The primary objective was to look at the incidence of acute myocardial infarction (AMI) in the female population in our setting, with particular interest in the. During the study period, which spanned from 2003 to 2016, data were extracted from a computerized database. Both groups were analyzed identically in terms of their age, clinical presentation, CVD risk factors, initial electrocardiogram, medical therapies and whether or not they were referred for angiogram and/or coronary artery bypass grafting.
Finally, we looked at the presence of major adverse cardiac events (MACE) in each of the age groups. So in principle, given the traditional risk factors for coronary artery disease (CAD), men and women can be considered to be at equal risk. Women are an understudied population when it comes to coronary heart disease and very few studies have been conducted in women with heart disease.
Coronary artery disease is one of the leading causes of death and disability worldwide.1,2,3 Also in South Africa, it has become a leading cause of morbidity and mortality among all ethnic groups.12,15 Although previously thought that coronary artery disease is a is a disease that primarily affects men, it is now understood that women with underlying cardiovascular risk factors are equally at risk for developing coronary artery disease and manifesting specifically as acute myocardial infarction.2,16 The traditional and well-studied risk factors for coronary artery disease in men appear to be diabetes mellitus, hypertension, dyslipidemia, obesity, cigarette smoking, and a family history of coronary artery disease play the same role in female counterparts.17 Due to the cardioprotective effects of estrogen, coronary artery disease can occur in women. generally occurs at an older age than in men.2,3 Multiple studies have shown that, on average, women develop coronary artery disease 6 to 10 years later than their male counterparts.2,5 Studies have also shown that the average age at which prevalence among women in developing countries is usually lower than that in Western countries.17,18 Although the disease was thought to primarily affect postmenopausal women, younger women can also develop coronary artery disease in the presence of significant cardiovascular disease. risk factors. A 2013 update on coronary artery disease in women3 stated that coronary artery disease is the leading cause of death in women and requires further sex-specific research into the disease.
PART TWO
THE MANUSCRIPT
INTRODUCTION
This was a single-center retrospective study conducted at the Coronary Care Unit (CCU) of the RK Khan Hospital (RKKH) in Chatsworth, Durban, over a period of 13 years. Consecutive female patients with a confirmed diagnosis of acute MI were included in the study, while patients with unstable angina were excluded. Ethical approval was obtained from the local ethics committee of the University of KwaZulu-Natal before commencement of the study and conducted in accordance with the principles of the Declaration of Helsinki.
Clinical assessment
Current smokers were defined as individuals who had smoked any tobacco within the past 12 months before their MI, and former smokers as those who had smoked for at least one year before their MI. Anthropometric measurements including body mass index [BMI] and waist circumference were used to define obesity. Waist circumference was measured halfway between the lower rib and the iliac crest on standing subjects, using a soft tape, and the central obesity threshold limits.
Patients with ST-elevation MI (STEMI) who were candidates for thrombolysis received Metalyse (Tenecteplase) as reperfusion therapy.
Biochemical analysis
RESULTS
Triple vessel disease was found in the majority of patients [TVD each had dual vessel disease [DVD] and single vessel disease [SVD 22.6%] and 6.2% had normal coronary epicardial vessels.
DISCUSSION
Previous studies have shown that women tend to present with coronary artery disease an average of 6-10 years later (around 69-70 years) than their male counterparts2 and this is believed to be partly due to the cardio-protective role of estrogen. . .2 In contrast, the majority of patients in our study presented in the younger age group and this is consistent with previous reports which showed that the mean age of presentation in women in developing countries tends to be lower than in the West. Very few studies have been undertaken in the South African setting and most of the information we have on CAD in our female population comes from other parts of Africa, with the Interheart study providing some valuable information.16 A study on CVD in Africa showed that women had a higher prevalence of Both DM and HPT were prevalent in both age groups in our study, with the total values for DM and HPT being 76% and 77%, respectively.
Furthermore, in addition to the traditional risk factors (mentioned above) for AMI, we found in our study that hyperglycemia, hypertriglyceridemia, and hyperuricemia were independent risk factors for the development of CAD and also contributed negatively to the development of MACE. Several studies have shown that women have poorer outcomes after acute myocardial infarction and have a higher mortality rate compared to men.1,3 In our study we found that a large proportion of our patients developed MACE (n =466, 40%). The most common adverse events in our study were cardiac failure (55%, n=255) followed by death (28%, n=131) and this was similar to adverse events in other studies.23,25 Reasons for Results poorer outcomes are not well understood but possibly related to a variety of events, including delayed hospital presentation, refusal of medical therapies and invasive interventions, as well as pathophysiological factors such as smaller coronary vessels in women with fewer collaterals .
One possibility is that the prevalence of DM is so high in our study population and the risk of cardiovascular disease is increased in the presence of diabetes mellitus. Although most studies reported on men and women found that STEMI was less common in women26 in our study, 74% of subjects had STEMI (n=858). In addition, only a small proportion of those with STEMI received thrombolysis with Metalyse (n=325, 38%).
This is consistent with other studies where only a small proportion of women received thrombolysis.24,25. The reasons for this may be multifactorial and may include delayed hospital presentation, prolonged door-to-needle times for various reasons, or patients refusing therapy. These are some of the reasons that have been found especially among women in international studies1,5.
A small proportion of our patients were referred for invasive intervention in the form of angiogram (n=337, 29%). The reasons for this again are most likely patients refusing further intervention and this would be consistent with international studies5. Of the patients who consented to angiogram, the majority were found to have triple vessel disease (48.7%) indicating the severity of the disease in this population and the importance of early screening for the disease (Graph 2).
LIMITATIONS
CONCLUSION
1160 patients is our study population, however it constituted 88.5% of the total number of women presenting to the study center with chest pain. STEMI: ST-elevation myocardial infarction NSTEMI: ST-elevation myocardial infarction PCI: Percutaneous coronary angiography.
Major Adverse Cardiac Events (n=466, 40.2%)
The final study protocol as approved by BREC
- THE PROTOCOL FOR STUDY
- PLAN OF INVESTIGATION FOR STUDY
- STATISTICAL PLANNING AND DATA ANALYSIS
- CLINICAL TRIALS
- POTENTIAL RISKS OR DISCOMFORT
- GENERAL
- INFORMED CONSENT: GIVEN TO PARTICIPANTS: Not applicable as the study is a
Research project title: Assessment of the risk factor profile of female patients presenting with acute myocardial infarction: A South African perspective. If approved, attach letter of approval) N/A Please indicate the name and number of Co-investigators in the project:1. if additional space is required for more details of the investigators, please add at the end of the application). If yes, is the study covered by your centre/unit's annual levy for BREC.
The primary objective of the study will be to determine the cardiovascular risk factor profile of patients presenting with a diagnosis of acute myocardial infarction to the coronary care unit at the RK Khan Hospital, Chatsworth, Durban from 2002 to December 2016. This will be determined based on information , obtained in studies conducted in men with acute myocardial infarction in a local setting, i.e. South Africa. All adult patients with a diagnosis of acute myocardial infarction based on the guidelines of the European and American Cardiology Associations will be selected during consecutive admissions for the above-mentioned study period.
The cardiovascular risk factor profile which will include: Diabetes Mellitus, Hypertension, cigarette smoking (current or former smokers), Dyslipidaemia, Obesity, a previous history of coronary artery disease and a positive family history of coronary heart disease, will be reviewed and stratified to determine which of the risk factors play a more significant role in predisposing female patients to the development of an acute myocardial infarction. Patients will be divided into 2 groups, namely those with ST-segment elevation myocardial infarction and those with Non-ST-segment elevation myocardial infarction. The main adverse cardiovascular events that will be assessed are as follows: Arrhythmias, heart failure, cardiogenic shock, complete heart block, recurrence of angina or myocardial infarction and death.
The study is based on estimating the prevalence of key risk factors in the population of women with acute myocardial infarction with a high degree of precision. Continuous variables will be summarized as means with standard deviations or medians with interquartile ranges depending on the distribution. The study is a retrospective chart review and all details will be obtained from an electronic database used by the Coronary Unit at RK Khan Hospital.
Currently, the data is stored in a computerized database where it will remain for the time period of the study and beyond. Not applicable as the study is a retrospective chart review in which data will be extracted from an existing database. I understand and agree that I will be required to submit an annual application for recertification, in which case authorization to continue studying is lost.
Progress reports may be required more frequently depending on the level of risk and other factors – this will be detailed in the BREC approval letter. Where applicable, all reports from Data Safety Monitoring Boards (or similar committees) will be provided to the Biomedical Research Ethics Committee within 7 days.
NB: DO NOT BIND SUBMISSIONS (STAPLE ONLY)
Note to Students
Ethical Approval
Permission To Conduct Study At RK Khan Hospital
The Guidelines for Authorship for the Journal selected for submission of the manuscript
Data collections tool (sample)
Raw data (sample)
