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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  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


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 Submission24-Sep-2019
Date of Decision24-Sep-2019
Date of Acceptance14-Nov-2019
Date of Web Publication10-Feb-2020

Correspondence Address:
MD Mohamed S Bashandy
Department of Cardiology, Faculty of Medicine, Al-Azhar University, Damietta, Cairo, 11754
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_74_19

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  Abstract 


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 Top


Coronary artery disease (CAD) represents an important form of cardiovascular disease (CVD). It has turned into an emerging epidemic in developing countries [1].

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 [2]. 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) [3],[4].

ACS makes the largest contribution to all acute hospitalizations these days. It is responsible for nearly half of all deaths due to CVD globally [5]. In 2012, ACS accounted for 12.8% of overall mortality [2]. It is expected to be the main cause of death till 2020 [6]. It is a remarkable cardiac issue accounting for disability both in men and women resulting in high personal, clinical, and financial burdens [7]. 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 [8].

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] [9],[10], with contribution of psychological/psychosocial factors [11].

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 [12].

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 Top


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 Top


Study design

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%) [13] 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 [4],[14].

Exclusion criteria

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.

Ethical consideration

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.

Study tools

A semistructured questionnaire was designed to be completed by a trained physician to obtain the following data:
  1. Detailed personal history including: sex, age, residence, etc., and social class score according to El-Gilany et al. [15].
  2. 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.
  3. Clinical examination:
    1. Complete general examination: conscious level, pulse, blood pressure, temperature, etc.
    2. 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 [16] 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.
  4. 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.
  5. 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 [17].
  6. Chest radiograph (posteroanterior, erect).
  7. 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].
  8. Management:
    • The protocol for management was done according to the guidelines [4],[14].
  9. 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 [18].
  10. Outcome of ACS patients was followed up during the time of hospitalization.


Statistical analysis

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 Top


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 [19].
  • 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]).
Figure 2 Number of risk factors in different age groups.

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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]).
Figure 3 Distribution of risk factors according to sex.

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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].
Table 5 Management and outcome of the studied patients

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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 Top


Prevention of ACS is a matter of public health that requires a lot of resources worldwide [20]. 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 [21].

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%) [22] and Lebanon (13%) [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 [21]. Also, Bacci et al. [20] 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) [23], 47% determined to have ST elevation. Also, Abdelmoneim et al. [24] showed that ACS patients admitted to Assiut University Hospital had mainly UA (41.5%). In addition, Papathanasiou et al. [25] 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 [21],[24]. 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 [23],[26].

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 [21],[22],[25] but by advancing age the sex ratio for incidence narrowed progressively as risk factors for ACS in both sexes has become nearly similar [27], where women have hormonal protection from developing ACS until menopause [28].

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. [29], 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. [21] also observed that ACS patients with STEMI were relatively younger versus those without ST elevation. Similarly, Antoniades et al. [30] 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. [31], 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 [32],[33]. Likewise, Yadav et al. [34] reported that smoking is one of the most common risk factors. In addition, Shaheen et al. [21] have shown that smoking and HTN were risk factors for ACS among Egyptian. In accordance with the Egyptian Demographic and Health Survey [35], 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 [23] 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 [32],[33], 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. [26], who showed that men and women with premature ACS, ∼92%, had at least one risk factor. Furthermore, other studies [36],[37] 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 [38] or physical inactivity after lunch and subsequent prothrombotic state [39].

On the contrary, some Western studies have declared circadian variation for the occurrence of ACS that was observed mainly early morning [40].

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 [21],[23].

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 [20],[21].

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 [21] 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 [23] 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 [21],[23]. 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 [21] while lower than in EHS-ACS-II [23] that can be mainly attributable to cost.

As regards hospital mortality, it was similar to other registries [21],[23] and is considerably lower than reported in studies from other countries [30],[41].

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.

Acknowledgements

The authors appreciate the help from the Cardiology Department members who assisted the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Cardiovascular diseases World Health Organization. Cardiovascular diseases. Fact sheet 317. 2007. Available at: www.who.int/mediacentre/factsheets/fs317/en/print.html. [Accessed on May 2017].  Back to cited text no. 1
    
2.
Rohit R, Atul T. Smoking, smokeless tobacco consumption and coronary artery disease − a case control study. Natl J Comm Med 2012; 3:264–268.  Back to cited text no. 2
    
3.
Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA et al. Task Force Members. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012; 33:2569–2619.  Back to cited text no. 3
    
4.
O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, De Lemos JA 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. J Am Coll Cardiol 2013; 61:e78–e140.  Back to cited text no. 4
    
5.
World Health Organization. Global status report on non communicable diseases 2014. Geneva, Switzerland: World Health Organization; 2014.  Back to cited text no. 5
    
6.
Barth J, Schneider S, Von Känel R. Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis. Psychosom Med 2010; 72:229–238.  Back to cited text no. 6
    
7.
Ruff CT, Braunwald E. The evolving epidemiology of acute coronary syndromes. Nat Rev Cardiol 2011; 8:140.  Back to cited text no. 7
    
8.
Vedanthan R, Seligman B, Fuster V. Global perspective on acute coronary syndrome: a burden on the young and poor. Circul Res 2014; 114:1959–1975.  Back to cited text no. 8
    
9.
Panwar RB, Gupta R, Gupta BK, Raja S, Vaishnav J, Khatri M, Agrawal A. Atherothrombotic risk factors & premature coronary heart disease in India: a case-control study. Indian J Med Res 2011; 134:26.  Back to cited text no. 9
    
10.
Bangalore S, Fayyad R, Laskey R, DeMicco DA, Messerli FH, Waters DD. Body-weight fluctuations and outcomes in coronary disease. N Engl J Med 2017; 376:1332–1340.  Back to cited text no. 10
    
11.
Albus C. Psychological and social factors in coronary heart disease. Ann Med 2010; 42:487–494.  Back to cited text no. 11
    
12.
Lasebikan VO, Ojediran B. Profile of problems and risk factors associated with tobacco consumption among professional drivers in Nigeria. ISRN Public Health 2012; 2012:580484.  Back to cited text no. 12
    
13.
Mansour H, Reda A, Mena M, Ghaleb R, Elkersh A. Pattern of risk factors and management strategies in patients with acute coronary syndrome, in different age groups and sex categories. Atheroscleros Suppl 2017; 25:e7–e8.  Back to cited text no. 13
    
14.
Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR 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. J Am Coll Cardiol 2014; 64:e139–e228.  Back to cited text no. 14
    
15.
El-Gilany A, El-Wehady A, El-Wasify M. Updating and validation of the socioeconomic status scale for health research in Egypt. East Mediterr Health J 2012; 18:962–968.  Back to cited text no. 15
    
16.
Killip IIIT, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two year experience with 250 patients. Am J Cardiol 1967; 20:457–464.  Back to cited text no. 16
    
17.
Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography: endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23:685–713.  Back to cited text no. 17
    
18.
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2016; 67:1235–1250.  Back to cited text no. 18
    
19.
Rallidis LS, Pavlakis G, Foscolou A, Kotakos C, Katsimardos A, Drosatos A et al. High levels of lipoprotein (a) and premature acute coronary syndrome. Atherosclerosis 2018; 269:29–34.  Back to cited text no. 19
    
20.
Bacci MR, Fonseca FLA, Nogueira LFF, Bruniera FR, Ferreira FM, Barros DMD et al. Predominance of STEMI and severity of coronary artery disease in a cohort of patients hospitalized with acute coronary syndrome: a report from ABC Medical School. Rev Assoc Méd Brasil 2015; 61:240–243.  Back to cited text no. 20
    
21.
Shaheen S, Magdi A, Esmat I, Mohannad A, El Kilany WAEL. National Heart Institute acute coronary syndrome registry. Med J Cairo Univ 2012; 80:141–149.  Back to cited text no. 21
    
22.
N’Guetta R, Yao H, Ekou A, N’Cho-Mottoh MP, Angoran I, Tano M et al. Prevalence and characteristics of acute coronary syndromes in a sub-Saharan Africa population. Ann Cardiol Angeiol 2016; 65:59–63.  Back to cited text no. 22
    
23.
Mandelzweig L, Battler A, Boyko V, Bueno H, Danchin N, Filippatos G et al. The second Euro Heart Survey on acute coronary syndromes: characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. Eur Heart J 2006; 27:2285–2293.  Back to cited text no. 23
    
24.
Abdelmoneim HM, Hasan-Ali H, Abdulkader SS. Demographics of acute coronary syndrome (ACS) Egyptian patients admitted to Assiut University Hospital: Validation of TIMI and GRACE scores. Egypt J Crit Care Med 2014; 2:3–11.  Back to cited text no. 24
    
25.
Papathanasiou AI, Pappas KD, Korantzopoulos P, Leontaridis JP, Vougiouklakis TG, Kyrgiou M et al. An epidemiologic study of acute coronary syndromes in northwestern Greece. Angiology 2004; 55:187–194.  Back to cited text no. 25
    
26.
Alberty R, Studenčan M, Kovář F. Prevalence of conventional cardiovascular risk factors in patients with acute coronary syndromes in Slovakia. Cent Eur J Public Health 2017; 25:77–84.  Back to cited text no. 26
    
27.
Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G et al. Executive summary: heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation 2010; 121:948–954.  Back to cited text no. 27
    
28.
Abid L, Hadrich M, Sahnoun M, Kammoun S. Percutaneous coronary angioplasty in women: clinical, procedural and prognostic features. Pan Afr Med J 2011; 9:44.  Back to cited text no. 28
    
29.
Schoenenberger AW, Radovanovic D, Stauffer JC, Windecker S, Urban P, Niedermaier G et al. and AMIS Plus Investigators. Acute coronary syndromes in young patients: presentation, treatment and outcome. Int J Cardiol 2011; 148:300–304.  Back to cited text no. 29
    
30.
Antoniades L, Christodoulides T, Georgiou P, Hadjilouca C, Christodoulou E, Papasavas E et al. Epidemiology of acute coronary syndromes in the Mediterranean island of Cyprus (CYPACS study, Cyprus study of acute coronary syndromes). Hellenic J Cardiol 2014; 55:139–149.  Back to cited text no. 30
    
31.
Jensen LO, Thayssen P, Lassen JF, Hansen HS, Kelbæk H, Junker A et al. Recruitable collateral blood flow index predicts coronary instent restenosis after percutaneous coronary intervention. Eur Heart J 2007; 28:1820–1826.  Back to cited text no. 31
    
32.
Chua SK, Hung HF, Shyu KG, Cheng JJ, Chiu CZ, Chang CM et al. Acute ST‐elevation myocardial infarction in young patients: 15 years of experience in a single center. Clin Cardiol 2010; 33:140–148.  Back to cited text no. 32
    
33.
Panduranga P, Sulaiman K, Al-Zakwani I, Abdelrahman S. Acute coronary syndrome in young adults from oman: results from the gulf registry of acute coronary events. Heart Views 2010; 11:93.  Back to cited text no. 33
    
34.
Yadav P, Joseph D, Joshi P, Sakhi P, Jha RK, Gupta J. Clinical profile & risk factors in acute coronary syndrome. Natl J Comm Med 2010; 1:150–151.  Back to cited text no. 34
    
35.
El-Zanaty F, Way A. Egypt health issue survey. Cairo, Egypt: Ministry of Health and Population; 2015.  Back to cited text no. 35
    
36.
Eriksson JG, Forsen T, Tuomilehto J, Osmond C, Barker DJ. Early growth and coronary heart disease in later life: longitudinal study. BMJ 2001; 322:949–953.  Back to cited text no. 36
    
37.
Juonala M, Järvisalo MJ, Mäki-Torkko N, Kähönen M, Viikari JS, Raitakari OT. Risk factors identified in childhood and decreased carotid artery elasticity in adulthood: the Cardiovascular Risk in Young Finns Study. Circulation 2005; 112:1486–1493.  Back to cited text no. 37
    
38.
Misiriya KJ, Sudhayakumar N, Khadar SA, George R, Jayaprakasht VL, Pappachan JM. The clinical spectrum of acute coronary syndromes: experience from a major center in Kerala. J Assoc Phys India 2009; 57:377–383.  Back to cited text no. 38
    
39.
Kolettis TM, Papathanasiou A, Tziallas D, Milionis HJ, Kastanioti CK, Achenbach K. Afternoon nap, meal ingestion and circadian variation of acute myocardial infarction. Int J Cardiol 2008; 123:338–340.  Back to cited text no. 39
    
40.
Bhalla A, Sachdev A, Lehl SS, Singh R, D Cruz S. Ageing and circadian variation in cardiovascular events. Singapore Med J 2006; 47:305.  Back to cited text no. 40
    
41.
Kristensen SD, Laut KG, Fajadet J, Kaifoszova Z, Kala P, Di Mario C et al. Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries. Eur Heart J 2014; 35:1957–1970.  Back to cited text no. 41
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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