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INTRODUCTION
Coronary heart disease (CHD) has reached enormous proportions striking
more and more at younger subjects. It will result in coming years the greatest
epidemic mankind has faced; unless we are able to reverse the trend by
concentrating on research into its cause and prevention1.Coronary Heart disease
and its major manifestations were a medical rarity prior to first world war.2
The prevalence of coronary heart disease is on the raise in our country, more
so in South India cutting across all class and age distinctions, imposing severe
burden on the health care system. Hence the present study aims to address the
reasons for high prevalence of CAD and the risk factors involved, namely the
Metabolic Syndrome3. Metabolic syndrome refers to constellation of inter-related
cardiac risk factors that appear to directly promote development of atherosclerotic
cardiovascular disease4. A recent review of insulin resistance syndrome revealed a
rapid escalation of this syndrome among Indians and the prevalence of predominant
component of METS varies from region to region.5
Studies have revealed the pathophysiology of this syndrome, with close to a
six fold increase in cardiovascular mortality in those possessing this disorders.6 The
increased risk of morbidity and mortality associated with the METS makes it
essential that there be a clear understanding of the dimensions of this syndrome for
the allocation of health care and research resources and for other purposes.8 Data
regarding the prevalence of metabolic syndrome in coronary artery disease from this
part of the country is scanty and conclusions are drawn based on the studies done in
northern India. Indian population is non-homogeneous and data specific to this
region is a dire necessity which this study aims to address.
1
Only very few studies have reported on the prevalence of IRS as a whole in
the native Indian population based on epidemiological studies. This is particularly
relevant as India has the maximum number of diabetes patients in any given country
in the world.10
This study was conducted in a large teaching hospital with a medical college
fully equipped with a cardiology department with cath lab facility and located in the
heart of Andhra Pradesh, thereby attracting representative population from all areas
and especially the lower strata of society. Results of this study are therefore relevant
to the general public in this part of the country. By examining the prevalence of
metabolic syndrome in established CAD, this study aims to create awareness
regarding the syndrome so that by early intervention, this menace could be tackled
effectively.
2
OBJECTIVES
1. To assess the prevalence of metabolic syndrome in angiogram
proven coronary artery disease.
2. To assess the extent of coronary artery disease in patients with
metabolic syndrome.
3
REVIEW OF LITERATURE
The concept of METS has existed for at least 80 years. This constellation of
metabolic disturbances, all risk factors for CVD, was first described in the 1920s by
Kylin, a Swedish physician, as the clustering of hypertension, hyperglycemia, and
gout.11
Abnormalities of glucose metabolism and diabetes were added to this risk
factor conglomerate later. IR in diabetes was reported by Himsworth in 1939 in a
series of Goulstonian lecturer to the Royal College of Physicians in London.12
Later in 1947, Vague drew attention to upper body adiposity (android or male-
type obesity) as the obesity phenotype that was commonly associated with metabolic
abnormalities associated with type 2 diabetes and CVD.13
The Reaven Banting lecture from the year 1988 introduced the concept of
syndrome X as a fundamental factor in the pathogenesis and clinical course of what
are often referred to as the diseases of western civilization – type 2 diabetes,
hypertension(HT), and atherosclerotic CVD – received much attention.14
Reaven’s syndrome X originally consisted of resistance to insulin stimulated
glucose uptake, hyperinsulinemia, hyperglycemia, an increased concentration of
very-low-density lipoprotein triglycerides, a decreasedconcentration of high-density
lipoprotein cholesterol (HDL-C), and high BP.14
Reaven did not offer specific criteria for having syndrome X, and he did not
include obesity or visceral obesity as a criterion. Later, others, including leading
organizations and associations working in primary and secondary prevention of
4
CVD, added measures of visceral obesity and offered specific criteria to define this
syndrome.15
The causes of the METS remain obscure. Reaven proposed that IR was the
most important abnormality, while Lemieux proposed that visceral obesity and
hyperglyceridemic waist was important.14,16,17
Despite the ongoing arguments among various groups, the ultimate
importance of this condition is that it helps to identify individuals at high risk of
CVD.16
Table.1 Various terminologies used to describe the METS18
• Athero-thrombogenic syndrome• Beer-belly syndrome• Cardiovascular syndrome• Chronic cardiovascular risk factor clustering syndrome• Deadly quartet• DysMETS• IR syndrome• Metabolic cardiovascular syndrome• METS• Multiple syndrome• Multiple METS• PluriMETS• Reaven’s syndrome• Syndrome X• New world syndrome
Epidemiologic research has identified risk factors that increase the likelihood
of coronary heart disease events. Basic and clinical studies have revealed plausible
biological links between many of the risk factors and atherosclerosis and have
demonstrated that management of risk factors can improve coronary endothelial
function, stop the progression of atherosclerosis, prevent disruption and thrombosis
5
of vulnerable atherosclerotic plaque, and reduce CHD morbidity and mortality. When
risk factors coexist, they multiply the risk of CHD several fold7. Identification and
management of risk factors are essential in preventing CHD in high – risk
asymptomatic individuals (primary prevention). A recent Bethesda conference
proposed a classification scheme according to the strength of evidence that risk
factor intervention favorably affects outcome9.
DEFINITION AND CONSTITUENTS OF METABOLIC
6
SYNDROME
The contemporary definition of METS “refers to a cluster of metabolic
abnormalities related to a state of IR which is often associated with a high-risk
overweight/obesity phenotype. The major characteristics of METS include IR,
abdominal obesity, elevated BP, and lipid abnormalities [i.e., elevated levels of
triglycerides (TGs) and low levels of HDL-C].
METS is associated with a proinflammatory / prothrombotic state that may
include elevated levels of C-reactive protein(CRP), endothelial dysfunction,
hyperfibrinogenemia, increased platelet aggregation, increased levels of
plasminogen activator inhibitor 1, elevated uric acid levels, microalbuminuria, and a
shift toward small, dense particles of low-density lipoprotein (LDL-C) cholesterol”9.
Several groups have attempted to develop diagnostic criteria for diagnosis of
METS.
The World Health Organisation19(WHO) proposal was designed as a first
attempt to define the syndrome in 1999 includes Diabetes or impaired fasting
glycemia or impaired glucose tolerance or IR (under hyperinsulinemic and
euglycemic conditions, glucose uptake in lowest 25%) plus two or more of the
following:
1. Obesity: body mass index >30 kg/m2 or waist: hip ratio >0.9 (male) or
>0.85 (female).
2. Dyslipidemia: TGs ≥ 1.7 mmol/L or HDL-C <0.9 (male) or <1.0 (female)
mmol/L.
3. Hypertension: BP ≥ 140/90 mmHg.
7
4. Microalbuminuria: albumin excretion ≥ 20 μg/min.
The European group for the study (EGIR)20 of IR also defined the METS in
1999 includes – IR (defined as hyperinsulinemia, top 25% of fasting insulin valves
among the non-diabetic population) plus two or more of the following:
1. Central obesity: waist circumference ≥ 94 cm (male) or ≥ 80 cm
(female).
2. Dyslipidemia: TGs >2.0 mmol/L or HDL-C <1.0 mmol/L.
3. Hypertension: BP ≥140/90 mmHg and/or medication.
4. Fasting plasma glucose >6.1 mol/L.
The National cholesterol Education Program(NCEP) Export Panel on
detection, evaluation and treatment of high blood cholesterol in adults – otherwise
known as the Adult Treatment Panel III (ATP III) definition of METS presented in
200121 includes –
Three or more of the following :
1. Central obesity : waist circumference > 102 cm(male) or > 88 cm (female).
2. Hypertriglyceridemia : TGs ≥ 1.7 mmol/L
3. HDL cholesterol : <1.0 mmol/L (male) or <1.3 mmol/L (female)
4. Hypertension: BP ≥130 /85 mmHg or medication.
5. Fasting plasma glucose ≥ 6.1 mmol/L.
In retrospect, it is apparent that the WHO definition more suited as a research
tool whereas the NCEP: ATP III definition was more useful for clinical practice22.
8
The criteria for defining METS in adult Asian Indians needs revision. Inclusion
of modified cutoffs of waist circumference (>90 cm for men, > 80 cm women) and
BMI (>23 kg/cm2) and measures of truncal subcutaneous fat in the NCEP ATP III
definition requires further validation.23
Yet another attempt at definition came from the American Association of
Endocrinology and American Association of clinical endocrinologist.24
There were problems associated with all these definitions in terms of
applicability, uniformity and positive predictive value. A major problem was
applicability to different ethnic groups, especially among East Asians and South
Asians.22
The International Diabetes Federation (IDF)25 has recently revised the
guidelines to remedy the ethic group based disparities in the original classification.
According to the new IDF, for a person to be defined as having the METS,
they must have: Central obesity (defined as waist circumference ≥ 94 cm for
European men and ≥ 80 cm for European women, with ethnicity specific values for
other groups).
In addition, any 2 of the following 4 factors:
Raised TGs level: ≥150 mg/dl (1.7 mmol/L), or specific treatment for this lipid
abnormality.
Reduced HDL – cholesterol: <40 mg/dl (1.03 mmol/L) in men and <50 mg/dl
(1.29 mmol/L) in women, or specific treatment for these lipid abnormalities.
9
Raised Blood pressure: systolic BP ≥130 or diastolic BP ≥85 mmHg, or
treatment of previously diagnosed HT.
Raised fasting plasma glucose: fasting plasma glucose ≥100 mg/dl
(5.6mmol/L), or previously diagnosed type 2 diabetes.
If above 5.6 mmol/L or 100mg/dl, an OGTT is stronglyrecommended, but is
not necessary to define the presence of the syndrome.
American Heart Association/Updated NCEP
There is confusion as to whether AHA/NHLBI intended to create another set
of guidelines or simply update the NCEP ATP III definition.
According to Scott Grundy, University of Texas Southwestern Medical School,
Dallas, Texas, the intent was just to update the NCEP ATP III definition and not
create a new definition.26,27
Elevated waist circumference:
Men — Equal to or greater than 40 inches (102 cm)
Women — Equal to or greater than 35 inches (88 cm)
Elevated triglycerides: Equal to or greater than 150 mg/dL
Reduced HDL (“good”) cholesterol:
Men — Less than 40 mg/dL
Women — Less than 50 mg/dL
Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of
medication for hypertension
10
Elevated fasting glucose: Equal to or greater than 100 mg/dL (5.6mmol/L) or
use of medication for hyperglycemia
Other
High-sensitivity C-reactive protein (hs-CRP) has been developed and used as
a marker to predict coronary vascular diseases in metabolic syndrome, and it was
recently used predictor for non-alcoholic fatty liver disease in correlation with serum
markers that indicated lipid and glucose metabolism.28
There is a need for standardized definition of METS. Furthermore, a definition
tailored for children and adolescents is essential.
Prospective long-term studies are needed to validate the prognosticpower of
these definitions. As new information becomes available, the definition of METS
might be further modified.29
METS is estimated to affect more than one in five adults, and itsprevalence is
growing in the adults and pediatric population.30
Coronary angiography :
First performed by Sones31 in 1959, coronary arteriography hassubsequently
become one of the most widely used invasive procedures in cardiovascular
medicine. Methods used to perform coronary arteirography have evolved
substantially since 1959.
Coronary arteriography remains the standard by which all methods of
diagnosing coronary artery disease are measured. It is the primary method of
11
defining coronary artery disease are measured. It is the primary method of defining
coronary anatomy in living patients.
Coronary arteriography remains the “Gold standard”32 for identifying the
presence or absence of arterial narrowing related to a atherosclerotic coronary artery
disease and provides the most reliable anatomical information for determining the
appropriateness of medical therapy, percutaneous coronary intervention or coronary
artery bypass surgery in patients with ischemic coronary artery disease.
Coronary arteriography can establish the presence or absence of coronary
stenoses, define therapeutic options, and determine the prognosis of patients with
acute myocardial infarction at young age.
A recent study33 also showed that young patients with acute myocardial
infarction had more often single vessel disease followed by normal coronary arteries
angiographically.
A finding in which older patients had extensive atherosclerosis with more
number of diseased and diffusely involved coronary vessels than the young patients
have led to the conclusion that younger patients having less extensive coronary
artery atherosclerosis with better prognostic probability should be evaluated
angiographically for further definitive management in the form of revascularization34.
PREVALENCE OF METS:
12
Metabolic syndrome is a strong marker indicating the likelihood of CAD, while
strongest association of CAD were found with obesity and microalbuminuria. This
seems strongly significant than traditional risk factors like elevated LDL cholesterol,
hypertension and triglyderides.35
A higher prevalence of metabolic syndrome in young females compared with
young males with premature coronary artery disease was found. The overall
prevalence of metabolic syndrome was 37%. Women with premature CAD were
found to have a higher premature of metabolic syndrome than man.36
Metabolic syndrome but not BMI predicts future cardiovascular risk in women.
Although it remains prudent to recommend weight loss in overweight and obese
women, control of all modifiable risk factors in both normal and overweight. Persons
to prevent transition to metabolic syndrome should be considered the ultimate goal.37
A very consistent finding is that the prevalence of METS is highly age –
dependent, in USA (National health and Nutrition examination surgery [NHANES III])
prevalence of METS increased from 7% in participants aged 20-29 years to 44% and
42% for those aged 60-69 years and at least 70 years respectively.38
Data from 12-19 years age group is the NHANES III study, with NCEP: ATP
III criteria modified for adolescents, reported that the prevalence of the METS in
adolescents was 4.2%.39
Of particular interest are the two Indian studies, which differed in their
definition of obesity; one study used obesity criteria that were suitable for Indians,
while the others used the standard ATP III definition of obesity. Both studies used
13
population-based samples writing the same age range but reported prevalence of
13% in Jaipur and 41% in Chennai.40,41
Interestingly, a third Indian study42 also from Chennai, reported a METS
prevalence of 11.2% (using EGIR criteria), which was much closer to the prevalence
reported for Jaipur than the other Chennai study. Therefore, even within the same
ethnic population group it appears that there can be significant differences in the
prevalence of both the individual factors that constitute the METS and the METS
itself.43
A low education level links cardiovascular disease with risk factors such as
smoking, HT, impaired glucose tolerance, diabetes mellitus, physical inactivity and
overweight associated with other metabolic abnormalities.
The prevalence of METS was found to be elevated in women who abstained
from alcohol. Slight and moderate alcohol consumption has been found to be
associated with low coronary heart disease risk possibly through beneficial
alterations in HDL cholesterol and BP.44
High prevalence of obesity and IR in urban Indian population is wellknown. A
study from Chennai report 18.7% prevalence of IRS in upper socio-economic strata
in south India, while it was 6.5% in the low socioeconomic strata.39\
14
Fig.1:Prevalence of the metabolic syndrom from ATP III definition.47
Fig.2:Age-specifi prevalence rates of metabolic syndrome
(Jaipur Heart Watch-2)43
15
The I164T mutation in adiponectin gene was a common genetic background
associated with metabolic syndrome and CAD in Japanese population.4
Higher prevalence of METS in women as compared with men is seen in urban
south Indian population.40
Approximately 20-25 percent of urban souths Asians have evidence of the
METS. Furthermore, IR was reported, to be present in nearly 30 percent of children
and adolescents in India, more so in girls.45
According to a recent study on south Indians, the prevalence of the METS (%)
was estimated to be 23.2, 18.3 and 25.8 according to WHO, ATP III and IDF
definitions respectively.46
High prevalence of cardiovascular risk factors and the METS (~12%) have
been shown by our group in intra-country rural-to-urban migrant population
belonging to low socio-economic stratum residing in urban shins. Further, certain
communities in India (eg. Punjabi, Bhatia community) have inordinately high
tendency to develop obesity, type 2 diabetes mellitus, and METS.45
The METS was present in 31.6% of Indian urban population, prevalence was
22.9% in men and 39.9% in women, the age-adjusted prevalence was 24.9%, 18.4%
in men and 30.9% in women there was a significant age-related increase in its
prevalence.47
CARDIOMETABOLIC RISK: is defined as a cluster of modifiable risk factors
and markers that identify individuals at increased risk for CVD (myocardial
infarction, stroke, peripheral artery disease) and Type 2 diabetes mellitus.
16
Cardiometabolic risk factors21 :
Elevated BP
Abdominal adiposity
Low HDL-C
Elevated TGs
Elevated blood glucose
Smoking
Elevated LDL-C
Inflammatory markers
IR
The risk of cardiovascular events conferred by the presence of the METS was
greater than the risk associated with any of the individual components, emphasizing
the predictive value of this clinical entity in terms of cardiovascular complications.48
Renin-angiotensin system is known to be present in human adipose tissue,
thereby offering a potential link between obesity and HT, as well as the
prothrombotic properties of CVD49.
In asymptomatic middle-aged adults, METS also is associated with
accelerated atherosclerosis.50
INTERHEART study found that nine potentially independent risk factors, such
as smoking, history of HT and diabetes, alcohol consumption, psychosocial factors,
waist/hip ratio, dietary habits, physical activity, apolipoproteins, and alcohol
consumption, were all related to myocardialinfarction.51
17
Applying the ATP III criteria to 10537 NHANES III participants resulted in a
significant association between the METS with prevalent myocardial infarction and
stroke.52
Cardiovascular disease rate over 7.6 year was 79% or 1% per year, but of
even greater significance was the fact that 22% of group with METS developed
cardiovascular disease during 7-8 years follow up.53
In patients who had myocardial infarction with in previous 3 months, 30% of
patients had METS.54
It is not known if the METS has a greater association with women versus
men, but the presence of coronary disease in middle-aged women is highly
associated with METS.55
People with the METS have atleast a 2 fold increase in the risk of CVD
events, and a much poorer prognosis following the event. The METS more strongly
predicts congestive heart failure and CVD mortality than its individual components.56
The presence of METS is a strong marker indicating the likelihood of CAD,
while the strongest association of CAD were found with obesity and
microalbuminuria. This seems more strongly significant than traditional risk factors
like elevated LDL-C, HT, and TGs.57
18
Fig.3: Risk factors Cardiometabolic syndrome9
Fig.4: Progression and outcome of metabolic syndrome
METHODOLOGY
19
This study is based on analysis of 100 patients admitted to the CCU of
Government General hospital attached to the Medical College, Guntur during a
period from March 2013 to March 2014.
Criteria:
The proforma was used for the selection of patients with definitive evidence of
myocardial infarction.
Inclusion criteria:
Patients with evidence of coronary artery disease proven by coronary
angiogram.
Age > 30 years independent of sex.
Exclusion criteria:
Patients with evidence of coronary artery disease who has not undergone
coronary angiogram.
Patients having coexisting valvular heart disease.
Age < 30 years.
All patients of CAD including both STEMI, and NSTEMI were included.
A final diagnosis of CAD was made in the presence of serial increases in
serum biochemical markers of cardiac necrosis, has associated with typical
electrocardiographic changes and by coronary angiography and/or typical symptoms
as defined by the joint committee of the European society of cardiology and the
American college of cardiology.109
20
Patients with ST segment elevation or new or suspected new left bundle
branch block on admission electrocardiogram were defined as having ST segment
elevation MI (STEMI). The remaining patients were categorized as having non-
STEMI.
Criteria of diagnosis of METS:
The NCEP-ATP III22 definition was used for the diagnosis of METS includes
any three of the following
Central obesity : waist circumference > 102 cm (male) or > 88 cm (female).
Hypertriglyceridemia : triglycerides ≥ 150 mg/dl ♠ HDL cholesterol : <40 mg/dl
(male) or <50 mg/dl (female)
Hypertension: blood pressure ≥ 130 /85 mmHg or medication.
Fasting plasma glucose ≥ 110mg/dl.
A detailed case history was taken including the symptoms, past history of
diabetes mellitus, HT, smoking and alcohol consumption.
A careful physical examination was done with special reference to resting BP
before discharge, WC, Height and weight. The BMI was calculated using the formula
BMI = Weight in kg/Height in m2.
WC was recorded according to the national health and nutrition survey.110
“The subject stand and the examiner, positioned at the right of the subject, palpates
the upper bone to locate the iliac crest. Just above the uppermost lateral border of
right iliac crest, a horizontal mark is drawn, and then crossed with vertical mark on
the midaxillary line. The measuring tape
21
is placed in a horizontal plane around the abdomen at the level of this marked
point on the right side of the trunk. The plane of the tape is parallel to the floor and
the tape is snug, but does not compress the skin. The measurement is made normal
minimal inspiration.”
Investigations:
The following investigations were done in all the patients. The blood samples
were drawn at the admission, the following morning (lipid profile) and day 5 for
FBS.111
Electrocardiogram
Cardiac enzymes creatinine kinase, lactate dehydrogenase, aspartate
transaminse.
Fasting blood sugar, fasting lipid profile including serum cholesterol,serum
triglycerides, HDL-C, LDL-C.
Coronary angiogram.
All the coronary artery disease patients were followed up over a period of one
week for the development of complications like Heart failure, arrhythmias (ventricular
tachycardia/fibrillation), Recurrent MI. Heart failure was defined according to Killip`s
classification112
Statistical analysis:
Results were expressed as mean± SD and median for continuous data and
were compared by unpaired t test/Mann-whitney test between two groups.
Categorical data are presented as numbers and percentages, were analysed by chi-
square test. Odds ratios were calculated wherever required. A p value of 0.05 or less
was considered for statistical significance.
22
RESULTS
TABLE -2: TOTAL ADMITTED CASES IN CCU OF ACUTE MI
No. Of cases admitted
Total No. Of coronary artery disease 100
METS with CAD 44 (44%)
A total of 100 cases of acute CAD admitted during the 1year study period, out
of which 44 cases had METS which showed an overal percentage of 44% in the
present study.
TABLE -3: AGE GROUPING
With METS ( n = 44 ) Without METS ( n =
56 )
Total
Age
( years )
No. % No. % No. %
31-40 8 18 9 16 17 17
41-50 14 32 20 36 34 34
51-60 13 30 14 25 27 27
61-70 6 14 12 21 18 18
71-80 3 7 1 2 4 4
Total 44 56 100
The age incidence was more between the age group 41-50 years followed by
51-60 years in both the groups. There was no statistical difference in Age between
the 2 groups. (p value 0.48)NS
23
24
Table -4: SEX DISTRIBUTION
Sex CAD with METS CAD without METS Total
N = 44 % N = 56 % N = 100 %
Males 33 75 44 79 77 77
Females 11 25 12 21 33 33
Chi-square test. X2=1.33, p value = 0.25 NS
It was observed that 77 case among the 100 studied cases were male. The males
perdominated in both the grounps. The METS was more in females with MI but it
was not statistically significant. (p value 0.25)NS
TABLE-5 : SYMPTOMATOLOGY AT PRESENTATION
25
With METS ( n =
44 )
Without METS (n =
56 )
Total
Symptoms No. % No. % No. %
Chest pain 42 95 56 100 98 98
Breathlessnes
s
14 32 11 20 25 25
Cough/ sputum 8 18 10 18 18 18
Palpitation 7 16 8 14 15 15
Syncope 2 4.5 1 2 3 3
Sweating 25 56 20 36 45 45
Vomiting 2 4.5 5 9 7 7
The most common mode of presentation in both groups was chest pain
followed by sweating. Breathlessness (32% vs. 20%) & sweating (56% vs. 36%)
were more common in METS compared to those without METS.
TABLE- 6: RISK FACTORS
26
With METS ( n = 44 )
Without MET (n = 56 )
Total
Risk factors No. % No. % No. % P* value,
sig.Diabetes Mellitus
25 57 16 29 41 41 0.004 S
Hypertension 24 56 16 29 35 35 0.01 SFamily History
12 27 12 21 24 24 0.49 NS
Current Smoker
13 29.5 14 25 27 27 0.61 NS
Alcohol Consumption
19 43 14 25 33 33 0.055 NS
Chi- square test. S=Significant, NS=Not Significant
The past history of DM and HT were more common in the METS group compared to
those without METS which were statistically significant. There was no significant
difference in the current history of smoking, alcohol consumption and family history
of CAD in both the groups
27
TABLE – 7 : COMPONENTS OF METS
Components of METS
With METS ( n = 44 )
Without MET (n = 56 )
Total P* value,
sig.No. % No. % No. %FBS =
110mg/dl36 82 21 38 57 57 P <
0.001HS
HTN or BP = 130/85 mm Hg
37 84 12 21 49 49 P < 0.001
HSTGS = 150
mg/dl42 95 18 32 60 60 P <
0.001HS
HDL< 40
mg/dl(males)<50
mg/dl(females)
42 95 32 57 74 74 P < 0.001
HS
Waist circumference
>102 cm(males)
> 88 cm(females)
17 39 8 14 25 25 0.01 S
28
TABLE -8 : MEAN VALUES OF PARAMETERS
MI with METS MI without METS P value
FBS (mg/dl) 174.2 ± 66 133.3 ± 54.2 0.001 HS
TC (mg/dl) 186.5 ± 46.7 191.2 ± 49.8 0.63 NS
TGS (mg/dl) 246.1 ± 109.8 157.9 ± 46.3 < 0.001 HS
HDL-C (mg/dl) 35.8 ± 5.6 39.1 ± 3.9 < 0.001 HS
LDL-C (mg/dl) 137.3 ± 40.4 129.1 ± 41.2 0.31 NS
SBP mm of Hg 139.6 ± 29.4 128.8 ±23.1 0.04 S
DBP mm of Hg 88.2 ± 19.6 81.6 ± 10.1 0.03 S
Unpaired t test. HS= Highly significant, NS : Not significant, S=Significant
It was observed that, the all the components were more common in the METS
group than patients without METS and were highly significant. Low HDL-C was the
major component in both the groups. High TGS is the next major component in
METS group followed by the DM or FBS ≥110mg/dl, HT or BP ≥ 130/85 and high
WC. HT or BP ≥ 130/85 was the next major component in patients without METS
followed by high TGS, DM or FBS ≥110mg/dl and high WC.
29
TABLE -9 : OTHER FACTORS
Other factors
CAD with METS CAD without METS
Total P value
N = 44 % N = 56 % N = 100 %
Obesity ( BMI ≥ 30kg/m2
17 38.6 3 5.3 20 20 0.01 S
Serum cholesterol (≥240mg/d
l
9 20.45 6 10.7 15 15 0.63 NS
LDL-C > 160mg/dl)
12 27.2 9 16.7 21 21 0.31 NS
S= Significant, NS: Not significant
The obesity with BMI> 30Kg/m2 was present in 38.6 (Mean 27.2± 3.3) of patients
with METS compared to 5.3% (25.7±2.4) of those without METS, which was
statiscally significant (p Value)
30
TABLE – 10 : ANGIOGRAM
Angiogram With METS ( n =
44 )
Without METS( n
= 56)
Total P*
value,
sig.No. % No. % No. %
LAD 28 64 40 71 68 68 0.4 NS
RCA 8 18 14 25 22 22 0.4 NS
LCX 8 18 10 18 18 18 0.9 NS
It was observed that LAD was the most common vessel involved of the 100
studied cases 70 case 71 case were LAD and there was no much significance
related to METS.
31
TABLE -11: IN HOSPITAL PROGNOSIS OF CAD IN 1 WEEK
Prognosis in 1
week of
hospital stay
CAD with METS CAD without
METS
Total P value
N = 44 % N = 56 % N = 100 %
Heart failure 23 52 10 18 33 33 < 0.001
HS
Arrhythmias
VT/VF
4 9 4 7 8 8 0.98
NS
Recurrent MI 3 7 1 2 4 4 0.74
NS
HS= Highly Significant, NS: Not significant
All the complication were more common in the METS group compared to
those without METS group. Heart failure was present in 52% of METS patents
compared to the 18% in those without METS which was statistically highly significant
(p value <0.001). There was no significant difference in the development of other
complications like arrhythmias (ventricular tachycardia/fibrillation), recurrent MI.
32
DISCUSSION
In the present study, which included 100 cases of CAD, METS was present in 44
cases (44%).
TABLE-12: INCIDENCE OF METS
Study % of METS in CAD
Zeller M113 et al (2005) 46%
Schwartz G114 et al (2005) 38%
Levatasi G54 et al (2005) 29%
Ninomiya52 et al (2004) 41.5%
Milani R6 et al (2003) 58%
Present study 44%
These findings suggest the METS, as defined by the NCEP ATP III criteria, is
very common among patients with CAD, because almost 1 in 2 patients had METS
and that is associated with advanced coronary artery vascular damage.
This high incidence may be related to the vascular damage in METS by
oxidative stress, endothelial dysfunction and pro-inflammatory state.108
AGE INCIDENCE:
In the present study age incidence was more between the age group 41-50
years (32% in METS group and 36% in without METS group). There was no
difference in mean age of presentation between the two groups. (p- value 0.04 NS).
33
TABLE -13: AGE OF PEAK INCIDENCE OF METS
Study Age in years
Schwartz G114 et al (2005) 65 ± 11
Levatasi G54 et al (2005) 68.2
Zeller M113 et al (2005) 70 (57-67)
Ninomiya52 et al (2004) 58.6 ± 10.3
Milani R6 et al (2003) 65.7 ± 10.3
Jeppesen et al (2007) 61 (41-71)
Present study 44
There is early incidence of METS in CAD patients in the present study
compared to the other studies. About 25% CAD in India occurs under the age of 40
and 50% under 50119. In general MI develops 5-10 years earlier in Asian Indian than
in other population.120-121
SEX INCIDENCE:
In the present study the males predominated in both the groups (75 in METS group
and 79 in without METS group).
34
TABLE -14: SEX INCIDENCE
Study Males Females
Zeller M113 et al (2005) 63% 37%
Schwartz G114 et al (2005) 55% 45%
Levatasi G54 et al (2005) 85% 15%
Ninomiya52 et al (2004) 64% 32%
Milani R6 et al (2003) 55% 45%
Present study 75% 25%
Comparison between the two groups indicates that patients with METS were
more likely to be a female, which was consistent with the other studies. In the
present study, confounding factors like pre or post menopausal status and presence
or absence of anemia have not yielded statistically significant results. Higher waist
circumference and BMI appeared to play a more significant role in female subjects
than in males.
35
SYMPTOMATOLOGY:
There was no difference in the 2 groups in presenting symptoms except that more
number of patients with METS had sweating, breathlessness (56% and 32% as
compared 36% and 20% without METS).
RISK FACTORS:
In the present study past history of diabetes mellitus (57%) and hypertension
(56%) more in METS patients compared with no METS, which were statistically
significant. However, there was no statistically significant difference in the current
smoking, alcohol consumption and family history of CAD
TABLE -15: RISK FACTORS.
Zeller M113 et al
(2005)
Schwartz G114
et al (2005)
Jeppesen et al
(2007)
Present study
Past history of
DM
48% 48% 8.1% 57.0%
Past history of
HT
79% - 17.1% 56.0%
Current smoker 23% 25% 44% 29.5%
Family history
of CAD
32% - - 27.0%
36
All the risk factors were comparable to other studies but there was wide variation for
the past history of HT.
BODY MASS INDEX:
The BMI of ≥30kg/m2 as obesity was present in 38.6% of METS group as
compared to 5.3% of without METS group. The mean values were 27.2± 3.3 and
25.7± 2.6 kg/m2 respectively, which was comparable to other studies. It was
statistically significant with p value of 0.04 (<0.01).
TABLE -16: BODY MASS INDEX
Study BMI kg/m2
Zeller M113 et al (2005) 25(23-37)
Schwartz G114 et al (2005) 46%
Milani R6 et al (2003) 38%
Present study 38.6%
COMPONENTS OF METS:
All the components were more common in METS group compared to those
without METS and were statistically highly significant. METS scoring was given to
each patient depending on the number of risk factors present in the individual
patient. METS score of 3 and above was associated with a significant increase in
CAD risk.
37
TABLE -17: COMPONENTS OF METS
FBS mg/dl BP mm of
Hg
TGS mg/dl HDL-C
mg/dl
WC in cms
Schwartz
G114 et al
(2005)
- 90% - 88% 76%
Ninomiya52
et al (2004)
- 48.2% 43.2% 45% 51%
Present
study
82.0% 84.0% 95.0% 95.0% 39.0%
TABLE -18: MEAN VALUES OF COMPONENTS OF METS
Milani R6 et
al (2003)
111 ± 26 140 ± 18/
76 ± 13
176 ± 101 37.7 ± 11 102 ± 12
Zeller M113
et al (2005)
123 - 160 37 106
Present
study
174 ± 67 139.6 ±
29.4/
88.2 ± 19.6
246.1 ±
109.8
35.8 ± 5.6 96.8 ± 6.7
Low HDL-C was the most prevalent individual component in both the groups
(95% and 57%) with mean values lower in the METS group (35.8±5.6 vs. 39.1±3.9).
High TGS was the next major component prevalent in the METS group (95%) and
HT (84%) in the without METS group. The very high prevalence of dyslipidemia in
38
the present study compared to other studies can be explained by the fact that most
patients in the present study were either not on statin therapy or were inadequately
treated. Known diabetic and hypertensive patients on prolonged duration of therapy
for above ailments were inadequately tested for serum lipids.
This highlights the need for making the Lipid Profile testing more affordable to
the common public, spreading the awareness regarding the need for periodical lipid
profile testing and early counselling regarding life style management in all diabetic
and hypertensive patients. Government initiative in this direction should include
making generic drugs available and advocacy regarding the menace of non-
communicable diseases. This should also serve as a reminder to the health care
providers to search for other risk factors when the patient presents with one risk
factor i.e., to screen for the full spectrum of METS at the beginning of therapy and
periodically thereafter.
The mean FBS was 174.2 ± 67 in METS group and 133.3 ± 54.2 in the
without METS group. Both these values were more than the cut off value for the
inclusion of FBS in the NCEP ATP III criteria for the diagnosis of METS. In the
present study, glycemic control measured by FBS was associated with high
prevalence of CAD. The degree of severity of lesions was directly related to the FBS,
though the number of vessels involved did not correlate with the presence or
absence of METS. Thus the pivotal role of glycemic control in the onset and
progression of CAD has been re-established in this study.
Even in non-diabetic individuals, impaired glucose tolerance could be
associated with CAD and its severity. But this correlation could not be adequately
established from this study due to limitations of sample size. However, this data is
39
sufficient to reinforce the fact that intensive glycemic control is an important
component of CAD prevention. Another significant observation from the present
study is that the duration of diabetes is directly related to the prevalence of CAD.
However, the scope of this study does not include collection of data regarding the
history of metabolic control of our subjects particularly in the early years of their
diabetes, this period being probably important in the metabolic memory of these
individuals.
This factor limits the more in-depth analysis of metabolic control in the
evolution of CAD. The proportion of denovo diabetes detected after admission with
symptoms of angina is similar in both the arms ie, those with and without METS in
this study. In the present study the METS patients had high FBS (174±67mg/dl)
compared to other studies. This may be due to poor control of blood sugar in our
study patients and also irregularities in the treatment by the patients.
WC was the minor component in both the groups but was also found to be
statistically significant. Visceral fat plays an important role in the pathogenesis of
CAD. Adeponectin is the biomarker for visceral fat. It has direct prognostic
significance in non-diabetic subjects but its significance in diabetic patients in
prediction of CAD is debatable.
This test could not be incorporated in our study. Patients of Indian origin often
fit into the model of normal weight but metabolically obese individuals. Though the
mean weight in our study is 69.2 +/- 2.34 Kg, the waist circumference was 97.57 +/-
9.14 cm and the mean BMI was 26.8 +/- 2.9, demonstrating that they all fall into the
metabolically obese group. The fact that METS can develop in Indian patients with
40
apparently normal BMI was also confirmed in our study, with METS being present in
14% of patients with BMI less than 25 Kg/sq.mt.
Most of the patients in this study were more close to attaining BP targets than
glycemic targets. Most were already on adequate dosage of antihypertensive
medication.
The HT or BP ≥130/80 was comparable to some studies, and there was also
a variation in the incidence of HT in between the studies.
The serum TGS was found to be very high in the present study
(246.1±109.8mg/dl) compared to the other studies which may be related to the south
Indians have high percentage of body fat and low muscle mass.45
Additionally insulin resistance also reduces the concentration of lipoprotein
lipase in the peripheral tissues.22
The predominant component in the present study HDL-C (35.8±5.6) was
found to be same as compared to other studies. This low HDL-C may be due to high
TGs which leads to decreased production and also increased clearance HDL-C from
the circulation.22, 75 Data from this study showed dyslipidemia pattern of high
triglycerides and low HDL which is typical of South-Indian CAD patients.
This pattern of dyslipidemia is commonly associated with high insulin
resistance. However, the role of each component of deranged lipid profile i.e.,
elevated triglycerides / high LDL / low HDL in causing and aggravating CAD could
not be independently ascertained in this study.
Whether elevated triglycerides play a direct role in the causation of CAD or
they are surrogate markers for metabolic disturbances needs to be assessed by
41
further studies. Considering that LDL targets in diabetic patients could be even lower
than 100 mg/dL, the present data shows more correlation with worse HDL levels with
CAD in diabetic patients.
In our study LAD was the most common vessel involving 68% and RCA
(22%), LCX (18%).
Badui E. et al115 also made the similar observation with left anterior
descending artery involvement in 41% of patients.
Similar observation were made by Shat A. et al116 with left anterior
descending artery involvement in 84% of young patients with acute MI. Though the
number of vessels involved was not determined by the presence or absence of
METS, the severity of lesions (tightness of stenosis) was more in patients with METS
The WC was less in the present study (median 95) compared to the other
studies. This may be related to the adult Asian Indians, along with the other ethnic
groups, have different anthropometric characteristics compared with others.
Metabolic abnormalities contributing to cardiovascular risk factors are detectable at a
lower WC in Asians comparison with Caucasians, suggesting that NCEP ATP III
criteria might under estimate the prevalence of METS in Asians.
Obesity, criteria for the diagnosis of METS need to be revised in Asian Indians
and other Asian ethnic groups. Inclusion of modified WC, BMI cut offs and
subscapular skin fold thickness may be considered as defining variables of METS in
the future studies on Asian Indians and other Asian ethnic groups. Interpretation of
BMI as an individual risk factor in the causation of CAD is confounded by the fact
that mortality due to CAD increases at both the ends of spectrum of BMI i.e., very
42
low and very high BMI. Keeping in view the fact that weight loss could also occur due
to poor glycemic control in our subset of patients hailing from the poorer sections of
the society.
Other biochemical parameters serum cholesterol (mg/dl) and LDL-C (mg/dl)
(186.5±46.7 and 137.3±40.4) in the present study, which is comparable to Milani6 et
al (172± 38 and 104± 49), and there was no significant difference.
IN HOSPITAL PROGNOSIS OF CAD (1WEEK):
The heart failure (52%) was the predominant complication in the present
study and was statistically highly significant. Other complications were less common
and were not significant.
TABLE -19: IN HOSPITAL PROGNOSIS OF MI (1WEEK)
Complications Zeller M113 et al (2005) Present study
Heart failure 41.7% 52%
Ventricular
tachycardia/fibrillation
11.7% 9%
Recurrent MI 9.37% 3%
In the CAD patients presence of METS was associated with about 4 times
(odds ratio 3.8, p value <0.001 HS) more chances of complications.
This may be related to the more advanced vascular damage associated with
the presence of METS in patients with manifest vascular disease like CAD, which
43
may worsen the prognosis.113 METS also represent a cluster of several risk factors,
each of which may be involved in this poor outcome.
One of the main result of our study is that the increased risk of development
of heart failure in patients with METS appears to be related to primarily to fasting
hyperglycemia, measured several days after the index event which was very high in
the present study compared to other studies.
The presence of DM and HT were also associated with diastolic/systolic heart
dysfunction, abnormal myocardial substrate metabolism resulting in increased free
fatty acid metabolism, and impaired. blood flow to the non-infarcted myocardium117
are the potential factors explaining the higher incidence of heart failure.
Both METS and DM were associated with unfavorable in terms of all cause
mortality.54 A recent study in India has shown the importance of insulin resistance
as a risk factor for carotid artery intima/media thickness and indirect marker of
atherosclerosis.64
People with METS have at least 2-fold increase in cardiovascular events and
a much poorer prognosis following the event. The METS more strongly predicts the
coronary heart disease and cardiovascular disease mortality than its components.56
Size of the infarct as inferred from the creatinine kinase levels, troponin levels
and regional wall motion abnormality and lower EF in the post-MI echo was
significantly more in the present study in diabetic patients with poor glycemic control
(higher Hb A1c) compared to those with good control or non-diabetic patients.
Scope For Further Improvements Of This Study And Shortcomings
44
1. This study is an attempt to find a clinically relevant relationship between the
concept of METS and its utility in prevention of CAD. As of now, METS may
be considered useful as an educational concept, but has limited practical
utility as a diagnostic or management tool. In this context, future research
should focus on: (a) further elucidation of common metabolic pathways
underlying the development of diabetes and CVD, including those clustering
within the metabolic syndrome; (b) early-life determinants of metabolic risk;
(c) developing and evaluating context-specific strategies for identifying and
reducing CVD and diabetes risk, based on available resources; and (d)
developing and evaluating population-based prevention strategies.
2. The study could have been more objective by including measurable markers
of systemic inflammation said to be associated with METS like highly sensitive
CRP, adeponectin and IL-6 and ‘Insulin Resistance’ derived from Homeostatic
Model assessment (HOMA). However, it could not be done in this study due
to financial constraints involved.
3. The METS score (number of risk factors in each patient) could not be
evaluated vis-a-vis the severity of lesions on coronary angiogram
4. All the patients included in the study belong to the same (lower)
socioeconomic stratum in view of the setting of the study in a Government
General Hospital. Inclusion of patients from higher socio-economic strata
where METS is much more common could possibly alter the figures attained.
5. The relevance of each of the components of METS in the the localization of
lesions (LAD / LCX / RCA / OM etc) could not be independently assessed in
this study
45
6. Asian Indians have a tendency to develop metabolic abnormalities at a lower
BMI and waist circumference than other population groups. Conventional
criteria may therefore underestimate the prevalence of METS. Criteria used
(NCEP - ATP III) may not be entirely appropriate for South Indian patients
who have a different genetic makeup with regards to lipid metabolism.
However, the above criteria were adapted in this study as they are universally
accepted and are convenient for comparisons purpose.
7. In the present study, low HDL, followed by high triglycerides was identified as
the important factor determining the severity of CAD. However, other Indian
studies have arrived at varying conclusions like FBS, BP or waist
circumference being the most important determinant. Larger studies are
required to identify appropriate factors determining the severity of CAD in
local populations.
8. Further studies are required to establish the incidence and the causative
relationship between conditions like cancer, liver disease, hyperuricemia and
sleep apnoea which are said to be associated with METS.
9. METS only offers a Relative Risk of cardiovascular disease. Studies have to
be done to compare them with other widely accepted algorithms like
Framingham score to assess whether this scoring improves the prediction of
cardiovascular mortality and morbidity.
10. Other important factors like smoking, stress, poor treatment adherence, low
BMI (<18 Kg/Sq.mt) and poor life style management have not been included
in the scoring though they have a significant impact in the causation of CVD.
46
CONCLUSION
This is one of the prospective study carried out to describe the prevalence of
metabolic syndrome in coronary artery disease and to assessits impact on hospital
outcome.
The metabolic syndrome is a highly prevalent condition among the patients
with coronary artery disease and has detrimental impact on shortterm outcome.
Metabolic syndrome is a clustering of risk factors of metabolic originthat are
together associated with higher risk of cardiovascular disease and the need to
develop strategies for controlling this syndrome and itscomponent conditions.
In the industrialized countries there is a continuing decline of CAD during the
last three decades. Between 1965-1990, CAD mortality had decreased by 60% in
Japan and Finland and by 50% in USA, Canada, France, and Australia. This has
been possible by focusing on public education programmes for modifying the known
risk factors and by targeting high risk individuals. This achievement of the
industrialized nations must become an inspiration for the physicians and the policy
makers in India.
Early investigations diagnosis, treatment including lifestyle modification and
prevention of the metabolic syndrome will reduce the development of cardiovascular
diseases like myocardial infarction including its complications and it present a major
challenge for health care professionals facing an epidemic of overweight and
sedentary lifestyle.
To conclude, Cardiovascular disease patients with METS must beidentified
and managed aggressively to reduce both morbidity and mortalitysince it is a
preventable condition.
47
SUMMARY
In the present study, 100 cases of acute myocardial infarction were studied
over a period of one year for metabolic syndrome using the NCEPATP III criteria and
metabolic syndrome was present in 44 cases (44%).
The age of the patients ranged from 31 to 80 years, with a median age of 50.5
years. Maximum number of cases was in the 41-50 years (34%).
Male cases predominated in both the groups with and without metabolic
syndrome (75% and 79% respectively). Females were more likely to have
metabolic syndrome.
Chest pain was the most common symptom in both the groups. (95% and
100%). Breathlessness (32%) and sweating (56%) was also more common in
metabolic syndrome patients.
57% and 56% of metabolic syndrome patients had past history of diabetes
mellitus and hypertension respectively. 29.5% of metabolic syndrome cases
were smokers and 43% were alcoholic and 27% had family history of
coronary artery disease.
The body mass index of ≥30 kg/m2 was present in 38.6% of metabolic
syndrome cases with mean value of 27.2±3.3 kg/m2.
Among the components of metabolic syndrome low HDL-cholesterol was the
most prevalent component in both the groups. (95% in metabolic syndrome
and 57% in without metabolic syndrome cases).
High triglycerides (95%) was the next most prevalent component in metabolic
syndrome cases followed by the diabetes or fasting blood sugar ≥110mg/dl
(82%), hypertension or blood pressure of ≥130/85 mm of Hg (84%) and high
waist circumference (39%).
48
During one week in hospital prognosis of myocardial infarction 52% of patients
had heart failure, 8% had ventricular tachycardia/fibrillation, 3% patients had
recurrent myocardial infarction in METS.
Development of complications in coronary artery disease patients was around 4
times higher in metabolic syndrome patients compared to without metabolic
syndrome cases.
RECOMMENDATIONS:
Detection of one component of metabolic syndrome should prompt the
health care provider to look for all the other risk factors so that the
progression to CVD from METS could be slowed.
Government and NGOs should focus on the menace of non-
communicable diseases in the society and spread awareness in the
public.
Low cost screening programmes should be made available and
publicized in the community.
Generic drugs should be made widely available and their usage
encouraged by health care providers.
More focus should be set on the management of post-infarct patients
with METS with strategies such as intensive glycemic control by insulin
infusion in view of significantly increased complication rate as can be
seen from this study.
Steps should be taken to reverse the alarming trend of younger
patients being detected with METS progressing to CVD and more
number of women with METS developing complications by specifically
addressing those particular groups from an early age.
49
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ANNEXURE – I
PROFORMA
Case NO :
D.O.A :
Name : D.O.D :
Age : Sex: IP. NO. :
Occupation :
1) CHIEF COMPLAINTS :
II) HISTORY OF PRESENT ILLNESS :
1) Chest pain : onset
Site
Nature
Duration
Radiation
Aggravating/ Relieving factors.
2) Breathlessness: onset
Duration
Degree
Orthopnoea/PND
3) Cough : Sputum
Mucoid/ Serous
Colour
Blood stained – Y/N
Postural variation
4) Palpitations : Onset
Regular/Irregular
Continuous/intermittent
Relieving factors
At rest – Y/N
5) Sweating : Y/N
6) Syncope : Y/N
64
7) Vomiting : Y/N
8) Miscellaneous :
III) PAST HISTORY: Diabetes mellitus – Duration
Treatment
Hypertension – Duration
Treatment
IHD
IV) FAMILY HISTORY: Coronary Artery Disease
Diabetes mellitus
Hypertension
V) PERSONAL HISTORY: Current smoking – Y/N
Alcohol consumption – Y/N
Diet
Sleep
VI) GENERAL PHYSICAL EXAMINATION:
1) Appearance
2) Built and nourishment
3) Pallor/ Icterus/ Cyanosis/ Clubbing/ Pedal oedema
4) Xanthoma/ Xanthelesma/ Arcus senalis/ juvenalis
5) Vital signs : pulse : BP: SBP Temperature:
JVP: DBP RR:
6) Waist circumference
7) Body-Mass index
8) Waist/ Hip ratio
VII) CARDIOVASCULAR SYSTEM:
INSPECTION: 1)Precordium
2) Apical impulse
3) Other pulsations
65
PALPATION: 1) Apical impulse
2) Para sternal heave
3) Thrills
4) Palpable sounds
5) Other pulsations
PERCUSSION:
AUSCULTATION: 1) Heart sounds
2) Murmurs
3) Extra sounds
4) Others
VIII) RESPIRATORY SYSTEM: 1) INSPECTION
2) PALPATION
3) PERCUSSION
4) AUSCULTATION – Basal Rales Y/N
IX) PER ABDOMAN: 1) INSPECTION
2) PALPATION
3) PERCUSSION
4) AUSCULTATION
X) CENTRAL NERVOUS SYSTEM: 1) HIGHER MENTAL FUNCTIONS
2) CRANIAL NERVES
3) MOTOR SYSTEM
4) SENSORY SYSTEM
5) MENINGEAL SIGNS
6) OTHERS
XI) CLINICAL DIAGNOSIS:
66
XII) INVESTIGATIONS:
1) BLOOD : FBS - PPBS -
BLOOD UREA - S.CREATININE –
LIPID PROFILE: T. CHOLESTEROL -
S. TRIGLYCERIDES -
HDL – C -
LDL – C –
CARDIAC ENZYMES A: CPK - AST - LDH -
2) ECG :
3) ECHO :
4) CORONARY ANGIOGRAM :
a. LAD
b. RCA
c. LCX
XIII) COMMENTS
XIV) FOLLOW – UP: Basal Rales
ECG
CARDIAC ENZYMES – CPK
67
ANNEXURE - II
INFORMED CONSENT FORM(ICF)
Title “Prevalence of Metabolic Syndrome In Coronary Artery Disease
Proven By Coronary Angiogram”.
Name of P.G/U.G. Student/Faculty member : Dr. VASUDHA KAVURU
Name of Guide : Prof Dr. G.Chakradhar Rao M.D
I ______________________________(Name) ______, aged about ______ years, a
resident of _________________ village of ________________ District, have been detailed
about the procedure in this study. I understood that my identity will not be disclosed and I
can withdrawn from the study at any point of the time with out assigning any reason. In fully
aware that my withdrawal from the study will not affect my ongoing treatment.
_________________________ ___________________________
Signature of the witness Signature of the patient/ Gaurdian
68
GUNTUR MEDICAL COLLEE & GOVT. GENERAL HOSPITALGUNTUR-522019(AP)
INSTITUTIONAL ETHICS COMMITTEE(IEC)
ETHICS CLEARANCE CERTIFICATE
The Institutional Ethics Committee of Guntur Medical College & Government General
Hospital, Guntur met on ___________ at _________________ to scrutinize the
Synopsis / Research projects of Post graduate students/Under graduate students/
Faculty members of this College from Ethics point of view. After scrutiny, the
following version of Synopsis of Dissertation/Research project has been accorded
Ethics Clearance.
Title “Prevalence of Metabolic Syndrome In Coronary Artery Disease
Proven By Coronary Angiogram”
69
Name of P.G/U.G. Student/Faculty member : : Dr. VASUDHA KAVURU
Name of Guide : Prof Prof Dr. G.Chakradhar Rao M.D
Date:
Guntur
Member Secretary, IEC Chairman, IEC
Principal
70