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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 50-55

Evaluation of clinical and biochemical parameters of trinidadian patients with coronary artery disease for predicting the revascularization strategy


1 Department of Pre-Clinical Sciences, Faculty of Medical Sciences, The University of the West Indies, Trinidad
2 Multidisciplinary Research Unit, Shimoga Institute of Medical Sciences, Shivamogga, Karnataka, India
3 Clinical Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, Trinidad
4 Department of Biochemistry; Department of Research, Panimalar Medical College Hospital and Research Institute, Varadharajapuram, Poonamallee, Chennai, Tamil Nadu, India
5 Department of Research, Panimalar Medical College Hospital and Research Institute, Varadharajapuram, Poonamallee, Chennai, Tamil Nadu, India

Date of Submission01-Sep-2021
Date of Decision21-Jan-2022
Date of Acceptance01-Feb-2022
Date of Web Publication24-Jun-2022

Correspondence Address:
PhD, DSc B Shivananda Nayak
Msc, PhD, NRCC-CC, PGDCHC, Department of Preclinical Sciences, Faculty of Medical Sciences, The University of The West Indies
Trinidad
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcpc.jcpc_46_21

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  Abstract 

Background: In recent times, optimal revascularization approaches have been used for treating multi-vessel obstructive coronary artery disease (CAD) patients. Based on the disease severity, making the decision to perform a suitable revascularization intervention in the patients is of paramount importance. Aim: This study aimed to evaluate the biochemical parameters of patients with suspected CAD in Trinidad and assess their clinical significance for predicting revascularization strategy. Materials and Methods: One hundred and twenty-four patients referred for angiography were recruited for the study. Biochemical parameters such as fasting blood sugar (FBS), lipid profile, cardiac enzymes, creatinine, uric acid, N-terminal probrain natriuretic peptide (NT-proBNP), soluble ST2, interleukin 6, and hemoglobin A1C (HbA1c) were explored. Similarly, we examined clinical parameters such as age, the presence of chronic conditions, and ethnicity. Results: With respect to revascularization strategies, FBS, NT-proBNP, HbA1c, and soluble ST2 correlated moderately with coronary artery bypass grafting (CABG) by Point-Biserial correlations: FBS-r = 0.196, P = 0.029, NT-proBNP-r = 0.208, P = 0.020, soluble ST2-r = 0.178, P = 0.048, and HbA1c-r = 0.282, P = 0.001. The presence of Type 2 diabetes (T2D) at baseline and ethnicity also formed statistically significant associations with CABG-ethnicity (χ2 (1) =7.267, P = 0.007) and T2D at baseline (χ2 (1) =12.858, P < 0.001). Conclusion: Ethnicity and presence of T2D were also significantly associated with both CAD severity and revascularization decision-making and should be taken into consideration for further study. Further investigation of these parameters might prove to be useful to predict the revascularization strategy required for treating CAD patients.

Keywords: Coronary artery disease, diabetes mellitus, glycated hemoglobin, N-terminal probrain natriuretic peptide, revascularization


How to cite this article:
Monplaisir TK, Nayak B S, Bhaktha G, Ali R, Mohan SK, Ambrose JM. Evaluation of clinical and biochemical parameters of trinidadian patients with coronary artery disease for predicting the revascularization strategy. J Clin Prev Cardiol 2022;11:50-5

How to cite this URL:
Monplaisir TK, Nayak B S, Bhaktha G, Ali R, Mohan SK, Ambrose JM. Evaluation of clinical and biochemical parameters of trinidadian patients with coronary artery disease for predicting the revascularization strategy. J Clin Prev Cardiol [serial online] 2022 [cited 2022 Dec 6];11:50-5. Available from: https://www.jcpconline.org/text.asp?2022/11/2/50/348081


  Introduction Top


Among the many diseases that comprise cardiovascular diseases, coronary artery disease (CAD) is the most prominent cause of morbidity and mortality globally[1] Despite all the successful heart failure treatment achievements in recent decades, the mortality of these patients continues to be high.[2] From the coronary angiogram procedure, cardiologists obtain detailed information about the status of the heart and its coronary arteries-number of arteries blocked or narrowed their location and severity. Depending on the extent of the disease and symptoms experienced by the patient, certain drugs such as antiplatelet, beta-blockers, nitrates, angiotensin-converting enzyme inhibitors, and statins may be prescribed, which could control various risk factors to prevent further development of the disease.[3] Coronary artery conditions with increased severity are required to be treated by various strategies. Angiogram result, therefore, aids them in recommending an appropriate treatment strategy to the patient.[4] In addition to these options, more severe CAD may require one of two revascularization strategies. These include percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).[5] PCI is a strategy used to widen a narrowed artery. Currently, available knowledge on the association between the above-mentioned parameters and the outcomes after angiography is limited. Physicians' understanding of how the various parameters predispose patients to coronary angiography and further revascularization strategies would be expanded. Further, the early identification and treatment of these risk factors will therefore aid in accelerating disease monitoring and prevention and in turn improve the morbidity rate. We focused to ascertain whether the biochemical and other risk factors could help in the early prediction of the revascularization strategy that's needed to be performed among the CAD patients. Hence, the present study aimed at evaluating the clinical significance of biochemical and clinical parameters of CAD patients' angiography in Trinidad.


  Materials and Methods Top


This research method was of a quantitative orientation, which collected the data in a numerical form and placed it into categories. As such, in this study, the numerical data collected were the measurements of the various clinical and biochemical variables examined, in addition to providing each patient with a questionnaire. Ethically approval was duly sought from and duly sought from and the University of the West Indies Campus Ethics Committee and North Central Regional Health Authority Public Health Observatory. After obtaining informed consent, 124 patients aged 18 years and above, who were referred for coronary angiography at the Catheterization laboratory at North Central Regional Health Authority were recruited for the study. The results obtained were then categorized into CAD severity and further analyzed. Information regarding age, self-reported ethnicity, smoking status, diet, and medical history was obtained from the subjects. Subsequently, blood pressure was measured using an automated blood pressure monitor. Waist-to-hip circumference ratio were determined using a tape. Similarly, the weight of the patients was measured in kilograms using a medical physician scale, and heights were obtained in meters using a stadiometer.

Ten millilitre of fasting blood sample was collected from each patient into four vacutainers-two clot activator tubes, one K2EDTA tube and one sodium fluoride/potassium oxalate tube. The serum isolated was used to analyze fasting blood sugar (FBS) (sodium fluoride/potassium oxalate tube), lipid profile, creatinine, uric acid, Interleukin-6, insulin, creatine kinase, creatine kinase MB isoenzyme, N-terminal probrain natriuretic peptide (NT-proBNP), and soluble ST2using the Cobas e601 machine while the other parameters were measured using the Vitros 4600 analyzer. We performed the statistical analysis using SigmaPlot 11 and SigmaPlot 11 and IBM SPSS statistics version 20.0 (IBM Corp., Armonk, NY, USA). Normally distributed data of the continuous variables were expressed as mean ± standard deviation, data with nonnormal distributions were presented as median (interquartile range) and categorical data were presented as percentages. Correlations between nonnormal parameters and the presence and severity of CAD were assessed using a nonparametric test, Spearman's Rank-Order Correlation coefficient. Similarly, the associations between categorical variables, for example, CAD severity and presence, and clinical variables were compared using the Chi-square test. P < 0.05 was considered statistically significant. Once statistically significant parameters were obtained from these analyses, multinomial logistic regression statistical tests were used to analyze these variables with the type of revascularization strategy recommended by the cardiologist. This was conducted to figure out whether these significant parameters would also be able to aid in predicting the revascularization strategy to be used in treating these cardiac patients.


  Results Top


The objective of this study was to determine whether the clinical and biochemical variables which formed statistically significant associations with CAD severity would also aid in predicting the revascularization strategy or treatment method to be recommended by the cardiologist. In observing a pattern between these relevant variables and the treatment strategies, the process between the onset of disease and treatment could possibly be an easier one. Correlations between each parameter and CAD, PCI, and medical therapy/lifestyle modification, respectively, were obtained from the Point-Biserial test (data not shown). A moderate positive correlation was observed between age and the tendency of CABG being the choice of treatment (r = 0.319, P < 0.001). This relationship suggested that as age increases, it may be more likely that CABG is chosen as the revascularization strategy. A weak statistically significant correlation was formed between FBS (r = 0.196, P = 0.029) and soluble ST2 (r = 0.178, P = 0.048), with CABG as the choice of strategy. This indicated that as FBS and soluble ST2 concentrations increase in the blood, these may be indicators of choosing CABG over the other two treatment options. Two additional moderate relationships with statistical significance were observed-between NT-proBNP and choice of CABG (r = 0.208, P = 0.020); and between hemoglobin A1C (HbA1c) level and choice of CABG as the revascularization strategy (r = 0.282, P = 0.001).

Likewise, correlations between the clinical and biochemical parameters and choice of revascularization strategy being PCI was conducted and no statistically significant correlations were revealed in this case.

The results of the Point-Biserial test revealed the correlation between each biochemical and clinical variable and the choice of medical therapy/lifestyle modification being the treatment for the cardiac patient were compared [Table 1]. Age was observed to be negatively correlated with statistical significance, with the possibility of choosing medical therapy/lifestyle modification as treatment. This suggested that as age increased, there was less tendency of selecting medical therapy/lifestyle modification as the treatment option (r = −0.228, P = 0.011). Two other moderate correlations with statistical significance were revealed. The first was between low-density lipoprotein (LDL) and choice of medical therapy/lifestyle modification (r = −0.209, P = 0.020). This parameter formed a negative correlation with this treatment choice. As LDL levels increased, it was less likely that medical therapy/lifestyle modification was the sole treatment strategy. Finally, a moderate negative correlation was formed with HbA1c (r = −0.306, P = 0.001). This also suggested that as this parameter increases the tendency of medical therapy/lifestyle modification as the treatment strategy decreases.
Table 1: Results of Point-Biserial correlation between clinical and biochemical parameters with medical therapy/lifestyle modification

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The associations formed between the clinical variables and each revascularization strategy were evaluated by Chi-square test. With respect to CABG-[Table 2], associations were found with presence of hypertension, hyperlipidemia and Type 2 diabetes (T2D) before angiography and ethnicity. With the presence of hypertension (P = 0.002), an unadjusted odds ratio (OR) of 3.872 (1.601, 9.365) was produced. This implied that the odds of a person with hypertension undergoing CABG as a treatment strategy are 3.872 times more likely than those without.
Table 2: Results of Chi-Square test associations between clinical categorical variables and coronary artery bypass grafting

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When compared to the PCI category [Table 3], an OR of 0.380 (0.153, 0.942) was revealed with the presence of hypertension (P = 0.033). This suggests that patients with hypertension at baseline are 0.380 times less likely to undergo PCI as their revascularization treatment. There was no association with the presence of hypertension and medical therapy/lifestyle modification (P = 0.609) [Table 4].
Table 3: Results of Chi-Square test associations between clinical categorical variables and percutaneous coronary intervention

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Table 4: Results of Chi-Square test associations between clinical categorical variables and medical therapy/lifestyle modification

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Another relationship was revealed between the presence of hyperlipidemia and CABG (P = 0.043) and hyperlipidemia and medical therapy/lifestyle modification (P = 0.005). With respect to CABG, hyperlipidemia presence revealed an OR of 2.165 (1.019, 4.602). It is therefore 2.165 times more likely that a person with hyperlipidemia at baseline would undergo CABG as treatment for CAD. Medical therapy/lifestyle modification produced an OR of 0.351 (0.169, 0.730) with hyperlipidemia presence at baseline. This suggested that patients with hyperlipidemia before angiography are 0.351 times less likely to use medical therapy/lifestyle modification as their treatment strategy.

Due to the small sample size of smokers, no statistical significance was found between smokers and CAD presence or severity. Hence, it is difficult to assess the likelihood of smokers being recommended for revascularization or treatment strategy (CABG, PCI or Medical Therapy/Lifestyle Management).

The presence of T2D before angiography also revealed a statistically significant association with CABG (P < 0.001) and medical therapy/lifestyle modification (P < 0.001). With respect to CABG, T2D produced an OR of 4.033 (1.846, 8.812) which explained that patients with T2D at baseline were 4.033 times more likely to undergo CABG than those without the condition. Most of the diabetic patients in this Trinidadian cohort were recommended with CABG as their revascularization strategy. Statistically significant positive correlation existed between glycated hemoglobin and the likelihood of CABG being recommended (r = 0.282, P = 0.001). Concerning the medical therapy/lifestyle modification category, T2D presence at baseline revealed an OR of 0.213 (0.099, 0.460). This revealed that patients with T2D before coronary angiography are 0.213 times less likely to pursue medical therapy/lifestyle modification as their only treatment option.

Ethnicity categorized as Indo-Trinidadian or not, formed statistically significant associations with CABG (P = 0.007) and medical therapy/lifestyle modification (P = 0.002) [Figure 1]. With CABG, an OR of 3.925 (1.385, 11.119) was identified. It was examined that this ethnic group tended to have a high incidence of T2D. This puts forward that patients of Indo-Trinidadian race, is 3.925 times more likely to undergo CABG than those of other ethnic groups (Afro-Trinidadians or Mixed). Ethnicity produced an OR of 0.274 (0.116, 0.651) with medical therapy/lifestyle modification suggesting that Indo-Trinidadian cardiac patients are 0.274 less likely to be recommended with medical therapy/lifestyle modification as their sole treatment strategy.
Figure 1: Relationship between Ethnicity and Number of Patients in each Revascularization Strategy Category

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  Discussion Top


The Diabetic state is a measure of the predictor events such as myocardial infarction also sometimes repeat revascularization. Eventually, cardiac death in subjects who have undergone CABG is also obvious.[6],[7]

It aimed to figure out if the parameters which formed statistically significant relationships with CAD severity would aid in determining which revascularization or treatment strategy would be best suited for the patient based on their disease severity. The main findings after these analyses were: (1) age, NT-proBNP, glycated hemoglobin, and soluble ST2 (to a lesser extent) all formed moderate positive correlations with CABG.

PCI and optimal medical therapy/lifestyle modification produced no relevant associations with these parameters, except in the case of HbA1c, which produced a moderate negative correlation with medical therapy/lifestyle modification; (2) CABG also formed statistically significant associations with the presence of hypertension, hyperlipidemia, T2D at baseline and patient being Indo-Trinidadian which means Trinidadians of East Indian descent. These four factors increased the odds of these cardiac patients undergoing CABG as a treatment for their CAD. As obtained from the study, most patients were recommended for medical therapy/lifestyle modification (n = 55) followed by CABG (n = 45) and to the least extent, PCI (n = 24).

A well-known therapeutic intervention is Coronary artery revascularization and is incorporated in all treatment guidelines for subjects with CAD.[5] Revascularization aims to improve the symptoms and prognosis of the disease and to aid in improving the patients' quality of life. Therefore, the indicating and selecting of a revascularization strategy by the cardiologist is a vital step. These decisions are made based on the clinical, functional, and anatomical features of the patients. The most relevant aspects to consider when selecting a strategy are age, sex, presence of diabetes, renal function, electrocardiographic changes, ventricular function, and quantification of the functional relevance of CAD. The search for prognostic markers will aid in identifying the populations at high risk and therefore those that will benefit most from a particular revascularization strategy.

As stated previously, age is a relevant factor for the specialist when making a decision about a revascularization strategy suited for the patient. Advanced age increases the possibility of mortality and rate of nonfatal ischemic events, according to an article written by Alonso Martín et al.[5] The occurrence and severity of angina is also prognostic marker in all groups. In addition, patients with high-risk non-ST-segment acute coronary syndrome have been shown to benefit clinically from an early interventional strategy of coronary angiography and revascularization.

Usually, revascularization is a sign in patients with extensive CAD with severe ventricular dysfunction, as evidenced by ischemia.[8] In this case, revascularization is associated with better long-term progress. From previous studies, patients >65 years were observed to benefit from an invasive coronary revascularization strategy. With respect to PCI, one of the main risk factors for complications was found to be ages >75 years. With CABG, the incidence of complications in elderly patients is higher than in the remaining population as these patients tend to generally have more advanced CAD and more concurrent diseases. Nevertheless, a reasonably high proportion of these patients obtained improved quality of life after the CABG option.[5] This trend was also observed among these patients studied, where, as age increased the likelihood of being recommended for CABG also increased.

Another main factor associated with revascularization strategy, CABG specifically, was the presence of T2D. CAD is highly prevalent among diabetic patients,[9] as this condition is connected to the worsening progress of CAD. In this case, revascularization procedures are more beneficial than medical therapy compared to nondiabetics. PCI in diabetic patients is associated with worse medium and long-term consequences than in nondiabetics because of a higher incidence of restenosis and a faster advancement of CAD in untreated segments.[10] It was stated in this article that diabetic patients with more than one diseased artery had significantly better survival rates after bypass surgery when compared to PCI.[5]

Though a common understanding of CABG is highly preferred/advocated in “East Indian” ethnicity background patients while Medical therapy is more preferred in Afro and Mixed Trinidadian ethnicity background patients. In our study, 75% of the cohort (n = 124) declared to be East Indian. This accounted for majority of the studied patients. In addition to this, 87 out of the 93 East Indian cohort were diagnosed with CAD. Approximately 33 of these were diagnosed with the triple-vessel disease, in comparison to 1 Afro-Trinidadian having triple-vessel disease and 4 mixed Trinidadian ethnic background patients being diagnosed with the triple-vessel disease (Data not shown). There was a greater proportion of the cohort being East Indian and diagnosed with triple-vessel CAD than not being East Indian (Afro-Trinidad or Mixed Trinidadian ethnicity) and being diagnosed with the triple-vessel disease. Furthermore, majority of Afro-Trinidadians were diagnosed with mild CAD. Triple-vessel disease is more likely to be treated by CABG. PCI and Medical Therapy/Lifestyle Management patients had similar prognosis as they had less extensive and severe CAD. Another reason for this trend is possibly the presence of T2D at baseline. Fifty-nine patients had T2D and most T2D patients were of East Indian descent and were recommended CABG as their treatment. T2D accounts for one of the criteria when selecting a revascularization strategy. In addition, a Chi-squared test of independence between the presence of T2D at baseline and the presence of CAD after angiography revealed that these patients diagnosed with T2D were 5.182 times more likely to be diagnosed with CAD. In these patients, CAD tends to be more complex, therefore often requires revascularization strategy instead of Medical Therapy/Lifestyle Management. A significant correlation was also observed between T2D and CAD severity (P < 0.001) to additionally explain this point. Ethnicity (being Indo-Trinidadian) was a relevant factor in this study. With respect to this, it has been examined that this ethnic group tends to have a high incidence of T2D, which was also observed in the study (Eta of 0.300). For this possible reason, ethnicity was positively associated with the likelihood of the patient needing CABG compared to the other treatment options-OR (95% confidence interval [CI]) =3.925, in comparison to OR (95% CI) =1.335 in patients needing PCI and OR (95% CI) =0.274 of patients needing medical therapy/lifestyle management.

In another study by Rocha et al., it was stated that in patients with diabetes, restenosis is more frequent has a negative impact on long-term survival. It was also demonstrated that myocardial revascularization reduced the risk of death between the 1st and 5th year of follow-up when compared to PCI. Most of the patients undergoing bypass surgery in this study had higher angiographic severity-triple vessel disease, more than 70% stenosis and more proximal lesions of the left anterior descending coronary artery; were older and had undergone more previous coronary interventions. It was therefore observed that patients treated with PCI, had a similar prognosis to those who were medically treated as they had less extensive and severe CAD, as well as normal left ventricular function.[11] Our findings in this study were in agreement with the previous reports.


  Conclusion Top


Our findings revealed that FBS, glycated hemoglobin, and NT-proBNP exhibited significant relationships with revascularization strategy, particularly CABG. Besides, the presence of T2D and ethnicity too were correlated with the revascularization strategy. However, these critical parameters need further investigation in this population is required to be conducted to implement the prediction for revascularization strategy.

Limitations of the study

  1. This research method was of a quantitative orientation, with the research design as experimental with patient questionnaires, hence low power of the study (n = 124). Furthermore, it is a nonrandomized study
  2. The hospital was selected on the basis that it is centrally located in Trinidad with a general high flow of patients nationwide. Hence, this was a single-center study
  3. Since the research design is experimental, the development of standard questions by researchers may lead to structural biases inherent to prospective observational cohort studies
  4. In this study, any short-term/or long-term follow-up is not undertaken.


Financial support and sponsorship

The authors would like to thank the Campus Research and Publication Fund, The University of the West Indies for providing the grant to conduct this study.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Raghav L, Waghmode P, Matin P, Pawar S. Clinical profile of patients undergoing coronary angiography with special reference to complications of coronary angiography. Int J Adv Med 2017;4:1170-4.  Back to cited text no. 1
    
2.
Bayes-Genis A, de Antonio M, Galán A, Sanz H, Urrutia A, Cabanes R, et al. Combined use of high-sensitivity ST2 and NTproBNP to improve the prediction of death in heart failure. Eur J Heart Fail 2012;14:32-8.  Back to cited text no. 2
    
3.
Available from: https://www.nhlbi.nih.gov/health-topics/coronary-heart-disease. [Last cited 2018 June 3].  Back to cited text no. 3
    
4.
Eric J, Bhatt DL., Coronary angiography. In: Text book of Cardiovascular Medicine. 3rd edition:Philadelphia: Lippincott Williams & Wilkins; 2007: p 1-34.  Back to cited text no. 4
    
5.
Alonso Martín JJ, Curcio Ruigómez A, Cristóbal Varela C, Tarín Vicente MN, Serrano Antolín JM, Talavera Calle P, et al. Coronary revascularization: Clinical features and indications. Rev Esp Cardiol 2005;58:198-216.  Back to cited text no. 5
    
6.
Kappetein AP, Head SJ, Morice MC, Banning AP, Serruys PW, Mohr FW, et al. Treatment of complex coronary artery disease in patients with diabetes: 5-year results comparing outcomes of bypass surgery and percutaneous coronary intervention in the SYNTAX trial. Eur J Cardiothorac Surg 2013;43:1006-13.  Back to cited text no. 6
    
7.
Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: A collaborative analysis of individual patient data from ten randomised trials. Lancet 2009;373:1190-7.  Back to cited text no. 7
    
8.
Lakshman HV, Rao VD. Revascularization in ischemic heart failure: A review. Indian J Clin Cardiol 2020;1:31-6.  Back to cited text no. 8
    
9.
Einarson TR, Acs A, Ludwig C, Panton UH. Prevalence of cardiovascular disease in type 2 diabetes: A systematic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol 2018;17:83.  Back to cited text no. 9
    
10.
Kereiakes DJ. Percutaneous coronary intervention in diabetic patients-improving outcomes through advances in catheter-based and adjunctive pharmacotherapeutic strategies. Risk 2008;1:1.  Back to cited text no. 10
    
11.
Rocha AS, Dutra P, Lorenzo AD. Choosing a revascularization strategy in patients with diabetes and stable coronary artery disease: A complex decision. Curr Cardiol Rev 2010;6:333-6.  Back to cited text no. 11
    


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