Prevalence of Metabolic Syndrome and its Clinical and Angiographic Profile in Patients with Naive Acute Coronary Syndrome : JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY

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Original Article

Prevalence of Metabolic Syndrome and its Clinical and Angiographic Profile in Patients with Naive Acute Coronary Syndrome

Kumar, Anil P.; Surhonne, Prakash Sadashivappa1; Reddy, Rohith P.; Nanjappa, Manjunath Cholenahally1

Author Information

Department of Cardiology, Yashoda Hospitals, Hyderabad, Telangana, India

1Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India

Address for correspondence: Dr. Anil P. Kumar, Department of Cardiology, Yashoda Hospitals, Somajiguda, Hyderabad - 500 082, Telangana, India. E-mail: [email protected]

Received December 12, 2021

Accepted March 17, 2022

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JOURNAL OF INDIAN COLLEGE OF CARDIOLOGY 12(4):p 162-167, Oct–Dec 2022. | DOI: 10.4103/jicc.jicc_64_21
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Abstract

INTRODUCTION

Metabolic syndrome (MS) is a mixture of various interrelated metabolic risk factors that are significantly known to increase the risk for the development of cardiovascular disease (CVD).[12] It represents a group of cardiovascular risk factors such as hyperglycemia, increased levels of triglycerides and blood pressure, central obesity, and decreased levels of high-density lipoprotein (HDL) cholesterol levels.[3] It is a known fact that each risk factor of MS is individually related to an increased risk of CVD.[2] However, whether many of these risk factors occur together or develop after the onset of MS remains a matter of debate.[4] Since cardiovascular risk increases as the number of risk factors increases, it has been suggested that the number of MS risk factors may be more useful in estimating CVD than MS itself.[5]

Globally, different studies have analyzed the prevalence of MS in patients with acute coronary disease, reporting an estimated prevalence of MS varied from 21.3% to 32.8% among the patients in San Antonio heart and Framingham offspring studies.[67] In a recent meta-analysis, it was reported that MS was associated with a 1.5 and 2 fold increase in all-cause mortality and cardiovascular outcomes, respectively.[8] In this sense, the diagnosis of MS and its risk factors in patients with CVD can influence the prevention and management of the disease.[9] Furthermore, understanding the results of MS on CVD is important for planning public health policy toward its prevention and management. There are very limited studies available on the association of MS with CVD and the prevalence of MS with angiographically proven CVD in the Indian population.[10] Thus, this study has been conducted to evaluate the prevalence of MS and its clinical and angiographic profile in patients presenting with naive acute coronary syndrome (ACS). Furthermore, this study tried to evaluate the severity of coronary artery disease (CAD) in patients with and without MS.

METHODS

Study design and population

This was a single-center, cross-sectional study conducted at a tertiary-care center in India. We prospectively enrolled 500 patients with naive ACS during the period from January 2017 to December 2018. MS was diagnosed based on the revised NCEP ATP III guidelines. The revised NCEP criteria require at least three of the following components: (1) Abdominal obesity (waist circumference ≥102 cm for men or ≥88 cm for women), (2) triglycerides ≥150 mg/dL, (3) HDL cholesterol ≤40 mg/dL for men or ≤50 mg/dL for women, (4) systolic/diastolic blood pressure ≥130/85 mmHg or receiving drug treatment, and (5) fasting plasma glucose ≥100 mg/dL.[11] Based on the presence of MS, 231 patients were included in the MS group and 269 patients were included in the non-MS group. The inclusion criteria were patients with age >18 years, first episode of ACS, ST-segment elevation myocardial infarction or new left bundle branch block on the admission electrocardiogram (ECG), and non-ST-segment elevation myocardial infarction. Patients with prior CAD, coronary artery bypass graft (CABG) or percutaneous coronary intervention, neoplasm, acute infections or surgical intervention in the past 6 weeks, liver decompensation or failure, evidence of renal insufficiency and patients who refused to sign informed consent form were excluded from the study.

Data collection and definitions

All patients baseline demographics such as age, gender, and risk factors such as hypertension, diabetes, and tobacco chewing or smoking were collected. General physical examination, systemic examination, and ECG were done. All patients' blood samples were taken to identify the baseline values of hemoglobin, creatinine, urea, troponin, blood sugar, bilirubin, liver enzymes, and lipid profile. Angiographic characteristics and treatment management of all the patients were collected from the patient records. The ACS was defined based on the Joint Committee of the American College of Cardiology.[12] The diagnosis of MS was made by revised NCEP ATP III guidelines.[11] Renal insufficiency was defined as serum creatinine >1.5 mg/dL.

Statistical analysis

Continuous variables were expressed as mean ± standard deviation and compared using Student's t-test. Categorical variables were expressed as counts and percentages and compared using the Chi-square test or Fisher exact test. Leven's test has been performed to assess the homogeneity of variance. A P < 0.05 was considered to be statistically significant. All statistical analyses were performed using statistical package for the social sciences (SPSS) 16.0 version (SPSS; Chicago, Illinois, USA).

RESULTS

Baseline demographics

The overall prevalence of MS in this study was 46.2% with the preponderance of male (81%) patients. Of these, majority of the population are from the age group of 40–59 years (55%). Among the risk factors, the prevalence of hypertension was significantly higher in patients with MS than in the patients without MS (134 [58.0%] vs. 61 [22.6%], P < 0.001). Similarly, blood pressure (P < 0.001) and ejection fraction (P = 0.018) levels were found to be significantly higher in patients with MS compared to patients without MS. Obesity as measured by the waist circumference was found predominantly in the female population than compared to the male population in the study, 76.59% versus 50.98%. Patients with MS were found to be more obese than the population without MS which was statistically significant P = 0.001. Obesity was seen in 55.61% of male patients with MS compared to 47.03% in those without MS and was 84.09% in females with MS compared with 70% of females without MS. Table 1 summarizes the baseline characteristics of the study population with and without MS, and Figure 1 shows the prevalence of MS.

T1-3
Table 1:
Baseline demographic characteristics of the study population
F1-3
Figure 1:
Prevalence of metabolic syndrome

Clinical characteristics

There was no statistical difference between troponin, hemoglobin, creatinine, urea, low-density lipoproteins, total bilirubin, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, and alkaline phosphatase levels between the patients with and without MS (P > 0.05). Besides, individual components such as random blood sugar (P < 0.001), total cholesterol (P = 0.004), triglycerides (P < 0.001), and very-low-density lipoprotein (P < 0.001) levels were significantly higher in patients with MS than in patients without MS, whereas HDL levels were significantly lower in patients with MS than in patients without MS (P < 0.001). The laboratory investigations of the study population are displayed in Table 2.

T2-3
Table 2:
Laboratory investigations of the study population

Angiographic characteristics

The angiographic characteristics of the study population are depicted in [Table 3 and Figure 2]. As shown in the table, patients belonging to STEMI were 69.14% in patients without MS compared to 60.60% in patients with MS and patients with NSTEMI or UNSTABLE ANGINA in patients with without MS were 30.85% compared to 39.39% in patients with MS. Angiographic profile revealed that single vessel disease was lower in patients with MS (36.8%) than without MS group (39.0%). Whereas, double vessel disease (26.8% vs. 18.2%) and triple vessel disease (TVD) (23.8% vs. 7.8%) were high in patients with MS compared to patients without MS. The degree of CAD distribution was statistically significant P = 0.03 in patients with MS than in those without MS. In this study population, the higher stenosis rates of 50%–70% were observed in patients with left main coronary artery and right CAD, whereas 70%–90% stenosis rates were observed in patients with left anterior descending artery, left circumflex artery, and obtuse marginal artery. Total occlusion of coronary arteries was seen in 57 (24.7%) patients with MS and 16 (5.9%) patients without MS. More complex coronary lesions were seen in patients with MS than insignificant lesions, which were observed in the rest of the population. Majority of the population in both the groups underwent management by percutaneous transluminal coronary angioplasty, 54%, about 29.6% were on optimal medical therapy and 16.4% underwent CABG (P = 0.222).

T3-3
Table 3:
Angiographic characteristics and management strategies of the study population
F2-3
Figure 2:
Coronary artery disease distribution (in percentage)

DISCUSSION

In the present study, it was observed that patients with ACS had a higher prevalence (46.2%) of MS. This percentage is similar to the studies described in CAD patients showed that the rate of MS in patients with ACS was between 43% and 51%.[13] Similarly, other studies such as Al Suwaidi et al.[14] and Sinha et al.[1] reported that the prevalence of MS in ACS was 46% and 37.65%, respectively. Whereas, lower prevalence of MS in ACS was reported in a study conducted by Danciu et al.(26%) and Pandey et al. (26.19%).[1516] The reasons behind these differences could be due to using other different definitions of MS, cultural and lifestyle factors such as stress, different dietary habits, lack of physical activity, and also variation in sample size.[4]

In this study, majority of the ACS patients with MS were >40 years which is similar to the previous studies.[1718] Furthermore, the current study shows that the prevalence of MS was higher in males as compared to females which is similar to the previous studies.[19] In contrast, some studies showed a higher prevalence of MS in females.[2021] Based on the results documented in different studies, there is still an ongoing debate in the relation between gender and MS.[4] The severity of CAD is directly proportional to the number of risk factors.[4] Similar to previous studies, the present study observed that diabetes, hypertension, smoking, increased blood pressure, abnormal lipid levels (high triglyceride levels, low HDL cholesterol levels), and increased RBS were significantly higher in patients with MS group as compared to patients without MS.[41622] Moreover, three meta-analyses reported that MS increases the risk of incident CAD.[232425] Furthermore, the other study reported that a combination of diabetes and hypertension sharply increased the cardiovascular risk[2] and increased triglyceride levels and low HDL levels are very common in patients with MS and diabetes.[226] This higher prevalence of lower HDL could be probably due to some genetic factors.[27] Hence, this study confirms that these are the well-recognized risk factors for CAD.

This study found that single vessel involvement and insignificant lesion was seen more in non-MS patients than in MS patients, but in contrast, double vessel and TVD with left main coronary artery involvement was more in those patients who had MS compared to patients who were non-MS. In contrast, other studies could not find significant difference in severity of CAD in patients with or without MS.[28] However, various other studies have shown that the prevalence of MS increased significantly in CAD patients and majority of whom had severe complex coronary artery lesions.[2930]

Based on the obtained results, this study supports the fact that the prevalence of MS is higher in patients with ACS and also demonstrates the association between MS and CAD. The presence of MS or any of its risk factors should initiate a quick approach toward patient education and implementation of primary management to reduce the prevalence of ACS. This study also suggests that several modifiable risk factors can be managed by early lifestyle and drug treatment which could reduce the prevalence of MS in patients with ACS.

Study limitations

This study is a single-center study. Majority of the study population was male with only 18% being females, this is due to the fact that many of the female patients are hesitant to seek medical help and they also are hesitant to undergo invasive procedure like CAG. Follow-up is needed to study the prognosis after ACS in patients with or without MS. Further refinement of CAD severity by using SYNTAX scoring or others needs to be done.

CONCLUSION

There is a high prevalence of MS in patients with ACS. Men with ACS showed a higher prevalence of MS than females. The most prevalent risk factors of the MS were low HDL levels followed by impaired glucose levels and hypertension. This study also demonstrates that patients with MS were found to have severe CADs.

Statement of ethics

The written informed consent was received from patient or from their family members.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Sinha SK, Goel A, Madaan A, Thakur R, Krishna V, Singh K, 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;8:667–73
2. Jover A, Corbella E, Muñoz A, Millán J, Pintó X, Mangas A, et al Prevalence of metabolic syndrome and its components in patients with acute coronary syndrome Rev Esp Cardiol. 2011;64:579–86
3. 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
4. Jain G, More BD. Prevalence of metabolic syndrome and its different components in patients with acute coronary syndrome Int J Adv Med. 2020;7:161–7
5. Solymoss BC, Bourassa MG, Campeau L, Sniderman A, Marcil M, Lespérance J, et al Effect of increasing metabolic syndrome score on atherosclerotic risk profile and coronary artery disease angiographic severity Am J Cardiol. 2004;93:159–64
6. Meigs JB, Wilson PW, Nathan DM, D'Agostino RB Sr., Williams K, Haffner SM. Prevalence and characteristics of the metabolic syndrome in the San Antonio Heart and Framingham Offspring Studies Diabetes. 2003;52:2160–7
7. Chung EH, Curran PJ, Sivasankaran S, Chauhan MS, Gossman DE, Pyne CT, et al Prevalence of metabolic syndrome in patients<or=45 years of age with acute myocardial infarction having percutaneous coronary intervention Am J Cardiol. 2007;100:1052–5
8. Mottillo S, Filion KB, Genest J, Joseph L, Pilote L, Poirier P, et al The metabolic syndrome and cardiovascular risk a systematic review and meta-analysis J Am Coll Cardiol. 2010;56:1113–32
9. Won KB, Chang HJ, Sung J, Shin S, Cho IJ, Shim CY, et al Differential association between metabolic syndrome and coronary artery disease evaluated with cardiac computed tomography according to the presence of diabetes in a symptomatic Korean population BMC Cardiovasc Disord. 2014;14:105
10. Aggarwal A, Aggarwal S, Sharma V. Metabolic syndrome and coronary artery disease in Indians younger than 40 years J Endocrinol Metab. 2012;2:39–45
11. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al Diagnosis and management of the metabolic syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement Circulation. 2005;112:2735–52
12. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Circulation. 2004;110:e82–292
13. Malik S, Wong ND, Franklin SS, Kamath TV, L'Italien GJ, Pio JR, et al Impact of the metabolic syndrome on mortality from coronary heart disease, cardiovascular disease, and all causes in United States adults Circulation. 2004;110:1245–50
14. Al Suwaidi J, Zubaid M, El-Menyar AA, Singh R, Rashed W, Ridha M, et al Prevalence of the metabolic syndrome in patients with acute coronary syndrome in six middle eastern countries J Clin Hypertens (Greenwich). 2010;12:890–9
15. Danciu SC, Iqbal MF, Manankil MF, Koul S, Raghuvir R, Herrera CJ, et al Metabolic syndrome in younger patients with acute coronary syndrome Eur J Gen Med. 2012;9:22–6
16. Pandey S, Baral N, Majhi S, Acharya P, Karki P, Shrestha S, et al Prevalence of the metabolic syndrome in acute myocardial infarction and its impact on hospital outcomes Int J Diabetes Dev Ctries. 2009;29:52–5
17. Gupta R, Sarna M, Thanvi J, Rastogi P, Kaul V, Gupta VP. High prevalence of multiple coronary risk factors in Punjabi Bhatia community: Jaipur Heart Watch-3 Indian Heart J. 2004;56:646–52
18. Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: Prevalence and associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988-1994 Arch Intern Med. 2003;163:427–36
19. Ghandi AU, Shrivastava P, Patel SV, Madan G. Study of Patients with Metabolic Syndrome and its association with End-organ Damage Indian Journal of Clinical Practice. 2011;22:279–82
20. Gupta A, Gupta R, Sarna M, Rastogi S, Gupta VP, Kothari K. Prevalence of diabetes, impaired fasting glucose and insulin resistance syndrome in an urban Indian population Diabetes Res Clin Pract. 2003;61:69–76
21. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Metabolic syndrome in urban Asian Indian adults – A population study using modified ATP III criteria Diabetes Res Clin Pract. 2003;60:199–204
22. Osei-Yeboah J, Owiredu WK, Norgbe GK, Yao Lokpo S, Gyamfi J, Alote Allotey E, et al The prevalence of metabolic syndrome and its components among people with type 2 diabetes in the Ho municipality, Ghana: A cross-sectional study Int J Chronic Dis. 2017;2017:8765804
23. Ford ES. Risks for all-cause mortality, cardiovascular disease, and diabetes associated with the metabolic syndrome: A summary of the evidence Diabetes Care. 2005;28:1769–78
24. Galassi A, Reynolds K, He J. Metabolic syndrome and risk of cardiovascular disease: A meta-analysis Am J Med. 2006;119:812–9
25. Gami AS, Witt BJ, Howard DE, Erwin PJ, Gami LA, Somers VK, et al Metabolic syndrome and risk of incident cardiovascular events and death: A systematic review and meta-analysis of longitudinal studies J Am Coll Cardiol. 2007;49:403–14
26. Kathiresan S, Otvos JD, Sullivan LM, Keyes MJ, Schaefer EJ, Wilson PW, et al Increased small low-density lipoprotein particle number: A prominent feature of the metabolic syndrome in the Framingham Heart Study Circulation. 2006;113:20–9
27. Koizumi J, Inazu A, Yagi K, Koizumi I, Uno Y, Kajinami K, et al Serum lipoprotein lipid concentration and composition in homozygous and heterozygous patients with cholesteryl ester transfer protein deficiency Atherosclerosis. 1991;90:189–96
28. Sundaramoorthy V, Mambatta AK, Chidambaram Y, Gopalan R, Menon S. Prevalence of metabolic syndrome in patients with premature coronary artery disease proven by coronary angiogram Int J Res Med Sci. 2017;5:5021–5
29. Marroquin OC, Kip KE, Kelley DE, Johnson BD, Shaw LJ, Bairey Merz CN, et al Metabolic syndrome modifies the cardiovascular risk associated with angiographic coronary artery disease in women: A report from the Women's Ischemia Syndrome Evaluation Circulation. 2004;109:714–21
30. Goswami B, Tayal D, Tyagi S, Mallika V. Prevalence of metabolic syndrome in patients with angiographically proven coronary artery disease presenting to a tertiary care hospital in Delhi, India Diabetes Metab Syndr. 2011;5:53–60
Keywords:

Acute coronary syndrome; coronary artery disease; metabolic syndrome; prevalence

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