Clinical Profile , Dyslipidemia and ACSa Correlation

Introduction: To analyze lipid profile in patients with ACS, and to study the pattern of the involvement and complication in ACS. Methods: Hundred and eight consecutive cases of ACS, attending the CCU of Tribhuvan University Teaching Hospital fulfilling the criteria, were taken for the present study. Patient from age 30 and older were studied. All cases were scrutinized to detail serial 12 lead EKG, serial cardiac biochemical markers, laboratory test, echocardiographic study. Design of the study was carried out in prospective, cross sectional study. results: Hyperlipidemia was present in 61% of the patients. Only 27% of them were on statins. Most of them had high cholesterol level 68%, high Tgl level 75%, Ldl 50%, where as <40 Hdl (93%) patient were found to be low. 40% was found to have UAP. In addition patient with hypertension (76%) diabetes (65%) also had comorbidity for obesity 35%, and lipid abnormalities 75% for triglycerides, 66% for TC, 50% for LDL-C, 93% for low HDL-C, and a family history of CAD in 57%. conclusions: The outcome of this study showed that the majority are male, relatively younger as compared to Western population. USA and STEMI were the dominant types of ACS. Strong correlations between TC, LDL-C, and  low HDL-C  in patient with ACS were noted. Majority of patients had hypertension, IHD in their families and Hyperlipidemia diabetes, smoking as the major risk factors. Better control of risk factors and the awareness of preventive strategies are needed. _______________________________________________________________________________________


IntroductIon
Atherosclerosis is a chronic, multifocal immuno inflammatory; fibroproliferative disease of mediumsized and large arteries mainly driven by lipid accumulation. 1The fundamental etiologic mechanism shared by all the forms of ACS is an imbalance between myocardial oxygen supply and demand.The most common cause of ACS is thrombus formation over a preexisting atherosclerotic plaque that has undergone disruption or erosion.Plaques vulnerable to disruption and thrombosis formation commonly have a large lipid core with elevated tissue factor content, a thin fibrous cap, and enhanced inflammatory activity within the plaque.When endothelial erosion of a plaque occurs, the subendothelial connective tissue is exposed, allowing platelets to adhere and eventual thrombus to form at the plaque surface. 2 Alternatively, during plaque disruption, the fibrous cap tears or fissures to expose the highly thrombogenic lipid core to arterial blood, leading to platelet aggregation and thrombus formation.The final common pathway leading to thrombus formation is platelet aggregation, which is mediated by the GP IIb/IIIa receptors.In UA and NSTEMI, the intraarterial thrombus does not fully occlude the lumen, and some ante grade blood flow remains intact.However, clumps of activated platelets at the surface of an intra-luminal thrombus as well as components of the disrupted plaque may be swept downstream into the distal myocardial vascular bed.These micro emboli may cause microscopic foci of myocardial necrosis and are believed to be primarily responsible for the release of biomarkers of myocardial infarction seen in patients with NSTEMI. 3The contrasting scenario is for the thrombus to fully occlude the arterial lumen, resulting in an acute Q-wave myocardial infarction (commonly with ST elevation).UA/NSTEMI primarily caused by a nonocclusive thrombus benefit from a treatment regimen including anti-thrombotic and antiplatelet agents. 3,4

the objectives of the study
To study of the clinical profile, measure the outcomes of cardiac biochemical markers, lipid profile in patient and correlate clinically with acute coronary syndrome.

MEtHods
These was a prospective cross sectional study of acute coronary syndrome; clinically and correlate them with lipid profile findings in Nepalese patients.This study was carried out in Tribhuvan University Teaching Hospital (TUTH), in-patient Department of CCU from 2009 to 2012.This hospital is a tertiary care hospital and referral center with all the facilities.During the study period all the cases of ACS patient attending the inpatient department were consecutively enrolled in the study.A total of 108 patients seen in the CCU with a primary diagnosis of ACS were studied according to the guidelines for ACS; fulfilling inclusion criteria and a set of baseline investigation needed for the study of acute coronary syndrome were done on the patient.

Inclusion criteria
1. Presenting or admitted to hospital with symptoms suspected to represent UA or NSTEMI.2. New onset or worsening symptoms within six hours of presentation to the ER. 3. Patient Age group from 30 Years and older 4. At least two of the three following additional criteria: Age greater than or equal to 30 years.Troponin T or I or CK-MB above the upper limit of normal for the local Institution ECG changes compatible with ischemia.5. Written informed consent dated and signed 6.Both sexes male and female.Recent (≤ 7 days) ACS Exclusion criteria.Age <30 years, Hemorrhagic stroke within the last 12 months, Associated Renal disease Severe renal insufficiency (i.e., estimated creatinine clearance <20 ml/min), Left Ventricular Failure, NYHA IV, Persistent severe hypertension, defined as systolic blood pressure of ≥180 mm Hg or diastolic pressure of 110 mm Hg, active bleeding or at high risk for bleeding (e.g., cirrhosis of the liver, any history of intracranial hemorrhage), Scheduled/planned cardiac catheterization, PCI, CABG or other invasive procedure planned in the 24 weeks, Co-morbid condition with life expectancy less than six months, Any contraindication to UFH or LMWH, Refused informed consent .statistical Analysis.Performed using the software SPSS for Windows, Version 11.5.Categorical variables were compared by chi square test and the continuous variables are presented as mean (+/-SD) and were compared by unpaired t-test.Odd's ratios were calculated and presented wherever necessary.A probability value of <0.05 was considered statistically significant.

rEsults
A total no of 108 patients were enrolled in this prospective, cross sectional study in the CCU, of Tribuhvan University Teaching Hospital.Among them gender wise 51% patient were male.

dIscussIon
The prevalence of acute coronary syndromes is increasing.The major pathophysiologic mechanism is plaque rupture or fissuring with superimposed thrombus.Today, ACS is one of the commonest causes of hospitalization. 1 Each year, more than 1.4 million patients in the United States 2 and more than four million worldwide 3 are hospitalized with ACS.These numbers will continue to rise as the prevalence of patients with dyslipideamia, obesity and diabetes increases. 3e syndromes of unstable angina, nonST-elevation MI (NSTEMI) and ST-elevation MI (STEMI) are a continuum, and the pathophysiology is heterogeneous and dynamic.Clinical presentation depends on the severity of the arterial injury; the size and type of thrombus formed the extent and duration of ischemia, and the amount of previous myocardial necrosis.
Between 2% and 15% of patients diagnosed with unstable angina subsequently develop Q-wave MI.The unstable angina classification developed by Braunwald 6 is based on the severity of symptoms, their clinical context, and the intensity of medical treatment.The classification has been validated clinically, 7 has been shown to correlate with coronary angiographic findings , 8 and has now been updated to include troponin levels. 9 The main findings of our study were the strong association of acute coronary syndrome with high Among study population, 39% patients were diagnosed to have UA followed by STEMI in 33% patients and 29% NSTEMI.This is in agreement with the previous study, where in EHS (42.3%) and GRACE registry (30%) was STEMI patients.Whole treatment pattern is comparable to GRACE study.In the present study, antiplatelet, anticoagulant and lipid lowering agent were found to be used in minimum patients, but maximum during their hospital stay, except few patients in which those drug class was contraindicated.9][10] Dyslipideamia, obesity have been shown to have important consequences for coronary heart disease morbidity and mortality 20 and are strongly associated with numerous coronary heart disease risk factors, such as elevated levels of total cholesterol, low-density lipoprotein cholesterol, triglycerides, blood pressure, C-reactive protein, and insulin resistance, as well as with lower levels of high-density lipoprotein cholesterol, an important protective factor for coronary heart disease. 20slipideamia and obesity pose a serious public health concern in Nepal in view of the rapid changes in lifestyle with processed foods increasingly replacing traditional foods.In a previous study of subjects with chest pain it was reported that Troponin was positive in 160 subjects (31.9%) and negative in 323 (64.3%) subjects. 14They also reported higher incidence of Acute Myocardial Infarction, Acute heart failure, and death due to cardiac event in the subjects with chest pain and positive Troponin confirming that it is a powerful, independent and valuable tool for risk stratification in patients with acute chest pain.Our data indicated that, of the subjects with chest pain (108), 56 subjects (65%) were detected positive and a proportion of subjects 30(35%) were detected negative for Troponin.Accordingly; those 65% subjects with chest pain are at high risk of developing cardiac event.6][17]  This research shows that patients who developed chest pain due to cardiac event as confirmed by positive Troponin test had lipid parameters in the risk levels as suggested by ATP III.Therefore the subjects who had lipid profile levels within risk level were at a greater risk of developing chest pain due to cardiac event.Therefore it is advisable to screen and identify those subjects with risk levels of lipid profile parameters and advise them to control their lipid profiles to maintain within the levels as per recommended.Cigarette smoking and hypercholesterolemia are the two most important, independent modifiable major risk factors for ACS at as seen for the anthropometric variables.Preventive strategies and accelerated efforts to create awareness are needed and point to the urgent need for targeted public health interventions.

table 1 . demographic characteristics of study popula- tion. socio-demographic information number (n =108) Percentage (%) Marital status
Bulks of the patient were from the urban areas 59%, and the rest from rural areas 41%.
The incidence of types ACS according to clinical profile is shown in table 4. On analyzing the clinical profile of the patient most common (94, 87%) patient were married, followed by widowed (10, 9.3%), and single (4, 3.7%).Most of the studied populations were illiterate 31% followed by read write only 25%, high school 13.9%, bachelor 20.4% and post graduate 9.3%.student.

table 4 . Correlation of clinical profile with Troponin (n =108).
We attempted to find out the correlation significance of clinical profile of the patient with types of acs in the number of subjects under our study group with the history of acs admitted in our hospital.The results are shown in table 3-7.We found very interesting outcomes of our research.We found a negative inverse correlaton of clinical profiles, though relavant with types of ACS in the low HDL group p<.303 showed no correlation with these variables though they were clinically significant relevant.A positive statistically significant correlation did show up in the subjects with hypercholesterolemia p<.037, than the normal subjects with types of ACS.40% with hypercholesterolimia had STEMI, followed by 31% NSTEMI, and 29% unsable angina compared to those with normal finding.Statistical significant correlation were noted with total cholesterol p<.001, high TGL p<.008, and high LDL p<.019 with types of ACS in compared to the subjects with normal parameters, where STEMI was found to be 44% followed by UAP 29% and NSTEMI 27% respectively.
p<.000, high TGL level p<.007, and high LDL level subjects p<.006, than those with normal levels but with positive troponin finding.A correlation with low HDL level though clinically relevant could not be established, the reason could be of low sample size or other factors influencing the study subjects.

table 7 . Correlation between Types of ACS and Lipid profile (n =108).
[20][21][22] marital status, age wise, gender wise and BMI with troponin and found to be significant p<.008, p<.000, p<.028 respectively than the normal subjects.Similar findings have been reported from the Bogalusa Heart Study, NHANES, and CARDIA study and many other North American and European studies.The present study shows that the increase in risk factors in Nepalese population starting at about the age of 30 years and beyond, focus of prevention should be at subjects lower than this age.[20][21][22]conclusIonsHigh rates of dyslipideamia were noted in middleaged and elderly patients.Diabetes Mellitus and hypertension are important risk factors for young ACS patient age group, especially in association with hypercholesterolemia. Developing and implementing effective population-based intervention strategies focusing on diabetes are warranted to lower the CHD risk for patient with.Better control of risk factors and the awareness of preventive strategies are needed to be implemented promptly and swiftly.