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Volume : 2  |  Issue : 3  |  Page : 70-75  Rao V

 Rao P
rs for acute myocardial infarction in coastal region of india: A case-control study  Carvalho N

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Rao1, Prasannalakshmi Rao2, Nikita Carvalho1
of Community Medicine, Father Muller Medical College, Mangalore, Karnataka, India     Search in Google
harmacology, Father Muller Medical College, Mangalore, Karnataka, India
 Rao V
blication 5-Sep-2014  Rao P
 Carvalho N

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Rao  Acute myoca
of Community Medicine, Father Muller Medical College, Mangalore - 575 003, Karnataka  coronary risk
 smoking

rt: None, Conflict of Interest: None Access Statistics

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Abstract
21-449x.140229 Introduction

Patients and methods

Results
 
Discussion
arious studies have shown that people of Indian origin have an increased risk of ischemic heart disease (IHD) compared with most
References
ps. This increased risk has been attributed to multiple risk factors related to lifestyle. Patients and Methods: A total of 100 cases
d sex-matched controls were taken into this prospective case-control study from Intensive Coronary Care Unit. Prevalence of the Article Tables
tors for myocardial infarction: Age, sex, diet, smoking, alcohol consumption, history of hypertension, history of diabetes mellitus,
were studied. Patient data were extracted from the medical records department and by interview. Results: The most important  Article Access Stat
e myocardial infarction (AMI) was high low-density lipoprotein (adjusted odds ratio [OR]: 4.124, confidence interval [CI]: 1.44-
) history of hypertension and of overt diabetes mellitus were also independent risk factors (OR: 2, CI: 1.4-3 and OR: 2.29, CI: 1.5-     Viewed
y. Low high-density lipoprotein was found to have no significant association with AMI. Heavy drinkers were found to have a high-     Printed
hile moderate drinkers were found to have protection (OR: 1). Conclusion: Smoking and heavy drinking cessation, treatment of
d reduction in blood glucose, correction of abnormal lipid profile either through use of statins or by dietary modification may be     Emailed
enting IHD in Asian Indians.
    PDF Downloaded

te myocardial infarction, coronary risk factors, smoking     Comments 

article:
arvalho N. Risk factors for acute myocardial infarction in coastal region of india: A case-control study . Heart India 2014;2:70-5

URL:
arvalho N. Risk factors for acute myocardial infarction in coastal region of india: A case-control study . Heart India [serial online]
Mar 11];2:70-5. Available from: http://www.heartindia.net/text.asp?2014/2/3/70/140229
[TAG2]
[TAG3]
[TAG4]

myocardial infarction (MI) in the world varies greatly. According to a Spanish study, the crude coronary heart disease (CHD)
as 300.6/100,000 person-years for men and 47.9/100,000 person-years for women. [1] The incidence of MI in India is 64.37/1000
aged 29-69 years, alcohol intake led to 30% lower CHD incidence. [1] Smoking is known to cause arterial thrombosis and MI, and
se endothelial dysfunction. [2] More than 80% of the cases of cardiovascular disease are in developing countries however studies
e mostly conducted in developed countries. [3] Hence, it is important to carry out relevant studies in a developing country such as
study the risk factors and their influence. The association between substance abuse and CHD has been widely studied. Many
ve shown that moderate alcohol intake reduces the risk of CHD [4] and smoking increases it. [2] As not many studies have been
e incidence of substance abuse in patients with MI in this region, this study aims to elicit a history of substance abuse among
and correlate the two. Consumption of small to moderate amounts of alcohol (2 oz [59.2 ml] or less daily) is associated with lower
onary death. [4] This has been attributed to improved plasma lipid profiles, particularly an increase in high-density lipoprotein (HDL)
eased adiponectin, reduced plasma fibrinogen, viscosity, platelet activity, C-reactive protein, and improved insulin sensitivity. [5] A
tion between alcohol consumption and a first MI in 464 patients was found in a study. [6] There was a larger proportion of people
sume alcohol among those who had an MI (P < 0.01) as well as a smaller proportion of moderate (two or less drinks per day) and
more drinks per day) drinkers. According to the study, the lower consumption of alcohol by persons who subsequently had an MI
related to ethnic origin, psychological traits or other unknown risk factors for MI. Furthermore, according to the study, alcohol
d cigarette smoking were habits that were found together often. The relative risk of MI increased with consumption of tobacco and
nhalers than in non-inhalers. [7] In another American study, it was proved that cigarette smoking causes marked inhibition of
uced tissue plasminogen activator release in vivo and this could provide the mechanism whereby endothelial dysfunction may
of atherothrombosis through a reduction in the acute fibrinolytic capacity. [2] South Asians have an increased risk of ischemic
HD) compared with most other ethnic groups, including urban Indians, [8],[9] which is due to various preexisting reasons leading to
 Despite these studies, variables associated with IHD may differ among patients from different regions within India. Most studies
ho have migrated to other countries or those living in major cities within India. These studies may not reflect the true relation
ors of MI and their influence on population from smaller cities. This hospital-based case-control study of patients with a first MI in
, is primarily to assess the relative importance of the risk factors for IHD among dwellers of smaller cities and towns along the
belt of Karnataka.

methods  

tients aged 30-85 years (both inclusive) admitted to the Intensive Coronary Care Unit of the Medical College Hospital with acute
ction (AMI) were taken as cases. AMI was defined as typical chest pain lasting minimum half an hour and an electrocardiogram
ST elevation of at least 2 mm in two or more contiguous leads with subsequent evolution of the ECG and diagnostic enzyme
se-MB) changes. Patients were excluded if they had a history of preexisting cardiac illness.

ntrols were chosen from the other wards of the hospital, from those admitted for conditions that would not confound the results.
preexisting heart disease or AMI were excluded. Controls were matched to cases for age (within 5 years range) and sex.

ectively recorded by patient interview and from patient charts by the same research assistant each time. In all participants, age,
ails of diet, smoking, alcohol use, and known history of diabetes mellitus and hypertension were recorded. Fasting lipids (total,
rotein [LDL] and HDL cholesterol, and triglycerides) were measured in all participants. Total cholesterol and triglycerides were
automated system with standard kits (Boehringer Manheim GmbH). Enzymic methods for cholesterol and triglycerides were used:
ase/peroxidase-aminophenazone and glycerol phosphate oxidase/peroxidase-aminophenazone, respectively. HDL cholesterol
with the precipitation method and glucose by the glucose oxidase method. Analyses were done on a Beckman Synchron CX4
. LDL cholesterol was calculated as total cholesterol minus (HDL cholesterol + triglyceride/5). All biochemical analyses were done
the knowledge of clinical information.

methods
 mean or median values or prevalence of a risk factor were conducted after matching each case with the next control subject
same sex and age within 5 years. A comparison of discrete variables in cases and controls was done with logistic regression
e matching of cases with controls. Estimates of relative risk and 95% confidence intervals (CIs) were also done. For continuous
ed t-test was done. Multivariate analyses were conducted with logistic regression methods on transformed values. The Statistical
cial Sciences version 16 IBM corporarion were used for analyses. P values were two-tailed. Collected data were analyzed by
entage, mean, standard deviation, and by odds ratio (OR) and its CI. An OR of 2 or more was taken as significant.

a confounding bias, cases and controls were matched for age and sex (potential confounders in the study). Cases and controls
ted based on the matched variables, such that both groups have a similar distribution in accordance with the variables. The
aracteristics and lipid data of the 100 cases and 100 controls are shown in [Table 1] and [Table 2], respectively. Among all risk
, smoking was the most important risk factor on comparison of lifestyle factors. About 61% of cases and 16% of controls had
current smokers of cigarettes (OR: 3.3, 95% CI: 2-5.1). A dose response effect is evident from [Table 3], where the higher
y smokers (taken as more than 10 pack-years) were found among the cases (51%). On the other hand, among the controls only
to be heavy smokers. The higher number of nonsmokers was among controls (84%), whereas among cases this percentage was
nary logistic regression [Table 4] too it was found that smoking was a significant risk factor (adjusted OR: 0.152, P = 0.001, CI:
ut 52% of controls were drinkers compared to 29% of cases (OR: 2.65, CI: 1.47-4.7). This may suggest a protective effect of
ontrols. On plain Chi-square analysis for alcohol exposure [Table 5], it was found that heavy drinkers had the highest risk, 17% of
vy drinkers as opposed to none of the controls (OR: 68), followed by nondrinkers. It was found that a high number of cases (71%)
s as compared with 48% of controls (OR: 6.41). Furthermore, all controls surveyed, were moderate drinkers (taken as <179 ml).
protective effect up to a moderate level of alcohol consumption and high-risk thereafter. In previous studies, vegetarianism has
have a protective effect. [21] Among the cases in our study, 93% consumed a nonvegetarian diet as compared with the controls,
he controls surveyed were vegetarian (OR: 3.3). This indicates the significance of meat consumption as a risk factor in the
Diabetes is another independent risk factor in the study. About 67% of cases had higher fasting blood glucose (FBG) compared to
(OR: 1.9, CI: 1.3-2.7). Cases had a mean FBG value of 175 mg/dl, while controls had a mean FBG value of 145 (t = 2.3, P =
e 1]; however, a higher FBG value among cases may be attributed to a higher number of diabetics among the cases (47%) as
ontrols (17%) (OR: 2.29, CI: 1.5-3.5). Cases were also seen to have a longer duration of diabetes (mean value: 7.5 years) as
ontrols (mean value: 4.7 years) [Table 6]. More cases (52%) were found to be hypertensive that controls (22%). As with diabetes,
es were seen to have a longer duration of hypertension as compared to the controls (mean value of 9.4 years vs. mean value of
e comparison of lipid profiles among cases and controls, it was found that the HDL value was not a significant risk factor for IHD
98-1.7). However, high LDL values were found to be very significant with 68% cases having a high LDL value as opposed to 36%
2.3, CI: 1.6-3.2). The mean value of LDL among cases was 151 mg/dl and among controls was 110 mg/dl (t-test 3.043, P <
er number of cases had high total cholesterol values (68%) as opposed to controls (35%) (OR: 1.9, CI: 1.4-2.6). Mean values too
ong cases (222 mg/dl) than in controls (184 mg/dl) (t-test 4.006, P < 0.001). A higher triglyceride value was found among cases
among controls (127 mg/dl) (t-test 2.75, P < 0.006). A binary logistic regression was done [Table 4]. The variables entered were
history of diabetes, history of hypertension, high cholesterol (>200), high LDL (>130), heavy consumption of alcohol (>180 ml). It
high LDL was the most significant risk factor (adjusted OR: 4.124, P = 0.008, CI: 1.44-11.73) followed by high consumption of
d OR: 2.47, P = 0.14, CI: 1.205-5.06) heavy smoking proved to be an independent risk factor on regression analysis (adjusted OR
-0.321, P = 0.001). Hypertension was an important risk factor for MI according to the analysis (adjusted OR: 0.274, CI: 0.132-
). Conversely, a high value of cholesterol was found to be unrelated to MI (adjusted OR: 1.245, CI: 0.44-3.527, P = 0.68).
 Table 1: Comparison of lifestyle factors

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Table 2: Comparisons of variables

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Table 3: Comparison of cases with controls according to current smoking status

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Table 4: Binary logistic regression (stepwise logistic regression)

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Table 5: Chi-square analysis for alcohol exposure

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Table 6: Comparisons of mean values

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control studies have been done to identify the relation between risk factors and AMI in people living along the coastal belt of
uth Indian state. This study, which is most likely the first to illustrate the relation, shows that tobacco smoking, a history of
story of diabetes, heavy consumption of alcohol, and a nonvegetarian diet are independent risk factors for AMI. Our study was
ertiary care hospital in Mangalore. All our cases are confirmed cases of AMI without any previous heart disease, thus ruling out
modification of risk factors by treatment of IHD. As the data were extracted from patients belong to Mangalore and surrounding
onmental factors, which are likely to contribute to the variation in arterial disease susceptibility, were assumed to be the same.

ed in developed countries have shown smoking of tobacco to be major risk factor for IHD. [22] Furthermore, in our country, the
kers is increasing versus a decrease in smokers in the western countries. [21] Though some studies have deliberated on the
oronary artery disease in Asian Indians, the importance of smoking as a risk factor has not been considered in them. [11],
our analysis, smoking was found to be adversely related the incidence of AMI. Pais et al. [21] have shown a similar result in their
ct to smoking as a risk factor. In addition, a study by McKeigue et al. [25] have reported a similar relation between smoking and IHD
ians residing in the UK. Our study signifies that cutting back on smoking could reduce the incidence of IHD in the population. At
 , heavy smoking must be curtailed as it carries a relatively higher risk compared to moderate smoking.

diet was found to be associated with a higher incidence of AMI in our study, with a higher number of cases being meat eaters as
ntrols. This is in accordance with studies that indicate a relationship between consumption of meat and increased risk of
re, the protective effect for vegetarians may be due to the fact that their diet is low in saturated fat and relatively high in
fats. [48]

and thrombogenesis is also believed to be lower in vegetarians as their platelet phospholipid linoleate and antioxidant
are higher, which is likely to lead to reduced oxidation of LDL. [49] From our study, it can be considered that following a
et may lead to an increased risk of IHD and hence encouraging a vegetarian diet among Indians may help bring about a lower
of AMI.

dies such as The Framingham Heart study have revealed the importance of LDL and HDL cholesterol levels in determining risk
ry disease, which in turn is a risk factor for MI. Some other studies too have underscored the importance of HDL cholesterol in
sk of MI and demonstrated the protective effects of both the HDL 3 and HDL 2 subfractions of HDL cholesterol. [18] Indian
her countries have been shown to have lower HDL cholesterol and higher triglyceride concentrations. [10],[11],[12],[13],[23],[26] Our study
ups the study population to have a lower mean HDL value. That being said, low HDL was found to be a nonsignificant risk factor
y. This is concurrent with the results of the case-control study done by Pais  et al. with regard to influence of HDL. [21] On the other
r study shows not much difference between cases and controls in any of the other lipid variables as well, our study shows a high
h LDL and high total cholesterol level to be of significant influence in the development of IHD as seen among cases. This is
other small studies from India, [27],[28] which showed that total cholesterol and triglycerides were higher in individuals with IHD than
IHD. All our blood samples were taken within the first 24 h to rule out alteration in serum lipids due to AMI, which occurs after the
has been shown that each 1 mmol/l (39 mg/dl) decrease in LDL cholesterol equates to a reduction in relative risk for stroke of
lowering of cholesterol concentrations with statins reduces the risk of stroke in high-risk populations and in patients with non-
roke or transient ischemic attack. [17] Univariate analysis from other case-control studies have indicated that MI cases had higher
and were more likely to have a previous history of diabetes than controls. [19] Our study is in conformity with above findings from
d underlies the importance of stricter lipid control for prevention of IHD either through use of statins or diet control as appropriate.

Framingham Heart Study indicates a relation between glycosylated hemoglobin and IHD. [38] An increasing risk with increasing
oncentrations has been observed in a previous study, which suggested that even high blood glucose within the euglycemic range
uals at higher risk of IHD. [21] FBG was higher in cases than in controls, in our study and this finding was significant. The increased
cular disease in type 2 diabetes is well-recognized [31] and is associated with both diabetes specific risk factors [32] and increased
ventional risk factors for cardiovascular disease. [33] It has been suggested that the risk of death from CHD in patients with type 2
en be as high as in patients who have had a MI. [34] In addition, a high prevalence of noninsulin dependent diabetes mellitus has
wn in Asians. [35],[36],[37] A history of diabetes mellitus was found to be a risk factor for AMI in our study. It was also seen that a longer
tes mellitus prevailed among the cases in comparison with the controls. This indicated a higher risk of IHD among long-standing
bove findings are in accord with studies suggesting diabetes as a risk factor for IHD. [9],[14] A study of the relationship between
tion and nonfatal MI, involving 399 cases and 2486 reference subjects, indicated absence of any major overall association (rate
ate of 0.9 with 95% confidence limits of 0.6 and 1.2), but there was some evidence of a lower rate in subjects consuming six or
day (rate ratio point estimate of 0.6 with 95% confidence limits of 0.3 and 1.1). [15] In our study, the larger number of drinkers were
control group. This indicated a protective effect of alcohol against IHD. In spite of this, heavy drinking was seen exclusively in the
heavy drinking (taken as more than 180 ml/day) to be a salient risk factor in the incidence of AMI. The inverse association
ate alcohol intake and CHD is documented in over 40 prospective studies in diverse populations. [42],[43],[44],[45],[46] In our study,
s were found to be the lowest risk category. This may partly be explained by a study [16] according to which, a polymorphism in the
dehydrogenase type 3 (ADH3) alters the rate of alcohol metabolism and hence moderate drinkers who are homozygous for the
DH3 allele have higher HDL levels and substantially decreased risk of MI. In a quantitative review, strong and consistent evidence
g moderate alcohol intake with higher concentrations of HDL cholesterol and apolipoprotein A-I and lower concentrations of
 r results are in concurrence with studies that report a J-shaped curves, whereby light to moderate drinkers have less risk than
heavy drinkers are at the highest risk. [41] Hypertension is known to induce endothelial dysfunction, exacerbate the atherosclerotic
ntribute to making the atherosclerotic plaque more unstable. Left ventricular hypertrophy, which is the usual complication of
omotes a decrease of "coronary reserve" and increases myocardial oxygen demand, both mechanisms contributing to myocardial
ertension is also frequently associated to metabolic disorders, such as insulin resistance with hyperinsulinemia and dyslipidemia,
onal risk factors of atherosclerosis. [40] More than half of the cases in our study had a history of hypertension and an average of 3
uration than in controls. Treatment aimed at attaining optimal values of blood pressure may therefore be helpful.

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2], [Table 3], [Table 4], [Table 5], [Table 6]

       

  

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