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ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 62-65

Finding association between lipid profile and demographic and disease status of patients undergoing coronary angiography: A retrospective study in rural South India


Assistant Professor, Department of Cardiology, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Submission22-Jul-2020
Date of Decision22-Jul-2020
Date of Acceptance12-Sep-2020
Date of Web Publication03-May-2021

Correspondence Address:
Dr. R M Prashanth
Assistant Professor, Department of Cardiology, Yenepoya Medical College, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_56_20

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  Abstract 


Background: Coronary artery disease has higher prevalence in India than the West. Studies suggest that vascular age of Asian Indians is older to their chronological age, making them more susceptible for the disease. Association between various factors involved in patients having coronary artery disease and their lipid profiles in rural India is not clear. Objectives: The study focuses on the prevalence and comparative analysis of dyslipidemia in the patient group with respect to demographic data and comorbid conditions. Patients and Methods: This was a retrospective study which analysed 957 patients' hospital record in whom angiography was done for their coronary artery disease in a rural south India. Results: Statistically significant data (P < 0.005) were found in case of total cholesterol levels, with a mean being elevated in age below 45 years (178 ± 46 mg/dl) as compared to age above 45 years (167 ± 48 mg/dl). The mean total cholesterol levels were greater (177 ± 49 mg/dl) in women as compared to men (166 ± 48 mg/dl) with P < 0.005. Hypertensive patients showed elevated levels of total cholesterol and triglycerides. Patients with diabetes had elevated triglyceride levels in general. Conclusion: Triglyceride levels might be playing an important role than total cholesterol in the pathophysiology of CAD and for atherogenesis, it is the presence of hypertension with a deranged lipid profile, more so with total cholesterol and triglycerides.

Keywords: Coronary artery disease, dyslipidemia, vascular age


How to cite this article:
Prashanth R M. Finding association between lipid profile and demographic and disease status of patients undergoing coronary angiography: A retrospective study in rural South India. J Indian coll cardiol 2021;11:62-5

How to cite this URL:
Prashanth R M. Finding association between lipid profile and demographic and disease status of patients undergoing coronary angiography: A retrospective study in rural South India. J Indian coll cardiol [serial online] 2021 [cited 2021 Sep 18];11:62-5. Available from: https://www.joicc.org/text.asp?2021/11/2/62/315264




  Background Top


India having the second largest population in the world with diverse cultural and lifestyle preferences faces a certain challenge when it comes to noncommunicable diseases. Cardiovascular diseases attributed to 17.9 million deaths globally, making it the top cause.[1] In the different parts of the country, several attempts have been made to compile the burden of cardiovascular disease. Dyslipidemia is a known key, independent modifiable atherosclerotic risk factor, and has been closely linked with the pathophysiology of cardiovascular diseases. Coronary artery disease (CAD) is the narrowing of the coronary arteries usually caused by atherosclerosis. These plaques can restrict blood flow to the heart muscle by physically clogging the artery or by causing abnormal artery tone and function. Other risk factors of CAD include patient's demographics such as age, gender, comorbidities such as diabetes mellitus, hypertension, and lifestyle such as smoking. Ethnicity-based causative factors have a role to play in Asians suffering from CAD.[2]

In Asian population, the arteries are almost a decade older than their chronological age as compared to other ethnic groups and have been found to develop cardiovascular conditions at a younger age.[3],[4] The proportion of total deaths from cardiovascular diseases was higher among people younger than 70 years than those aged 70 and older.[5] A study involving North Indian patients of CAD noted that total cholesterol and low density lipoprotein cholesterol (LDL-C) were found to be much lower than other populations, also younger patients showing more atherogenic lipid profile than the older group.[6] One study concluded that hypertriglyceridemia and low high-density lipoprotein cholesterol (HDL-C) were common in patients with CAD compared with hypercholesterolemia, which suggests that different preventive strategies need to be employed in Indian patients with CAD.[7] Hence, the Indian population is more prone to the disease with risk factors adding to the already present ethnical susceptibility.

Not many studies have been done in the Indian scenario to evaluate the prevalence and comparative analysis of dyslipidemia in young CAD patients. There is an urgent need to better understand the presentation in the young, in order to facilitate diagnosis and treatment, to initiate aggressive risk factor intervention, and to improve the quality of life. This study investigates the prevalence of dyslipidemia in the study group. This will help compare with available data for patterns or trends with respect to lipids and other risk factors in the study sample.


  Procedure Top


The study is a retrospective one involving 957 patients. Approval from the institutional ethical committee was sought. All subjects irrespective of age and gender presenting with CAD and in whom coronary angiogram was done were included in the study. Data from the files having the minimum required data as per the pro forma were taken.

The hospital records of the patients with CAD who visited the tertiary care center in South India, during the period from July 2017 to April 2019, were reviewed. The data were collected by a technical assistant from the Medical Record Department files of all the patients who presented with CAD during the said period. Patient's demographics; comorbidities such as diabetes mellitus and hypertension; and laboratory values such as total cholesterol, LDL, HDL, and triglyceride were noted. Data analysis was done on blinded excel sheet (excluding the patient's name and any other identifiers). Patient's confidentiality was maintained throughout the data collection process. Statistical analysis was done using IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA).


  Results Top


Out of the total study sample of 957 patients, the mean and standard deviation of total cholesterol in the age below 45 was 178 ± 47 mg/dl and patients of age above 45 were 167 ± 49 mg/dl. The difference was statistically significant with P < 0.05 [Figure 1]. Males had lower levels of total cholesterol (166 ± 48 mg/dl) and HDL (35 ± 15 mg/dl) as compared to females' mean total cholesterol (177 ± 49 mg/dl) and HDL (39 ± 16 mg/dl). In both the cases, the probability value was highly significant (P < 0.005) [Figure 2]. Diabetic patients had a mean triglyceride level of 195 ± 143 mg/dl, while nondiabetic patients were having mean triglyceride of 153 ± 79 mg/dl. In this case too, the difference in the two parameters was statistically highly significant with P < 0.001. The mean values and standard deviations of total cholesterol and triglycerides in hypertensive patients were found to be 173 ± 50 mg/dl and 175 ± 115 mg/dl, respectively. Normotensives had similar values for total cholesterol of 165 ± 46 mg/dl and that of triglyceride was 157 ± 97 mg/dl. In both these parameters, the probability value was < 0.05 (P < 0.05) [Figure 3].
Figure 1: Age versus mean levels of total cholesterol in mg/dl

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Figure 2: Gender versus lipids

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Figure 3: Hypertension versus lipids

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  Discussion Top


The concern for a developing nation like India today is not just the mortality caused due to disease but also the morbidity of the population resulting in large number of money being used in the health-care sector. A study reported that disability-adjusted life years lost by heart disease in India by 5.5 million men and 4.5 million women during 1990 and would increase to 14.4 million and 7.7 million, respectively, in 2020.[8] The modernization and change in lifestyle of Indians is significantly contributing to CAD by increasing risk factors in the society. Indians harbor most conventional risk factors such as diabetes, hypertension, atherogenic dyslipidemia, smoking, central obesity, and physical inactivity. However, it is also observed that conventional risk factors may not contribute in all ethnic groups and novel risk factors may play a role. In South Asians, genetic factors such as insulin resistance, low birth weight, lipoprotein (a), and psychosocial factors may contribute to cause atherosclerosis.[9]

A cholesterol-centric approach is obsolete as there are many instances which prove that other lipids also play an essential role in the determination of vascular age.[10] Studies have suggested that irrespective of total plasma cholesterol levels being desirable in a patient, it is wise to order a complete lipid profile to rule out other lipoproteins.[11] Atherogenic profile is characterized by high TG and low HDL levels. Hypercholesterolemia is not seen generally in Indians.[7],[12] In this study, similar pattern is observed in the lipid profiles. The mean age of normal Indians with atherogenesis is low than the western counterparts. These variations may not be true to all Indians. A study by Goel et al. noted that in North Indians, CAD occurs at much lower levels of cholesterol and triglycerides.[6] This can be contradicting to the level of cholesterol in South Indians with CAD.[13] In this study, it was found that the level of mean total cholesterol was more in the age below 45 years, possibly suggesting that there might be other factors which can contribute to increase in cholesterol along with age and that age is not an independent factor for hypercholesterolemia.[14] A study conducted on Dutch men by Weijenberg et al. suggested that the total cholesterol decreased by 0.04 mmol/L with every year of increase in age.[15] This observation is prevalent in men than in women according to this study and many others.[16],[17] Gender-wise correlations between the lipids and body mass index were stronger in women than in men for cholesterol, LDL, and triglycerides.[18] Another study indicated that LDL-C increased with greater abdominal circumference among younger subjects but not among men over 50 years.[19] This gives us an insight as to how the gender physiology and anthropometric variations may affect lipid levels possibly indicating to different treatment strategies. Anemia is prevalent in Indian women and studies have investigated the relation between anemia and lipid levels. A study by Verma et al. found that triglycerides and very LDL-C levels were found to be significantly elevated (P < 0.001) in the iron-deficiency anemia group, whereas levels of LDL-C were found to be significantly lower in patients as compared to controls. After treatment, reduction was seen in the levels of triglycerides and very LDL-C. The findings indicate that iron-deficiency anemia in Indian adults is attended by abnormal serum lipid profile, and response to iron therapy is significant.[20] However, the result is contrary to the findings of NK Nithyananda C et al. who noted that levels of all lipids decreased with the severity of anemia.[21] Further studies should be done to assess whether this phenomenon is true to the entire nation or is this specific to certain region. This particular question arises because South Indian patients may possibly have a different lipid profile than other parts of the country owing to the fact that environmental and lifestyle patterns vary.[22]

Triglyceride levels in diabetic were found to be higher in studies and as noted in this study also.[7],[23] A study in Punjabi type 2 diabetic patients revealed that among lipids, abnormal levels of LDL were found in 93% of the study population.[24] HbA1c above 7% had a direct relation with cholesterol, triglyceride, LDL, and inversely with HDL. Studies suggest that it can be used as a predictor for CAD in diabetic patients.[25],[26] It is difficult to consider triglyceride as an independent risk factor in any heart disease as the number of interrelated factors makes it difficult to appreciate the contribution of triglyceride independently. Other confounding issues such as diabetes and low HDL-C should be considered. However, studies like the PROCAM, PROVE IT-TIMI 22 showed increase in cardiovascular events risk with an increase in triglyceride levels; but residual risk remaining the same even after accounting for other major risk factors. Also, triglyceride levels with acute coronary syndrome showed a substantial impact on cardiovascular outcomes in patients which was independent of LDL-C.

HDL-C has an inverse relation with coronary vascular events and risk. It is inversely correlated to insulin resistance, obesity, and triglyceride.[27] The first instance of this relation was noted by the Framingham Heart Study in 1966. Over the years, quality research has established that HDL is an independent risk factor for CVD. A retrospective study conducted on angiography patients found that 60% of the population with desirable levels of total cholesterol had low HDL levels.[28] Total cholesterol and triglycerides along with non-HDL-C were higher in patients of hypertension adding to the risk of CAD.[29],[30] To add another concern, high prevalence of hypertension was found in young adults in Indian diasporas than their American counterparts. This may be one of the reason that Indians succumb to CAD at a very young age than others.[31] Prediabetes is common in South Asians, but its relationship with CAD is not significant unlike for the white population. At the same time, prediabetes in South Asians is associated with an increased risk for cerebrovascular disease. The differentiating factor could be the high lipids in Europeans and their relationship to CAD. Likewise, higher diastolic blood pressure in SA may explain the risk of CeVD.[32]

It is certain that in a diverse country like India, the challenge is huge owing to the fact that there are many variables to address. The burden varies according to different states of India. There is an urgent need to gather data for the same.[5] The study is hoped to serve as an assessment of trends in the disease prevalence and perhaps a comparator, with studies from other states of the country to evaluate prevalence trends for CAD.


  Conclusion Top


The study speaks about South Indian people seeking angiography for suspected CAD. It can be concluded from this study that young South Indian females can get CAD at an early age due to their tendency of having an atherogenic profile (especially total cholesterol). Triglyceride levels may play a major role in diabetics than total cholesterol for occurrence of CAD. The presence of hypertension itself being overwhelming for atherogenesis is further complicated with a deranged lipid profile, more so with total cholesterol and triglycerides. The reason to these must be investigated thoroughly with concurrent clinical studies done pan India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Weijenberg MP, Feskens EJ, Kromhout D. Age-related changes in total and high-density-lipoprotein cholesterol in elderly Dutch men. Am J Public Health 1996;86:798-803.  Back to cited text no. 15
    
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Gostynski M, Gutzwiller F, Kuulasmaa K, Döring A, Ferrario M, Grafnetter D, et al. Analysis of the relationship between total cholesterol, age, body mass index among males and females in the WHO MONICA Project. Int J Obes Relat Metab Disord 2004;28:1082-90.  Back to cited text no. 16
    
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