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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 4  |  Page : 163-167

Coronary artery disease in young diabetics (under 40 years): Are they Different?


1 Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka
2 Department of Cardiology, Apollo Hospitals, Bannerghatta road, Bengaluru, Karnataka

Date of Submission10-May-2020
Date of Decision03-May-2020
Date of Acceptance12-Jul-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Dr. Laxmi H Shetty
514, Laxmi Venkayya Nilaya, 1st A Cross, 32nd Main, Banagirinagar, BSK-3rd Stage, Bengaluru - 560 085, Karnataka
Karnataka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_29_20

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  Abstract 


Aims: The aim is to study the clinical, social, biochemical, and angiographic profiles of Indian diabetic youth presenting with premature coronary artery disease (PCAD). Subjects and Methods: Of 3450 patients registered in PCAD registry till date, 375 (10.86%) satisfied the entry criteria. The data were analyzed by statistical software R version 3.5.0. Further, a subgroup analysis based on age was made, and comparisons were drawn. Results: The study had 375 patients. The average age was 35.94 years; there were 228 (60.8%) patients between 36 and 40 years, 104 (27.7%) between 31 and 35 years, and 43 (11.5%) between 26 and 30 years. There were 291 (77.6%) males and 84 (22.4%) females. There were 152 (42.10%) smokers, 102 (27.2%) hypertensives and 68 (18.1%) with family history of CAD in the group. Around 285 (75.9%) had abnormal body mass index (BMI) and 290 (77.3%) had abdominal obesity. The most common index presentation was ST-elevation myocardial infarction (STEMI), 275 (73.34%). Single-vessel disease was the most common presentation in 265 (79.1%). A subgroup analysis by age showed that younger diabetics more often presented with STEMI and triple-vessel disease was less common, whereas the older diabetics presented more often with dyslipidemia and non-STEMI. Conclusions: Patients with diabetes have a high cardiovascular risk. Diabetes negates the cardiovascular protection seen in premenopausal women. High BMI and abdominal obesity are the most common risk factors for diabetes in the young. Diabetics with premature CAD present more often with STEMI and have single-vessel disease, unlike older diabetics. Hence, aggressive lifestyle modifications that begin in childhood are very important to tackle this growing epidemic.

Keywords: Abdominal obesity, diabetes mellitus, lifestyle modifications, premature coronary artery disease


How to cite this article:
Patil RS, Shetty LH, Chidananda C G, Raj V A, Trivedi AS, Raghu R T, Manjunath N C. Coronary artery disease in young diabetics (under 40 years): Are they Different?. J Indian coll cardiol 2020;10:163-7

How to cite this URL:
Patil RS, Shetty LH, Chidananda C G, Raj V A, Trivedi AS, Raghu R T, Manjunath N C. Coronary artery disease in young diabetics (under 40 years): Are they Different?. J Indian coll cardiol [serial online] 2020 [cited 2022 Sep 24];10:163-7. Available from: https://www.joicc.org/text.asp?2020/10/4/163/307613




  Introduction Top


The rising prevalence of obesity, especially in the young, is the cause for increased prevalence of type 2 diabetes mellitus.[1],[2],[3],[4] This is a worrying trend. Studies have shown, such individuals have worse risk factor profiles (such as, body mass index [BMI], lipids, and glycemic levels) at the point of diagnosis. They also have worse clinical outcomes compared to those who get diagnosed at older age.[5],[6],[7]

Atherosclerosis is a chronic inflammatory condition which starts at young age and depends on many factors, mainly abnormal lipid metabolism.[8] Studies have shown that atherosclerotic plaques or their precursors can be seen even in children younger than 10 years.[9] In later life, unhealthy nutrition, smoking, alcohol consumption, obesity, sedentary lifestyles, and family history of cardiovascular disease accelerate atherosclerotic disease.[9]

Premature coronary artery disease (PCAD) by definition occurs at a younger age (before the age of 55 years in men and 65 years in women).[10] In its severe form, it occurs below the age of 40 years.[11] Indians are prone to coronary artery disease (CAD) at a much younger age.[12] Approximately 50% of first heart attacks occur before 55 years and 25% occur before 40 years of age.[13] Studies among persons with unexplained or PCAD reveal an unusually high number with preclinical diabetes.[14]

South Asians have high rates of diabetes and the highest rates of PCAD in the world, both occurring about 10 years earlier than in other populations. Metabolic syndrome (MS), which is common for both of these conditions, is high among South Asians because South Asians develop metabolic abnormalities at a lower BMI and waist circumference than other groups, and conventional criteria often underestimate the prevalence of MS by 25%–50%.[15]

People under 40 diagnosed with type 2 diabetes are more likely to suffer or die from cardiovascular disease than those of similar age without diabetes, more so young diabetic women.[16] Although there are several population studies on young CAD, there is a paucity of data from risk factor subgroups. Therefore, we have analyzed the other risk factors, clinical presentation, and angiographic profile in Indian diabetic youth from the ongoing premature CAD registry at our institute. The varied presentation between the youngest group (26–30 years) and the older diabetics (36–40 years) has been discussed.


  Subjects and Methods Top


The PCAD registry is a prospective multisite descriptive observational study examining a cohort of young Indian adults aged ≤40 years with CAD from the point of index admission till a period of 5 years. This is registered under the Clinical Trials Registry of India (CTRI/2018/03/012544).

This registry included all patients with index admission for ischemic heart disease, as proven by (i) documented episode of acute coronary syndrome (ACS) and (ii) chronic stable angina with documented evidence of CAD. Patients with (1) with myocarditis, cardiomyopathies, and pulmonary embolism; (2) previously diagnosed case of CAD or on medications such as antiplatelets and statins; and (3) with chronic kidney disease, liver failure, and steroids were excluded from the study.

Once admitted into the hospital, patients who satisfied the entry criteria for age group and occupation were selected. Demographic factors such as age, gender, and address and socioeconomic factors such as income, occupation, marital history, and religion were noted. Risk factor profiles such as the presence of smoking, diabetes, hypertension, physical activity, and family history of CAD were recorded. Clinical presentation to hospital, primary method of management, course in hospital, and echo on admission were all documented. Blood samples for lipid profile were collected immediately on admission to hospital. Total cholesterol and triglycerides (TGs) were estimated using commercially available kits (Accurex Biomedical Pvt. Ltd., Mumbai, Maharashtra, India). Measurement of direct low-density lipoprotein cholesterol (LDL-C) was done by enzymatic homogeneous colorimetric assay using Cobas Gen3. C502 analyzer. Diabetes was diagnosed by the American Diabetes Association 2020 definition.[17]

Body mass was measured using a portable electronic scale to the nearest 0.1 kg. Height was measured to the nearest 0.1 cm using a portable wall-mounted stadiometer. Waist (just above the iliac crest) and hip (the widest part of the hips at the middle of the pelvis) circumferences were measured to the nearest 0.1 cm. BMI was calculated as body weight (kg) divided by height squared (m) by the International Diabetes Federation criteria.[18] “Aborted myocardial infarction (MI)” was defined as a prompt decrease in ST-segment elevation early after completion of thrombolysis, without subsequent Q-wave development and the absence of regional wall motion abnormalities with a normal left ventricular (LV) function on two-dimensional echo. Coronary angiographic profile and mode of intervention (if any) were all documented.

Statistical methods

The qualitative data were summarized by count and percentage, whereas quantitative data were tabulated by descriptive statistics such as mean, median, standard deviation, interquartile range, minimum, and maximum.

The data were analyzed by R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/ which is released under the GNU General Public License, version 2, published by the Free Software Foundation. The P value was derived by Chi-square calculator with Yates correction, and P < 0.001 was considered statistically significant.


  Results Top


A total of 3450 patients were registered under the PCAD registry during the 3 years (2017–2020). The present study analyzed 375 (10.86%) patients.

Demographic characteristics

The average age was 35.94 years; there were 228 (60.8%) patients between 36 and 40 years, 104 (27.7%) between 31 and 35 years, and 43 (11.5%) between 26 and 30 years. There were 291 (77.6%) males and 84 (22.4%) females. There were 115 patients (30.66%) from rural areas, 229 patients (61.06%) were from urban areas, 130 (34.66%) were from surrounding districts, and 16 (4.26%) were from other states. Around 72 patients (19.2%) were graduates, 54 (14.4%) had completed their 12th grade, 119 (31.73%) were educated only up to 10th standard, and 18 (4.8%) had not received any formal education. Nearly 212 patients (56.53%) were economically poor, 104 (27.7%) were under the self-payment category, and the remaining 59 (15.73%) were covered under various other health schemes. Majority of the patients (310, 82.66%) were Hindus, whereas 54 (14.4%) were Muslims. Only 26 patients (6.93%) were vegetarians.

Risk factor characteristics

Smoking, hypertension, abdominal obesity and lipid abnormalities were the prominent risk factors noted in the study. Physical parameters showed that 75 patients (20%) had normal BMI, 175 (46.6%) had high BMI (98 – overweight and 77 – obese), and 110 (29.33%) had BMI which according to the revised BMI classification for South Asian Indians comes under the category of overweight. Going by waist–hip ratio (WHR) definition, 290 patients (77.3%) had abdominal obesity [Table 1]. The mean total cholesterol of the entire study population was 186.135 ± 47.11, LDL was 138.37 ± 84.81 mg/dl, high-density lipoprotein (HDL) was 39.68 ± 9.64, and TG was 205.36 ± 87.11.
Table 1: Risk factor profile of patients

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In the group, 96 patients (25.6%) had elevated total cholesterol levels, 101 (26.93%) had elevated LDL cholesterol, 143 (38.13%) had low HDL cholesterol levels, and 145 patients (38.3%) had elevated TG levels [Figure 1].
Figure 1: Graph showing distribution of conventional lipid parameters. LDL: Low-density lipoprotein, HDL: High-density lipoprotein

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Clinical and angiographic characteristics

The most common index presentation of CAD was ST-elevation myocardial infarction (STEMI) noted in (275 patients – 73.3%). The next common presentation was unstable angina/non-ST-elevation MI seen in (125 patients – 25.33%) and only 5 patients (1.33%) presented with aborted MI. Only 335 of 375 (89.3%) patients underwent coronary angiogram, of which 265 (79.1%) had single-vessel disease, 17 (5.07%) had double-vessel disease, 26 (7.8%) had triple-vessel disease (TVD), and 27 (8.1%) had normal or nonobstructive disease.

LV ejection fraction (LVEF) recorded for each of patients showed adequate systolic function (>55%) in 113 patients (30.13%), mild LV systolic dysfunction (46%–54%) in 100 patients (26.7%), moderate LV systolic dysfunction (305%–45%) in 76 patients (20.3%), while it was severe LV dysfunction (<30%) in 86 patients (22.93%). Of the group, nine patients had severe LV dysfunction, cardiogenic shock, and succumbed.

A subgroup analysis [Table 2] according to age was done by dividing into three groups, as 26–30 years, 31–35 years, and 36–40 years. Compared to the youngest age group, the older age group had more dyslipidemia and presented more often with non-STEMI presentation. The prevalence of high BMI and abdominal obesity was almost equal in all groups. The presence of family history of CAD and index presentation as STEMI was more common in the youngest age group. TVD was more common in older diabetics.
Table 2: Subanalyses of the diabetic group into three age groups

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  Discussion Top


Asian Indians have the highest risk of PCAD and diabetes. When compared with When compared with American Indians, Asian Indians have double the risk of CAD and triple the risk of diabetes mellitus.[19] In the Global Registry of Acute Coronary Events study, the prevalence of young ACS was 6.3%; in Thai ACS registry, it was 5.8%; and in Spain registry, it was 7%.[20],[21],[22] In a study in South Indians by Iragavarapu et al., it was 10.4%.[23] Our PCAD registry shows a higher prevalence of 16%. Of this, 10.86% of the registry population belonged to the diabetic PCAD group.

Demographic and risk factor characteristics

The population under study had predominantly males (77.6%), with an average age of 35.94 years. Majority of the patients (93.07%) were nonvegetarians. Among traditional cardiovascular risk factors, the most common risk factor was smoking present in 42.40% of the patients similar to observations in the INTERHEART study, more so in Indians, as noted by Gupta et al.[24],[25] The profile of our population reflects the unique nature of Indian PCAD, and 175 patients (46.6%) had high BMI (98 – overweight and 77 – obese) and 110 (29.33%) had BMI which according to the revised BMI classification for south Asian Indians comes under the category of overweight. Going by WHR definition, 290 patients (77.3%) had abdominal obesity (average BMI: 23.52 and average WHR: 1.1). Several studies have noted the association between obesity and young CAD.[26],[27],[28]

Obesity and current smoking are the two important conventional risk factors associated with adverse outcomes such as future acute coronary events.[29] Our study in patients with young diabetic CAD reflects the same observations.

There were 27.2% hypertensives and 18.1% had familial CAD. Family history of CAD is emerging as an important independent risk factor for CAD in young Indians.[30] Lipid analysis in our patients showed high values of total cholesterol, LDL-C, and TGs, along with a low HDL cholesterol value. The lower HDL-C and higher TG levels were found prominently in young Indians.[23],[30] All these studies implicate abnormal lipid metabolism in the development of CAD among young Indians, more so in diabetics.[31],[32]

Clinical and angiographic characteristics

The most common acute coronary presentation was STEMI (73.3%), also noted in other studies.[23],[33] However, a subgroup analysis based on age showed that non-STEMI presentation was common in older diabetics (36–40 years).

Single-vessel disease was common (79.1%) in our group. Several studies noted similar observations.[33],[34],[35],[36],[37] Furthermore, subgroup analyses showed that TVD was more common in older diabetics. The prevalence of normal coronary arteries in patients with young CAD is about 8%–22%, as reported in various studies.[28],[38],[39] In our study, 27 (8.1%) patients had normal or nonobstructive disease.

Nearly 56.8% of the patients had an LVEF of >45%, of which 48% had normal LV function. The remaining 43.2% of the patients had moderate-to-severe LV dysfunction. Young CAD patients are noted more often to have normal-to-mild LV dysfunction.[33],[40] However, our diabetic PCAD group seemed to have decreased LVEF than usually observed.

Of the group, 2.4% had severe LV dysfunction, cardiogenic shock, and succumbed.


  Conclusion Top


The diagnosis of diabetes at a younger age is associated with an increased incidence of CVD morbidity and mortality. Conventional risk factors such as smoking and obesity need to be recognized as an emerging danger in Indians and have to be dealt with aggressive lifestyle modifications beginning early in childhood than in other populations. A cause of concern to developing countries such as India is the incomplete detection, treatment, and control of these risk factors. The nonavailability of guidelines for various risk factor cutoffs with particular reference to Indians hampers treatment.

Limitations of the study

  1. Duration of diabetes was not included as a variable due to inadequate documentation
  2. LDL subfractions such as small dense LDL levels were not analyzed
  3. It is only an observational study without any comparator group and follow-up details.


Acknowledgment

We would like to thank our Research Coordinator Mrs. Rani B J and Research Assistant Mr. Prateesh for technical help.

Financial support and sponsorship

This study was financially supported by Sri Jayadeva Institute of Cardiovascular Sciences and Research.

Conflicts of interest

There are no conflicts of interest.



 
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