The Association of Cardiovascular Risk Factors with Coronary Stenosis Severity and

Lesion Distribution in Patients Undergoing Percutaneous Coronary Angiography

A.R. Lutfia1, Y.C. Khasanah1, R.P. Tarigan1, H. Fakhruddin1, R. Handayani2

1
General Practitioner, Department of Cardiology, RSUD Abdoel Moloek Bandar Lampung,
Lampung, Indonesia;
2
Cardiologist, Department of Cardiology, RSUD Abdoel Moloek Bandar Lampung,
Lampung, Indonesia

Objectives: To investigate the association of cardiovascular risk factors (CRFs) with

coronary severity stenosis and the location of coronary lesion in patient undergoing
percutaneous coronary angiography (PCA).
Material and Method: We collected 189 medical records from patients who underwent PCA
at Abdoel Moloek Hospital Bandar Lampung between October 2020 until March 2021, who
fulfilled the inclusion and exclusion criteria. The severity of coronary stenosis determined by
vessel score and coronary score. A significant vessel score was defined as stenosis of ≥ 50%.
The location of coronary lesion was divided to left main (LM), left anterior descending
(LAD), left circumflex (LCX), right coronary (RCA) artery. Samples were analysed by
logistic regression and chi square. Odd ratio (OR) and confident interval (CI) of 95% were
reported.
Results: From 189 samples we found 161 (85.2%) multivessel disease and 28 (14.8%) non
multivessel disease. Most frequent CRFs was men 144 (76.7%) and smoking 114 (60.3%).
The location of occlusion, LAD 156 (82.5%), RCA 101 (53.4%), LCX 92 (48.7%), and LM
26 (13.8%). The association between severity coronary stenosis with gender (men with
multivessel disease 128 cases vs women 33 cases) defined by p value 0.03 with odd ratio
(OR) 0.398 (0.170-0.932). Age group 62-68 y.o (34.6%) and type II diabetes (30.8%) and
LM were analized by logistic regression with p value 0.018 OR 1.48 (1.070-2.045) compared
to p value 0.033 OR 0.35 (0.133-0.921). Smoking with p value 0.039 OR 0.536 (0.296-0.972)
were significant with RCA.
Conclusion: Men are more likely to have severe coronary stenosis than women. Type II
diabetes and age group 62-68 years old were associated with left main coronary lesion, while
smoking was associated with right coronary artery lesion.

Key words: coronary angiography, cardiovascular risk, stenosis severity

Introduction There are many risk factors for coronary
Cardiovascular disease is the leading artery disease (CAD) and some can be
caused of mortality over the world. controlled but not others. The risk factors
Especially in development country, that can be controlled (modifiable) are:
Indonesia, coronary artery disease and hypertension; high blood cholesterol
stroke are the most frequent caused levels; smoking; diabetes; overweight or
mortality and morbidity over one third obesity; lack of physical activity;
factors of death. unhealthy diet and stress. Those that
Table 1. Characteristics of Patient who cannot be controlled (non-modifiable) are:
Underwent Coronary Angiography Age (simply getting older increases risk);
Variable All (n=189)
sex (men are generally at greater risk of
Age 56.23 ±9.57
coronary artery disease); family history;
Age group
34-40 13 (6.9) and race.
41-47 21 (11.1) Percutaneous coronary
48-54 46 (24.3) angiography is a gold standard procedure
55-61 54 (28.6)
with invasive non surgery. This procedure
62-68 38 (20.1)
is aimed to identify anatomy of artery
69-75 14 (7.4)
76-82 2 (1.1) coroner; severity artery stenosis or
83-89 1 (0.5) obstruction inside of lumen artery;
Gender measure the length, diameter and form of
Men 145 (76.7)
coronary artery.
Women 44 (23.3)
According to high of mortality and
Hypertension 65 (34.4)
Diabetes mellitus 30 (15.9) morbidity that caused by CAD, this study
Smoking 75 (39.7) is aimed to identify cardiovascular risk
Lesion Distribution factors that can relate to coronary stenosis
LM 26 (13.8)
severity and lesion distribution from
LAD 156 (82.5)
patient who underwent angiography
LCX 92 (48.7)
RCA 101 (53.4) coroner.
Stenosis Severity Methods
0VD 26 (13.7) This was cross-sectional study
1VD 66 (34.9)
using medical records of patient who
2VD 50 (26.4)
underwent angiography coroner as samples
3VD 47 (24.8)
in Cardiology Department of Abdoel ≥50% were included either in the 3VD
Moloek Hospital, Bandar Lampung, group, if the right coronary was
between October 2020 until March 2021. hypoplastic or with stenosis ≥50%, or in
All samples were grouped by the 2VD group if the right coronary was
cardiovascular risk factors; gender, ages, without significant stenosis. Severity
smoking, hypertension, and diabetes; stenosis will be grouped by two categories,
characteristic result from angiography multivessel disease (≥2VD) and non-
coroner; severity of stenosis and location multivessel disease (<2VD).1
of lesion. Age variables were grouped by All samples that were fulfilled by
using Sturgess formula to stratified. inclusion and exclusion criteria would be
Vessel score was defined as the analysed with IBM SPSS 25. Bivariate
number of vessels with coronary stenosis ≥ analysis was using Chi-square to find
50%. This score was ranged by 0-3 point. significancy from all cardiovascular risk
Zero-vessel disease or 0VD (normal factors that were found in this study with
angiogram/ non-significant CAD) was stenosis severity and location of lesion
mild or moderate artherosclerosis either from coronary artery. all cardiovascular
without stenosis ≥ 50%. one-vessel disease risk factors that were significant, would be
(1VD) with stenosis ≥50%; two-vessel analyzed with regression logistic. All
disease (2VD) with stenosis ≥50%; or statistic data would be presented by p
three-vessel disease (3VD) with stenosis value, odd ratio (OR) and confident
≥50%. Patients with left main stenosis interval (CI) of 95%.
Table 2. Association between age group and characteristic result coronary angiography
Age group P value
Variable
34-40 41-47 48-54 55-61 62-68 69-75 76-82 83-89
Lesion distribution
LM 1 0 6 6 9 3 1 0 0.017
LAD 9 18 38 42 32 14 2 1 0.255
LCX 5 10 20 28 20 8 1 0 0.607
RCA 7 10 26 27 22 6 2 1 0.728
Stenosis severity
Non Multivessel 7 14 23 26 15 6 1 0
Disease
0.461
Multivessel 6 7 23 28 23 8 1 1
Disease
 (51.3%) was the second lead; 69 cases
with 1VD was most found. Multivessel
disease slightly higher than non-
multivessel, 97 cases (51.3%). The
Result distribution of patient was explained in
We found 189 samples that were table 1.
fulfilled inclusion and exclusion criteria. There was a statistically significant
Cardiovascular risk factors were found association between LM with age group
from patient underwent coronary 62-68 y.o (p value 0.017) and diabetes (p
angiography; 75 cases (39.7%) smoking, value 0.025). These variables showing
65 cases with hypertension (34.4%), 30 statistically significant either by using
cases with diabetes (15.9%), most frequent multivariate analysis using logistic
age group was 55-61 y.o (28.6%) with regression. Stenosis severity was only
men 145 cases (76.6%). Characteristic associated to gender with p value 0.034,
distribution from coronary angiography; other cardiovascular risk factors did not
left main artery (LM) was most frequent show significances. Table 2,3,4 explained
found with stenosis 163 cases (82.2%) and bivariate and multivariate analysis between
left circumflex artery (LCX) 97 cases variables.
Table 3. Association between cardiovascular risk factors and characteristic result coronary angiography
P Diabetes P P
Gender P Hypertension Smoking
Variable value Mellitus value value
value
Men Women Yes No Yes No Yes No
Lesion
distribution
LM 22 4 0.305 8 18 0.675 22 4 0.025 8 18 0.317
LAD 123 33 0.133 57 99 0.177 123 33 0.241 61 95 0.723
LCX 74 18 0.239 38 54 0.051 74 18 0.340 37 55 0.884
RCA 84 17 0.025 33 124 0.594 84 17 0.113 47 54 0.039
Stenosis
severity
Non 66 26 28 64 12 80 33 59
Multivessel
Disease 0.034 0.265 0.300 0.297
Multivessel 79 18 37 69 18 79 42 55
Disease

Discussion Based on this study, we found

many cases were men and over sixty years
old. Same result as study from Gheisari et
al. age group over fifty years old and male
was most founded.2
Other study, Wegner et al, the results
showed that CAD and the first acute
myocardial infarction happened several
years later in women compared to men. It
relevant with hormone estrogen, prior
factor againts coronary disease in women.
After menopause probability of women
having CAD are higher than men.3
According to bivariate analysis of
this study, only LM statistically associate
with age group 62-68 yo (p value 0.017)
and diabetes (p value 0.025). After we did
the risk factors to stratified, it appeared
that age group 62-68 y.o (OR 1.480) had
higher risk to had LM stenosis rather than
Table 4. Multivariate analysis between cardiovascular risk factors and lesion distribution.
LM
Variable
P value Odd ratio 95% CI
Age group 0.018 1.480 1.070-2.045
Diabetes 0.033 0.350 0.133-0.921
Men - - - 0.130
Smoking - - - 0.214
Another analysis that we studied was
association among multivessel disease and
cardiovascular risk factors, the analysis
showed only varible gender, men, was
significant related to multivessel disease
with p value 0.034 over others risk factors;
older age, hypertension, diabetes and
smoking. This result is distinct with other
study, showed only men (p value 0.07)
diabetes (OR 0.350). RCA was statistically
associated with variable gender, men (p
value 0.034), and smoking (p value 0.039).
While multivariate analysis was not
showing the same statistically significant
result between the variables. Study in Los
Angles has similar result that both LM and
RCA associated with age by OR 1.03 and
OR 1.02.4 Older patient has higher risk to
have left main chronic total occlusion
according to long term study.5
Naghshtabrizi et al, using crossectional
analysis study to evaluate numbers and
location of CAD with artherosclerotic risk
factors, RCA and LM were significant
related to diabetes mellitus, hypertension
and family history with CAD.6
RCA
P value Odd ratio 95% CI
- - -
- - -
1.794 0.841-3.824
0.661 0.344-1.271
variable was not significant related to
multivessel disease, but hypertension,
diabetes, and smoking were related.7 39
cases man over 16 cases women in patient
have multivessel disease with p value
0.003, statistically associated. This study
presented men are more likely have risk to
have multivessel disease than women. 8
Multivessel involvement is found to be
related with older age, hypertension and coronary arteries atherosclerosis extent
diabetes mellitus compared to patient with on coronary angiography: a historical
single vessel disease.9,10 cohort study. 2017; 17:279.
Conclusion 2. Farshid Gheisari, Melika Emami, Hadi
Most of patient who underwent Raeisi Shahraki, Saeid Samipour,
coronary angiography in Abdoel Moloek Parastoo Nematollahi, “The Role of
Hospital was men with age over fifty-five gender in the importance of risk factors
years old and one-third all patients were for coronary artery disease”, Cardiology
smoker. Men are more likely to have Research and practice. 2020,6
severe coronary stenosis than women. 3. N. Wenger, “Clinical characteristics of
Type II diabetes and age group 62-68 coronary heart disease in women:
years old were associated with left main emphasis on gender differences,”
coronary lesion, while smoking was Cardiovascular Research. 2002;53:
associated with right coronary artery 558–567.
lesion. 4. Isma'eel H, Hamirani YS, Daga N,
Acknowledgements Kadakia J, Mao S, Ahmadi N, Budoff
The authors would like to offer special MJ. Determinants of left main
thanks to all nurses and staff from calcifications in a cohort of 2136
Cardiology Department of Abdoel Moloek diabetes patients. Int J Cardiol.
Hospital for their contribution. 2010;142(3):48-50.
Limitation 5. Winter MP, Goliasch G, Bartko P,
Study population is small and Siller-Matula J, Ayoub M, Aschauer S,
many of medical records are not complete Distelmaier K, Gebhard C, Mashayekhi
for history and laboratory of patient to see K, Ferenc M, Hengstenberg C, Toma A.
further study. Left Main Coronary Artery Disease and
Financial disclosure Outcomes after Percutaneous Coronary
None. Intervention for Chronic Total
Conflic of Interest Occlusions. J Clin Med. 2020; 9 (4):
None. 938-9.
References 6. Naghshtabrizi B, Moradi A, Amiri J,
1. Alzuhairi, K.S., Søgaard, P., Ravkilde, Aarabi S, Sanaei Z. An Evaluation of
J. et al. Long-term prognosis of patients the Numbers and Locations of Coronary
with non-ST-segment elevation Artery Disease with Some of the Major
myocardial infarction according to Atherosclerotic Risk Factors in Patients
 with Coronary Artery Disease. J Clin
Diagn Res. 2017;11(8):21-3.
7. Larifla L, Armand C, Velayoudom-
Cephise FL, Weladji G, Michel CT,
Blanchet-Deverly A, Deloumeaux J,
Foucan L. Distribution of coronary
artery disease severity and risk factors
in Afro-Caribbeans. Arch Cardiovasc
Dis. 2014;107(4):212-8.
8. Majeed H, Khan MN, Naseeb K, et al.
Multivessel Coronary Artery Disease
and Subsequent Thrombolysis in
Myocardial Infarction Flow Grade
After Primary Percutaneous Coronary
Intervention. Cureus. 2020;12(6):8752.
9. Karamfiloff KK, Stoykova ZD,
Georeva PG, Trendafilova DK, Jorgova
JB: Multivessel disease as a prognostic
factor for mortality in STEMI patients.
J Biomed Clin Res. 2015;30(4):534-8.
10. Toma A, Stähli BE, Gick M, et al.:
Impact of multivessel versus single-
vessel disease on outcomes after
percutaneous coronary interventions for
chronic total occlusions. Clin Res
Cardiol. 2017; 106:428-435.