kim HM, Kim KJ, Lee HJ, et al. Epicardial adipose tissue thickness is an indicator for coronary artery stenosis in asymptomatic type 2 diabetic patients: its assessment by cardiac magnetic resonance. Cardiovasc Diabetol. 2012;11:83. http://dx.doi.org/ 10.1186/1475-2840-11-83.
Please cite this article in press as: Mustafa TM, Al-Daydamony MM. Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome, J Indian Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2016.11.072
JICC-384; No. of Pages 4 Journal of Indian College of Cardiology xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Indian College of Cardiology journal homepage: www.elsevier.com/locate/jicc
Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome Tamer M. Mustafa, Mohammad M. Al-Daydamony * Cardiology Department, Faculty of Medicine, Zagazig University, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 October 2016 Accepted 29 November 2016 Available online xxx
Background: Coronary artery disease (CAD) is a major health problem around the world. Acute coronary syndrome (ACS) is a serious and life threatening presentation of CAD. Metabolic syndrome (MetS) is a major risk factor for CAD. Objectives: To study the impact of MetS on angiographic severity in Egyptian ACS patients. Methods: The study included 100 patients admitted to coronary care unit of Zagazig University Hospital by ACS, among them 50 patients had Mets. All patients had undergone history taking and clinical examination, ECG, echocardiography, laboratory tests, and coronary angiography with measuring of Gensini score. Results: Patients with metabolic syndrome were significantly younger (p = 0.003). Body mass index, waist circumference, systolic, and diastolic blood pressures, fasting blood glucose, hemoglobin A1c, and serum triglycerides were significantly higher, and HDL-cholesterol was significantly lower in metabolic syndrome patients (p < 0.00001 for each). Incidence of left main coronary artery disease and threevessel disease were significantly higher in metabolic syndrome patients (p = 0.027, and 0.0211 respectively). Gensini score was significantly higher in metabolic syndrome patients (p = 0.0007). There was a significant positive correlation between Gensini score and waist circumference (r = 0.345, p = 0.0004), hemoglobin A1c (r = 0.297, p = 0.0027), and systolic blood pressure (r = 0.253, p = 0.012). Conclusion: Acute coronary syndrome patients when associated with metabolic syndrome tend to have more extensive coronary artery disease. ß 2016 Indian College of Cardiology. All rights reserved.
Keywords: Metabolic syndrome Coronary artery disease Coronary angiography Gensini score
1. Introduction Coronary artery disease (CAD) is a major worldwide heath problem,1 and this problem is even more pronounced in developing countries.2 Among the different forms of CAD, acute coronary syndrome (ACS) represents one of the severest, most important, and life threatening presentation.3 Metabolic syndrome (MetS) represents a group of cardiovascular risk factors. This group includes elevated blood pressure (BP), hyperglycemia, central obesity, elevated triglyceride (TG) levels, and decreased high-density lipoprotein cholesterol (HDL-C).4 Metabolic syndrome represents a major health problem as all components of MetS are well defined risk factors for developing of cardiovascular diseases (CVD). Also, patients with MetS are at higher risk of morbidity and mortality from CVD.4
* Corresponding author. E-mail address: [email protected] (M.M. Al-Daydamony).
Previous researchers have found a relation between different components of MetS and the angiographic severity of CAD in the western countries,5 in India,6 in Korea7 as well as in Turkey.8 However, no data are available about this relation in Egypt, a country with different and variable lifestyle patterns, food habits, urbanization, and socioeconomic and cultural factors. So, we aimed to study the impact of MetS on angiographic severity in Egyptian ACS patients. 2. Patients and methods Our study was cross-sectional study; we included 100 ACS patients who were presented to the Coronary Care Unit of the Cardiology Department, Zagazig University during the period from June 2015 to June 2016. The inclusion criteria met were first episode of ACS and age 18 years. The diagnosis of ACS was made in the presence of serial increase of cardiac biomarkers, associated with typical ECG changes and/or typical symptoms, as defined by the ACC/AHA guidelines.9 Patients with ST-segment elevation or new, left bundle
http://dx.doi.org/10.1016/j.jicc.2016.11.072 1561-8811/ß 2016 Indian College of Cardiology. All rights reserved.
Please cite this article in press as: Mustafa TM, Al-Daydamony MM. Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome, J Indian Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2016.11.072
G Model
JICC-384; No. of Pages 4 2
T.M. Mustafa, M.M. Al-Daydamony / Journal of Indian College of Cardiology xxx (2016) xxx–xxx
branch block on the admission ECG were diagnosed with STsegment elevation myocardial infarction (STEMI).9 Patients without STEMI were categorized as having non-ST-segment elevation ACS (NSTEACS).10 We excluded the patients with prior CAD or who underwent coronary revascularization. Also the patients with advanced liver or kidney disease, neoplasm, acute infections, or any contraindication for coronary angiography9,10 were excluded from our study. According to the presence of MetS, patients were classified into two groups: Group I: Included fifty patients with Mets. Group II: Included fifty patients without Mets. MetS was diagnosed if the patient had three of the five items of MetS according to the harmonized definition of MetS provided by the World heart Federation and the International Association for the Study of Obesity11 (Table 1). Central obesity was defined according to the cutoff values of waist circumference and associated cardiovascular risk in Egyptians.12 Therefore, we defined central obesity as waist circumference was 93.5 cm men and 92 cm for women. An informed written consent was obtained from every patient, and we did the following for all patients: 1) Full history taking and thorough clinical examination with emphasis on: - Body weight and height. - Waist circumference: measured using an inelastic tape, taken after expiration at the level of mid-distance between the bottom of the rib cage and the top of the iliac crest.12 2) Complete standard 12-leads electrocardiography. 3) Laboratory testing: the following laboratory test were done to all patients: - Cardiac biomarkers: creatine kinase (CK), CK-MB, and Troponin I. - Fasting serum lipids: with measuring of cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-C), and highdensity lipoprotein cholesterol (HDL-C). - Fasting and 2 h postprandial blood glucose level and hemoglobin A1c level.
Table 1 Clinical and laboratory data. MetS (n = 50) Age (years) Sex Male Female Clinical presentation: - STEMI - NSTEACS Waist circumference (cm) Body mass index (kg/m2) Heart rate (beat/min) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Fasting blood glucose (mg/dl) Hemoglobin A1c (%) Triglycerides (mg/dl) HDL-C (mg/dl)
No MetS (n = 50)
p
47.5 8.72
52.9 9.11
0.003
28 (56%) 22 (44%)
35 (70%) 15 (30%)
0.147
18 (36%) 32 (64%) 100.4 12.51 34.8 6.32 75.3 11.54 133.2 18.33 87.3 11.62 158 24.1 8.15 1.91 163 25.4 41.2 8.21
22 (44%) 28 (56%) 85.8 11.26 23.8 4.51 72.1 12.81 116.1 10.54
<0.00001 <0.00001 0.192 <0.00001
78.2 7.23
<0.00001
87.1 9.4
<0.00001
5.23 1.22 118 14.2 53.1 7.5
0.414
<0.00001 <0.00001 <0.00001
Data are expressed as mean SD or number (%). HDL-C = high density lipoprotein cholesterol. STEMI = ST-segment elevation myocardial infarction. NSTEACS = non-STsegment elevation acute coronary syndrome.
4) Coronary angiography: coronary angiography was done to all patients. The coronary artery system was visually estimated by an expert angiographer who was unaware of patients’ clinical data. The coronary artery narrowing expressed as percentage of luminal diameter stenosis. Lesions with 70% narrowing in major epicardial artery or 50% narrowing in the left main coronary artery were considered significant angiographic stenosis.13 Gensini score was calculated for every patient to assess the angiographic severity. In this score, give points to every lesion according to the percentage of stenosis multiplied by the importance of the diseased artery. Accordingly, we give 1 for 25% stenosis, 2 for 50%, 4 for 75%, 8 for 90%, 16 for 99% and 32 for total occlusion. The score is then multiplied by a factor according to the site of the lesion.14 All data were analyzed using the SPSS for Windows (Version 20.0; Armonk, NY, USA: IBM Corp.) package program. Differences between patients’ groups were analyzed using chi-square test and Student’s t-test. Correlations between different variables were investigated by Pearson correlation analysis. A p value <0.05 was regarded as being statistically significant. The study protocol had been approved by the Institutional Review Board of the Faculty of Medicine, Zagazig University.
3. Results Regarding clinical and laboratory findings and as shown in Table 1, there was no significant difference between the two groups regarding sex, duration or heart rate. Patients with Mets were significantly younger in age (p = 0.003). Waist circumference, body mass index, systolic blood pressure, diastolic blood pressure, fasting blood glucose, hemoglobin A1c, and serum triglycerides level were significantly higher in patients with MetS (p < 0.00001 for each), while serum HDL-C level was significantly lower in patients with MetS (p < 0.00001). Regarding findings of coronary angiography and as shown in Table 2, among patients with MetS, there were significantly more patients with left main coronary artery (LMCA) disease (14% versus 2%, p = 0.027), and more patients with three-vessel disease (22% versus 6%, p = 0.0211). Gensini score was significantly higher in patients with MetS (30.1 13.11 versus 21.4 9.21, p = 0.0002). As shown in Fig. 1, there was a significant positive correlation between waist circumference and Gensini score (r = 0.345, p = 0.0004). As shown in Fig. 2, there was a significant positive correlation between hemoglobin A1c level and Gensini score (r = 0.295, p = 0.0027). As shown in Fig. 3, there was a significant positive correlation between systolic blood pressure and Gensini score (r = 0.253, p = 0.012). Table 2 Coronary angiography results. MetS (n = 50) Diseased vessel: - LMCA 7 (14%) - LAD 40 (80%) - LCX 33 (66%) - RCA 23 (46%) Number of diseased vessels: - Single vessel 14 (28%) - Two vessels 25 (50%) - Three vessels 11 (22%) Gensini score 30.1 13.11
No MetS (n = 50)
p
1 33 29 20
(2%) (66%) (58%) (40%)
0.027 0.115 0.41 0.545
21 (42%) 26 (52%) 3 (6%) 21.4 9.21
0.142 0.841 0.0211 0.0002
Data are expressed as mean SD or number (%). LMCA = left main coronary artery, LAD = left anterior descending, LCX = left circumflex, RCA = right coronary artery.
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Fig. 1. Correlation between Gensini score and waist circumference.
Fig. 2. Correlation between Gensini score and hemoglobin A1c level.
4. Discussion In our study, we have found that patients with Mets had more extensive CAD as shown by increased incidence of three-vessel disease and LMCA disease as well as increased mean Gensini score among patients with MetS. Also we have found significant positive correlations between Gensini score and different components of MetS like waist circumference, hemoglobin A1c level, and systolic blood pressure. Metabolic syndrome represents a great challenge to health providers in the 21st century. If the trend MetS continues to increase by the same present rate, the premature deaths and morbidities caused by it will adversely affect the social and financial burden in developing and developed countries as well.6 Metabolic syndrome is a major health problem in Egypt. Incidence of Mets among Egyptian population is about 7.4% among adolescents between 10 and 18 years15 and reaches 55% in middleage and elderly Egyptians.16
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Metabolic syndrome is well known risk of developing CAD and was found to be an independent predictor of angiographically significant CAD lesions.17 Zidi and his colleagues have reported that MetS score correlates with the angiographic severity of CAD. They have also found that the predictive ability for CAD was stronger with high fasting blood glucose and high triglycerides and associated low HDL-C and high blood pressure.17 In our study, we found higher incidence of LMCA disease and multi-vessel disease, and higher Gensini score in patients with MetS. These results were concordant to those found by Kim et al.18 We also found a significant correlation between Gensini score and all of waist circumference, hemoglobin A1c, and systolic blood pressure. In concordance with our results, Kim and his colleagues have reported similar correlations between Gensini score and some components of MetS which were blood pressure (systolic and diastolic), fasting blood glucose, and HDL-C level.19 The exact mechanisms by which MetS increases CAD risk have not been fully elucidated, but given the clear associations between the two. It probably directly influences atherosclerotic plaque development and progression as well as its instability.6 Variable mechanisms have been proposed to explain the proven link between MetS and atherosclerosis among which are the vascular effects of advanced glycation end products (AGEs), pernicious effects of circulating free fatty acids (FFAs), increased systemic inflammation, and endothelial vasomotor dysfunction.20 Endothelial vasomotor dysfunction, which was found to have a major role in the development of vascular disease in patients with MetS, is associated with adverse CVD outcomes. The mechanisms that contribute in the process of endothelial dysfunction include abnormal nitric oxide release and function, increased angiotensin II and endothelin levels, reduced prostacyclin activity, and impaired endothelial fibrinolytic capacity.21 Insulin resistance and central obesity are essential components of MetS.22 Obesity as a predictor of cardiovascular events is related to many cardiovascular risk factors which are also components of MetS.23 Visceral adipose tissue has been shown to be an active endocrine organ from which several bioactive derivatives are secreted including proinflammatory and prothrombotic adipokines, and protective adiponectin.24 The accumulation of visceral fat results in increased production of proinflammatory adipokines and decreased production of adiponectin which is associated with individual components of MetS such as insulin resistance, hypertension, and dyslipidemia.25 Eventually, these abnormalities could lead to atherosclerosis and cardiovascular events.26 Our study was concordant with other studies in different parts of the world and we have shown that patients with MetS do not only have an increased risk of developing CAD but also tend to have more severe and extensive degree of it and this fact is well applied on Egyptian population as on other nationalities. 5. Conclusion Egyptian patients with ACS, when associated with Mets, tend to have more severe and severe angiographic CAD manifested by increased incidence of multi-vessel CAD and LMCA disease as well as higher mean Gensini score when compared with patients without MetS. 6. Study limitations
Fig. 3. Correlation between Gensini score and systolic blood pressure.
Actually, our study had several limitations as the relatively small number of patients, being cross-sectional study and being a single center study. In addition to these limitations, an important limitation is the study population as we only included patients with ACS in whom we always expect to find a flow limiting
Please cite this article in press as: Mustafa TM, Al-Daydamony MM. Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome, J Indian Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2016.11.072
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lesion(s) in their coronary angiogram, so we cannot search for incidence of angiographically significant CAD. Other important limitation as we used Gensini scoring system for assessing CAD severity which depends only on degree of luminal stenosis and site of lesion, so, lesion complexity and plaque vulnerability could not be analyzed in the present study. However, angiographic assessment of coronary stenosis is a clinically useful and widely accepted method for risk stratification in CAD patients. Conflict of interest The authors declare that there is no conflict of interest. References 1. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367:1747–1757. 2. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middle-income countries. Curr Probl Cardiol. 2010;35:72–115. 3. Salvagno GL, Pavan C. Prognostic biomarkers in acute coronary syndrome. Ann Transl Med. 2016;4:258. 4. Zimmet P, Magliano D, Matsuzawa Y, Alberti G, Shaw J. The metabolic syndrome: a global public health problem and a new definition. J Atheroscler Thromb. 2005; 12:295–300. 5. Solymoss BC, Bourassa MG, Campeau L, et al. Effect of increasing metabolic syndrome score on atherosclerotic risk profile and coronary artery disease angiographic severity. Am J Cardiol. 2004;93:159–164. 6. Sinha SK, Goel A, Madaan A, et al. Prevalence of metabolic syndrome and its clinical and angiographic profile in patients with naive acute coronary syndrome in north Indian population. J Clin Med Res. 2016;8:667–673. 7. Yoon SE, Ahn SG, Kim JY, et al. Differential relationship between metabolic syndrome score and severity of coronary atherosclerosis as assessed by angiography in a non-diabetic and diabetic Korean population. J Korean Med Sci. 2011;26: 900–905. 8. Aykan A&cd, Gu¨l I˙dt., Kalaycıog˘lu E, et al. Is metabolic syndrome related with coronary artery disease severity and complexity: an observational study about IDF and AHA/NHLBI metabolic syndrome definitions. Cardiol J. 2014;21:245–251. 9. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–e425. 10. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344–e426.
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Please cite this article in press as: Mustafa TM, Al-Daydamony MM. Impact of metabolic syndrome on angiographic severity in Egyptian patients with acute coronary syndrome, J Indian Coll Cardiol. (2016), http://dx.doi.org/10.1016/j.jicc.2016.11.072