|Year : 2019 | Volume
| Issue : 3 | Page : 625-634
Epidemiological and clinical profile of acute coronary syndrome of Egyptian patients admitted to the Coronary Care Unit, Al-Azhar University Hospital, New Damietta
Mohamed S Bashandy1, Heba M Abd Elgalil2, Hanaa A.E Abou Elhassan2
1 Department of Cardiology, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
2 Department of Community and Occupational Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
|Date of Submission||24-Sep-2019|
|Date of Decision||24-Sep-2019|
|Date of Acceptance||14-Nov-2019|
|Date of Web Publication||10-Feb-2020|
MD Mohamed S Bashandy
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Damietta, Cairo, 11754
Source of Support: None, Conflict of Interest: None
Background Acute coronary syndrome (ACS) is a multifactorial disease that represents a serious life-threatening health issue and health-care cost globally. Therefore, identifying the risk factors is of value in its prevention. We aimed to report on the epidemiological and clinical profile of ACS patients admitted to the Coronary Care Unit in Al-Azhar University Hospital, New Damietta.
Patients and methods A hospital-based analytical cross-sectional study was performed for over 6 months on ACS patients recruited from the Coronary Care Unit of Al-Azhar University Hospital, New Damietta, Egypt. Assessment of patients was carried out by history, clinical cardiac examination, resting ECG, echocardiography, and laboratory investigation. Coronary angiography was done according to the clinical scenario and the patients were followed up during the time of hospitalization to assess their outcomes.
Results Overall there were 184 ACS patients, 66.3% of them were either in the young (16.3%) or middle (50%) age groups with a mean age of 55.6±11.6 years; 52.2% diagnosed as ST segment elevation myocardial infarction which was more common significantly among young and middle aged patients. Male sex was predominant. Overweight/obesity was the most prevalent risk factor in all age groups, followed by current smoking in young and middle age groups. Hypertension and diabetes mellitus were more common in the older age groups.
Conclusion Overweight/obesity and male sex were the major significant risk factors, followed by smoking, hypertension, and diabetes mellitus. There is an appreciable burden of major cardiovascular risk factors as all patients had at least one of them.
Keywords: acute coronary syndrome, Damietta, Egypt, epidemiology, risk factors
|How to cite this article:|
Bashandy MS, Abd Elgalil HM, Abou Elhassan HA. Epidemiological and clinical profile of acute coronary syndrome of Egyptian patients admitted to the Coronary Care Unit, Al-Azhar University Hospital, New Damietta. Sci J Al-Azhar Med Fac Girls 2019;3:625-34
|How to cite this URL:|
Bashandy MS, Abd Elgalil HM, Abou Elhassan HA. Epidemiological and clinical profile of acute coronary syndrome of Egyptian patients admitted to the Coronary Care Unit, Al-Azhar University Hospital, New Damietta. Sci J Al-Azhar Med Fac Girls [serial online] 2019 [cited 2020 Feb 29];3:625-34. Available from: http://www.sjamf.eg.net/text.asp?2019/3/3/625/278040
| Introduction|| |
Coronary artery disease (CAD) represents an important form of cardiovascular disease (CVD). It has turned into an emerging epidemic in developing countries .
Acute coronary syndrome (ACS) is often the first presentation and serious acute life-threatening clinical manifestation of CAD. It is associated mostly with rupture of an atherosclerotic plaque in a coronary artery resulting in partial or complete thrombosis . ACS includes unstable angina (UA) and myocardial infarction (MI); the latter is further classified according to ECG changes as non-ST segment elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI) ,.
ACS makes the largest contribution to all acute hospitalizations these days. It is responsible for nearly half of all deaths due to CVD globally . In 2012, ACS accounted for 12.8% of overall mortality . It is expected to be the main cause of death till 2020 . It is a remarkable cardiac issue accounting for disability both in men and women resulting in high personal, clinical, and financial burdens . These burdens are not constrained to the rich or the elderly, with affecting even the poor nowadays; it has been observed in young age groups more frequently; thus ACS requires timely risk detection, prompt diagnosis, and early care .
Most epidemiological studies have categorized the risk factors for CAD as well as ACS into nonmodifiable (e.g. genetic factors, age, family history, etc.) and modifiable risk factors either behavioral (e.g. unhealthy food, physical inactivity, smoking and alcohol intake) or physical factors [e.g. diabetes mellitus (DM), hypertension (HTN), dyslipidemia, increased waist circumference, and improper BMI] ,, with contribution of psychological/psychosocial factors .
In last few decades, the epidemiology of ACS showed changes that can be explained sometimes by advanced management or change in risk factors because of urbanization that could convey a major impact on the overall health-care system .
Therefore, early risk detection is essential in guiding the treatment and predicting the prognosis. However, in Egypt data are lacking concerning the epidemiological pattern and clinical presentation of ACS.
| Aim|| |
This study aimed to highlight a brief overview of the clinical and some epidemiological profile of ACS hospitalized patients that could help in providing clear information for various levels of prevention.
| Patients and methods|| |
A hospital-based analytical cross-sectional study was performed for over 6 months from June to December 2017 on ACS patients older than 21 years who were admitted to the Coronary Care Unit (CCU) of Al-Azhar University Hospital, New Damietta, Egypt.
Sample size calculation
Sample size was determined using EPI Info (Centers for Disease Control and Prevention, Atlanta, GA, USA), version 7, according to the annual flow of CVD patients at the hospital and prevalence of ACS in Egypt (in 2001) (8.3%)  using 5% margin of error, 95% confidence level, and response distribution of 80%.
Study population and sampling technique
During the study period, we identified 184 consecutive ACS patients who were diagnosed according to the standard criteria based on clinical manifestations, ECG findings, and cardiac-enzyme abnormalities ,.
Patients who were inhabitants of another governorate, stable angina patients, or in whom ACS was considered to be secondary to coronary embolism, arteritis, spontaneous dissection, muscular bridges, or an anomalous origin of the coronary artery were excluded from the study.
Informed consent was obtained from patients or their accompanied relatives. The study protocol was approved by the local ethics committee and all procedures were in accordance with the Helsinki Declaration.
A semistructured questionnaire was designed to be completed by a trained physician to obtain the following data:
- Detailed personal history including: sex, age, residence, etc., and social class score according to El-Gilany et al. .
- Medical history with emphasis on risk factors of CAD (such as HTN, DM, dyslipidemia, special habits of medical importance as smoking), history of other chronic diseases (chronic renal failure, peripheral vascular disease, etc.) and family history of premature CAD. Patients’ current complaints were also taken into consideration.
- Clinical examination:
- Complete general examination: conscious level, pulse, blood pressure, temperature, etc.
- Local cardiac examination including auscultation of lung bases. Special interest was directed to the presence of S3 gallop, cardiac murmurs, and/or lung crepitations.
- Killip class  was recorded according to clinical examination:
- Class I: absence of rales over the lung fields and absence of S3.
- Class II: rales over 50% or less of the lung fields or the presence of an S3.
- Class III: rales over 50% of the lung fields (pulmonary edema).
- Class IV: cardiogenic shock.
- Resting 12-lead ECG: it was performed at the emergency room on arrival for all patients with suspected ACS. In patients with inferior STEMI, right-sided ECG leads (VR3 and VR4) were obtained together with posterior leads (V7, V8, and V9) for possible ST elevation, suggestive of right ventricular and/or posterior infarction, respectively.
- Transthoracic echocardiography: it was done for every patient using a standard commercial system (Philips IE 33 Ultrasound, Bothell, Washington, USA) with S5-1 phased array sector probe (frequency range, 1.5–4.3 MHz) with assessment of left ventricular end diastolic diameter, left ventricular end systolic diameter, fractional shortening percent, ejection fraction, and assessment of segmental wall motion abnormalities according to the American Society of Echocardiography .
- Chest radiograph (posteroanterior, erect).
- Full laboratory investigation including [random blood sugar, compete blood count, renal function test, arterial blood gases, cardiac biomarkers (creatine kinase, cardiac troponin-I), serum K+ and Na+, alanine transaminase, and aspartate transaminase].
- The protocol for management was done according to the guidelines ,.
- Coronary angiography was done according to the clinical scenario; the coronary artery is considered to be significantly affected if it has atheroma causing more than or equal to 50% stenosis in the left main or more than or equal to 70% stenosis in the nonleft main coronary artery .
- Outcome of ACS patients was followed up during the time of hospitalization.
Continuous data were described in terms of mean±SD, whereas categorical variables were described in number and percentage. To assess the statistical significance in the observed differences; χ2 test was used for categorical variables while Student’s t test and analysis of variance were used for means of quantitative data. The significance level was taken at P value less than or equal to 0.05. All analyses were performed using SPSS, program version 16 (SPSS Inc., Chicago, Illinois, USA).
| Results|| |
Baseline characteristics are presented in [Table 1].
|Table 1 Sociodemographic characteristics of acute coronary syndrome patients and family history of premature coronary artery disease according to age groups|
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In all, 184 patients who fulfilled the criteria for ACS and admitted to the CCU were enrolled in this study [represents 32.3% out of 569 patients admitted to the CCU and 12.2% from all CVD (1508) patients over the time of study).
Their age ranged between 32 and 85 years with a mean of 55.6±11.6 years.
The patients were classified according to their age into three groups:
- Group I: included 30 (16.3%) young patients with age less than or equal to 45 years defined as premature ACS .
- Group II: included 92 (50.0%) patients in middle age (>45–60 years).
- Group III: included 62 (33.7%) old age patients of more than 60 years.
Men were predominant (81.5%); the ratio of men to women was 4.4 to 1. Male sex was significantly common in all age groups and different ACS diagnosis ([Figure 1]a), while as the age rises this observed sex difference was decreased, where men accounted for 67.7% of those more than 60 years old. More than half (54.7%) of men were in the middle age group (46–60 years), while 58.8% of women were in the older group ([Figure 1]b).
|Figure 1 (a)Sex difference according to diagnosis and (b) distribution of patients according to age and sex.|
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Most (59.8%) of ACS patients belonged to middle social class. Only 7.1% of patients had a positive family history of premature CAD and it was more presented in the young age group (10.0%) (P>0.05).
Nearly half (52.2%) of patients was diagnosed with STEMI which was significantly higher among young (60.0%) and middle (54.3%) age patients in comparison to old age (45.2%). It was also found that 18.5% of patients were with NSTSMI, and 29.3% with UA.
Concerning risk factors, the majority (81.5%) of patients weighed more than normal limits (BMI≥25 kg/m2) followed by smoking, HTN, and DM (46.8, 38, and 35.9%, respectively). Overweight/obesity was the most prevalent risk factor in all age groups particularly among young, followed by current smoking in young and middle age groups, while HTN and DM were common in older age groups (P<0.05). History of dyslipidemia was detected only in 2.2% of patients all of them in the age group of 46–60 years ([Table 2]).
|Table 2 Medical history, laboratory findings, and diagnosis of the studied acute coronary syndrome patients according to age groups|
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All premature ACS patients had at least one of these conventional risk factors (HTN, DM, dyslipidemia, smoking), similar to those above 60 years ([Figure 2]).
Overweight/obesity was the most common risk factor in both sexes especially women (88.2%) followed by HTN (52.9%) and DM (41.2%) among them, while smoking was detected only in men (57.3%) (P<0.05) ([Figure 3]).
Most of admissions (55.5%) happened between 8 am and 8 pm. Patients presented mainly (95.6%) with typical anginal chest pain, and 94.6% had sinus rhythm ([Table 3]).
|Table 3 Characteristics of acute coronary syndrome patients at time of admission|
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Details of presentation severity and vessels involved are demonstrated in [Table 4].
|Table 4 Killip class, echocardiographic and angiographic profile according to diagnosis|
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Majority (89.1%) of patients presented with Killip class I, without statistically significant difference regarding diagnosis (P>0.05).
Impaired ejection fraction (<50%) was significantly more prevalent in those with STEMI, 43.8% versus NSTEMI (20.1%) and UA (3.7%).
The proportion of patients with single-vessel disease was insignificantly higher in STEMI and UA groups (44.0 and 68.2%, respectively) compared with NSTEMI (25.0%) with insignificant more stenoses in the STEMI group versus NSTEMI and UA.
Management and outcome of patients are shown in [Table 5].
Most of patients with STEMI (68.7%) received thrombolytic therapy with mean±SD door-to-needle time 9.6±3.2 min, while 16.7% underwent primary percutaneous coronary intervention (PCI) with mean±SD door-to-balloon time 46.5±12.4 min; only 14.6% were treated conservatively.
In patients with NSTEMI/UA, 48.9 and 29.5%) underwent coronary angiography and PCI, respectively, during their index hospitalization.
Regarding outcome 2.2 and 3.3% had in-hospital complications or died respectively, which was detected only among patients with STEMI (P>0.05).
| Discussion|| |
Prevention of ACS is a matter of public health that requires a lot of resources worldwide . In spite of increasing the number of ischemic heart disease patients particularly ACS in Egypt and the change in the natural history of the disease affecting certain category of patients especially the young and women as well as its aggressive nature in many patients; there were lack of accessible national registries or surveys till now .
In the current study 184 ACS patients who were admitted to the CCU, Al-Azhar University Hospital, New Damietta, the prevalence of ACS was 12.2% from all CVD patients over the period of study, which is similar to that of sub-Saharan Africa (13.5%)  and Lebanon (13%) .
All patients were recruited from the same hospital which provides services for patients belonging to the same social class that can explain the observed insignificant difference regarding social class.
Patients varied with respect to age groups, sex, and diagnosis. ACS with STEMI comprised 52.2% and the rest 47.8% was without ST elevation (18.5% for NSTSMI and 29.3% for UA).
This was somewhat similar to the Egyptian National Heart Institute registry in which 59.1% had an initial diagnosis of ACS with STEMI . Also, Bacci et al.  showed that the most prevalent diagnosis was STEMI (57.3%), followed by NSTEMI (22.1%) and UA (20.6%).
On the contrary, in European Heart Survey II for ACS (EHS-ACS-II) , 47% determined to have ST elevation. Also, Abdelmoneim et al.  showed that ACS patients admitted to Assiut University Hospital had mainly UA (41.5%). In addition, Papathanasiou et al.  stated that ACS without ST segment elevation was the most widely recognized clinical presentation.
In the present study, ACS patients were relatively younger as they were either less than or equal to 45 (16.3%) years old or 46–60 (50%) years with a mean age of 55.6±11.6 years. This is in agreement with other studies in Egypt ,. This denotes that ACS occurs during the working productive age leading to economic load on personal and public levels, while in Western countries the mean age of ACS was ∼65 years ,.
This controversy might be due to overweight/obesity and smoking, and familial impact on the development of ACS was common among young patients versus older age.
Attacks of ACS were more common among men that constituted 81.5% of the studied sample, clarifying male sex as an important risk factor for ACS patients of different diagnosis and age groups (P<0.05). However, beyond 60 years the sex ratio has become smaller as women accounted for nearly one-third (32.3%) of old patients. Moreover, most (54.7%) of the men presenting with ACS was in the middle age group versus 58.8% of women of more than 60 years.
These findings were similar to most of the studies suggesting ACS as a disease of men ,, but by advancing age the sex ratio for incidence narrowed progressively as risk factors for ACS in both sexes has become nearly similar , where women have hormonal protection from developing ACS until menopause .
The present research showed that 60% of young ACS patients had STEMI and this proportion declines gradually with middle and old age groups (54.3, 45.2%, respectively) (P<0.05).
This was in consistence with Schoenenberger et al. , who showed that ACS patients less than or equal to 35 years were probable to develop STEMI (73.1%) and those young patients are of particular worry attributable to the years of potential life lost. Shaheen et al.  also observed that ACS patients with STEMI were relatively younger versus those without ST elevation. Similarly, Antoniades et al.  distinguished STEMI commonly in patients under 50 years of age, while UA was detected frequently in patients over 60 years of age. This can be explained by Jensen et al. , who stated that high collateral supply has a beneficial impact on the occurrence of major ischemic events.
In this study, the observed high proportion of unhealthy lifestyle such as overweight/obesity in women and smoking in men and also in the young and middle aged ACS patients versus old age were consistent with the findings in previous studies ,. Likewise, Yadav et al.  reported that smoking is one of the most common risk factors. In addition, Shaheen et al.  have shown that smoking and HTN were risk factors for ACS among Egyptian. In accordance with the Egyptian Demographic and Health Survey , it was reported that more than 90% of women aged more than or equal to 40 years and the majority of men more than or equal to 25 years were overweight and obese where men reach peaks (79%) at 50–54 years of age. As the extent of men who smoke keeps on rising with age, peaking at 59% in the 50–54 age group and there is a tendency to give up smoking as they become older.
It is worth noting that younger age can endure conventional risk factors but over time if these conditions are accompanied by unhealthy eating pattern that emerged over the last few decades, in addition to smoking or physical inactivity among the relatively young Egyptian patients, they will lead to high morbidity and mortality from coronary illness later in the adulthood.
On the contrary, in EHS-ACS-II  smoking was detected in 36.5%, while hyperlipidemia in 47.6%.
This distinction might be attributed to the older age and better primary prevention in addition to regular follow-up in Europe.
In agreement with previous reports ,, the present study denoted that older patients had an increased frequency of poor prognostic factors such as DM, HTN, and renal impairment.
There is an argument in the relationship between the number of conventional risk factors and age at the time of an ACS event. In this study, it was found that all patients with premature ACS and those over 60 years had significantly at least one of the conventional risk factors versus 95.7% of those in the middle age group. This was in agreement with Alberty et al. , who showed that men and women with premature ACS, ∼92%, had at least one risk factor. Furthermore, other studies , have declared that having these risk factors early in life was shown to provoke permanent changes in arterial blood vessels that lead to the development of atherosclerosis.In consistent with some researches, 55.5% of admission occurred between 8 am and 8 pm, which ascribed that to genetic variations  or physical inactivity after lunch and subsequent prothrombotic state .
On the contrary, some Western studies have declared circadian variation for the occurrence of ACS that was observed mainly early morning .
Typical anginal chest pain was the main presenting symptoms (95.6%); the majority (89.1%) of the studied patients presented with Killip class I. These were similar to other studies ,.
It was observed that multivessel disease was more prevalent than single-vessel disease among the studied patients with NSTEMI followed by those with STEMI compared with UA. These findings were in agreement with other studies ,.
Among STEMI patients, 68.7% received thrombolysis, while 16.7% underwent primary PCI and only 14.6% were treated conservatively due to late presentation as patients delay in seeking medical help.
This was to some extent in agreement with Egyptian National Heart Institute registry  in which 65.5% of ST elevation ACS patients received thrombolysis, 14.6% had rescue PCI, while 12.4% were referred to the cath laboratory for primary PCI.
However, in another study  primary PCI was used in a higher extent (51.8%) of reperfused patients.
This difference may be due to the cath laboratory being active for primary PCI only during daytime as all the working staff and nurses are prepared in their places notwithstanding monetary causes.
Door-to-needle time and door-to-balloon time (9.6±3.2, 46.5±12.4 min), respectively, were within the recommended guidelines and they were shorter than the comparing time in other studies ,. This might be because of the better and prompt care in our hospital.
Coronary angiography was performed on 48.9% of patients with NSTEMI/UA similar to other research  while lower than in EHS-ACS-II  that can be mainly attributable to cost.
As regards hospital mortality, it was similar to other registries , and is considerably lower than reported in studies from other countries ,.
Conclusion and recommendations
ACS is presented in a relatively young age with STEMI as a predominant type that is considered an increasing health problem.
All major well-known risk factors for CVD were distinguished among ACS patients particularly obesity, smoking, and HTN which significantly differ between young and older patients.
Subsequently, primordial and primary preventive measures had to be encouraged throughout the life span.
It is necessary to ensure the availability of cheap healthy food and to promote healthy lifestyles starting from young ages. Public health education is needed to achieve that with adherence to it.
New precautionary measures about smoking must be taken as children who grow up in an environment with few opportunities to smoke will be less likely to adopt this behavior in adult life.
Secondary preventive measures are mandatory such as giving up smoking and exercising.
Public health education is essential to diminish the time from beginning of symptoms to presentation.
Such efforts will require cooperation between individuals to make behavioral changes and society to make substantial environmental changes with long-term commitment.
There is a requirement for further researches, so as to play out a uniform registry for ACS patients all over Egypt; accordingly guidelines can be modified regarding Egyptian characteristics and availability of resources in diverse cardiac centers.
The authors appreciate the help from the Cardiology Department members who assisted the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]