Indian J Cardiol 2005; 8: 3637 Short Term Mortality in Acute Coronary Syndrome : Clinical Considerations BS Kushwaha, S Dwivedi Department of Medicine Lniversity College of Medical Sciences, GTB Lospital N. Delhi Abstract Despite immense: scientific advancement. in the diagamntic techniques and manigement, coronary artery disewse (CAD) continaes to be one ofthe feachny causes of death all over the world. initial few: houss are very critical In the management v| the acute myceacdial infraction (AMI) andl unstable angina (LSA). was therefore planned ti study the varioa chien! markers determining the short ferm nhiralty in patients admitied in CCU ol this boepital from fan. 200] to Dec. 2001. This inciuded all patients (n-672) of AMI, and pust Mangia based on classical history, £OG changes and elevated cuntiac enzymes Thorough assessment of risk laciozs vie-smoking alcohol, hypertension, diabetes melitus and anaiemnca! ste of iarction, associated arrhythmias, Kiliy class and other complications fike acute cenalfallure (ARF), septicemia, ewbeovasculae aceidents (CVA) etc was made Short terrt morality up to sever ays was noted in each case, Total number of deaths worw 54 (8%): Male: Female ratio was 241, age range 35:80 years. Maximum ations (n 29, 68%} wore in the 41-60 years oF age group. Anterioe wall MI (inctuding anteroseptal and anterolateral] was most comron Lise ir4, 8%), Eleven patients (22%) suffered from USA. Ventricular zochycordis (VT) wes the commonest arahythmia (n-10, 20%), Four pat KEI), Our s 1Dhours died of chest infeeiions with septicemiz, Zeach due ty ARF and CVA, Meumum deaihs were completed with catdinystnic shock fy indicates that smoking, hypertension, diabetes mellitus, anterior wall MI and delay in reaching to hospital beyond acute pain Were lntimately awsociated with eoriy moriality. Most deaths in acute esronary’ episodes occuring within 24 Ihalies are day (a arshythinias (VT/VE/CHB), Cardingenie shock and complications like ARF. septicemia due to chest infections and CVA ate other deteiminats. These observations are pertinent for preventive and therapeutic strategy to bring down the short term momality acute enronary events. Introduction The tuber of deaths dav to coronary artery disease (CAD) in Indias projected to increase from 1.178rnillion in year 7990 to 2034 milion by yewe 2000" This in despite inprenive strides in diagnostic Seid axyressive management of acute coronary events. Inillal few hours are very critical In the smagement of acute Goénnary episodes Price awareness and “appropri therapeutic atategy to tackle those factors save many lives. We thereiore planned to study the various sinicol markers detesmining. the short term mortality tr. patients presenting with acute cormmary eisodes in oar setting where Patients were basleslly managed by pharmacological Zeperhislon therapy and when tequicing immediate _Aiterventions.ace transferred to ther aper centers. Materials and Methods ‘Our study included all patients (9-472) suffering trom acute myocardial infarction (AMD, unstable angina (USA) and/or reinfaretion in coronary care unit of the Hospital between Jai, 200i Dec. 2001, the diagnoms of acute coronary everis was based an classical history. ECG changes anid /or elevated cardiac injury enzymes (CPK-MB or Typ T), A through assessment of risk factors Like age sex. smoki alcohol, hypertension (BP = [26 mg/dl. post pradial Blood 3200 my/dl) and short term mortality up to7 days.was recorded Jin each case. The anatomical sive of Infarction, USA, aswoclated ‘archyihmias, Killip class and other complications like acute renal failure, cerebrovascular accident (CVA) and peripheral ‘Addvess (or Comespondence » BS Kuchwaha, Dourtnen? Medicine, University Calege of Matial Sermes (Ueccersity of Dein) ~ GTB. Hospiat Delt» 95, 102/IV/ Sector tl, BLL Rampur, Hardoear «249403 Uttarenctal Faas batkusbitsheltr conto — Vascular disease (PVD) ele were abio studies Results Out of total 72 adiitied carey 54 B.0%) padionts die ‘within 7 days oftheir presentation 1o the hospital. Out of $8 why ied. detail work sp could be dan in 50 caes only. Male Female ratio was 2 1, age ange 35-80 years Maxima patients (r-2 5) were in thw 41-60 years oF age group. Anterior wal Ml including, anisreseptal end anterclaleral) was. common prewntation (7-25, 50%) followed by inferior wall MI (0 20%), Four patients (8%) had both anterior as well as iterioz intarction. Eleven (22%) audfered from unstable angina. Thirty cone (62%) patients were smokers, 22 (4%) hypertensive, 14.) Albetic and $ (10%) were alcchlic (table 1), Ventrieaisr tachycardia (VI) was the most cammion (7-10, 20%) errhytbvae (observed in those who died. Complete Heart block (CHB) (n= 10%) and ventricular fibsillatin (VF) (rvs. 8%) were next cimmon catsun of dasths due lo arrhythmia. Ventriéular premature complexes (VPC) n-3, 6, tafe bundle branch bioek (LBBB) (7-2, 4%, and right buncle branch biock (RBBO) (ee $i) Were also ted in few cases (Tabie2), Twelve Qa plients died despite thrombolysis: Hour patients diod of chese infections with septiceia and two each due to acule ren failure and carvbrovascalar accidents. Masconumy deaths (2-35 16%) wwcurred within 24 hours of admission. Asworyg them, 2 (Go.0%) were chrunic smoker, \6 (485%) hypertensive and (121%) diabetic, Fitoen (48.4%) deaths were complicated With candiogenic shock (KC IN), Discussion Jn our study, Sahospital death in acute coronary syndrome Within 7 days was 8% Other internation studies depicts that the short term mortality of pationes with AME receiving aggressive pharmacolngesl sepertusion therapy c=Indian J Caidiol 2005;8:36-97 _Kushwahs and Dwivedi ‘Short Term Mortality in ACS the Fange oF 8.5 10 7.9 perewnt: Jose etal studied 1320 patients of acute ST segment elevation MI and found 16.9% mortality in 30 ays of follow up.' There are various factors which ane associated with mortality like members of some ethnic [population marwart bani; tin) history of gestational diabetes Imelifios (ange birth weight 2 90 pounds) hypertension 2 190/9) mg Hg HDL < 30 mg/dl, C2150 my/al, history of vascular disease’ Among, known risk factors, smoking is the ‘most prevalent and modifiable rik factor, In our study, 62% ratients were strikers. Pate ct al studied 300 cases of AMI and found that 197(65:7%) patierss were curert or preicus smokers" Devivedi et al als found that smoking (61.1%) was most ‘common risk fact.’ Hypertension (44%) wins tho sezond itost ‘common tisk factor while diabetes mellitus (18%) was the next Important factor responsible tor acute coronary syndrome in sour study, Dwived) ct al and Isser ot at found its prevalence in 7.1 and 14% cases neapectively while Sowach etal observed its prevalence 1.7% cases.” This disparity may be due w ditierent setting im which these studies have been made; tho earlier wo ‘are from metropolis nd the lest is from semi urban-rural ares. Major risk factors like smoking. hypertension and diabetes rrellitus arent the only culprit for short term rnartlity Delay. {in artival to the hospital thas not qualifying the thrombolytic Uhetapy and presence of campilcations like serious arrhythmias ‘and /or cardiogenic shockare the other impartant factors forthe immediate morality. The very fact that only 12 patlents sit of 3 could be thesmbolysed and rest of the patients reiched to the ‘hospital beyond window period amply testifies this paint In gur study maxi desth (68%) pecurm! within 24 hours of onset of chest pain and were mainly dur to exedicgeai shock and ventricular archythmis. Bengison et a! studied prognosis in cardiogenic shock aiter acute myocartin|infereion 4n 200 patients" Kl was found that in hospital mortality rate was S¥vand was aseuxialed! to palerey of the nfaret related artery, patient age, low cardiac index, high arteriovenous oxygen, \ifference'and left main coronary artery disease. Hochinan rt st ‘studied Cdiogenie shock complicating acute myocacdial Infarction and comelicied that loft ventsieular talure (7.5%) ‘was mest common with isolated right veniriculat shockin23%>, severe mitral ragungitation in 6.4%, ventricular seplal rupture 2.9% and tamponade in $44 in such ces’ Besides cardiogenic ‘shock and arrhythmias, complications like acute renal failuie (ARF) ana extebrovascular accidents (CVA) ane ater common factors assoeiated with short term mortaity. CVA complicaninys MLis generally schaethic but it can be hemorthagi also due thrombolytic therapy Balachandran studied acute ML presenting o® sttuke over a period of 10,year and Jound that 1.6% of total MI presenta! as stroke.” In our study CVA was present in 4% cases whi had died Conelwsion ‘Our study indicates that ehconiec ameking, hypertension, snierice wall Mi, delay is arcval to the hospital raul is rongualifeation (or thrombolytic therapy are essocated with shoriterm mortality, Most deatns in acute corerary episodes scrutring within 24 hours are due to arrhythmiss (VT and/or VP) and CHB. Cardiogenic shock i the next most important facie. Thee abservations are pertinent for preventive and Iherapeutie stintegy wo bing down the short wm mortality im acute coronary event References 1 WHO Rego Yh to wh, Aile 1958.1 Regina Orfeo Sih Et Aaa Nw Dal > SS 2 The GUSTO Invetigstom An etemancnal indolent a Comparing. ‘Our ambeiyuc” wales. We auieonyocaal inlay (Mer 19, ase ad “The Ciba of rnin for sete mpi ntete Xp dad fe, SOO 4 Jove ¥ J, Gupes'S Ne Monatiy of 4gute ST essen yall nun che cuenta Busy Mr 2s; 650218 5) ADA Position Staiemmect: The prwalnce Wh dolay of ype HE DM. ratte care 3 862-59, 6 Pa Pay MP, YoslS nerase ik of ace year alreion “psa dted wich be and Gare smuking in Ines Fal cerort on emacs sk eh ca eer dy nha tf 300, SA7SETS 7 Dyn & Boones, Chanunets A. Sharma S Gonoesey astery Blew te jangeHereatanla Lolly ile wpe arbors me ‘Clay te 2000, 1322S A Isler HS Punt Vk, Sxaln VS. Satan RE. Dwiveal SK. Sigh S. Lipoprotem (a) and apad levels In young stots wise mpocarciah dain ‘i thee fete reatves. fii Hit} 20GH: SBS be 4 Siovat SB Singh 1, Sharma B Kalval VI. Profle of young aeike myocardial snlaetion in Haryana. APL 9) i246 10. Bengisn JR, Keplan A). Piper KS, Widderman NM Mark 5B, Proyor (Dp, Pips HR Cali RSE: Progen in canlogwak shock ue ace (nyogara sdascoor in the interest era] As Col id 1 pile 1. Mecha 8, Bar CE Sedper LA; Bolaed f Brant Vs Senbexn TA Gostiey White #49, Lex jlejwmtel -B. Cargenic shoxk complicating sevieowvowrthlidaretion eelayes titagemen ahd ‘oulgemne a report trom the STOCK ial tegatey Should me ‘oergenly tiguculariee veladed dovorarie foe cacgenic sock] ‘Ae ell Cand 2000, 993 Suppl A 168-7 52 Balachandan'V Myocandit ntact presenting as stoke; [APT 1998) sbntboi—