We identified 351 from medical records; after careful verification and search of records, 121 patients were excluded due to missing medical records, duplication, or alternative diagnosis (High-risk NSTEMI) and staged PCI procedures entry. 230 patients were included in the final study analysis.
The demographic and clinical characteristics of the patients are summarized in Table 1. The cohort was predominantly male (n = 192,83.5%), with a median age was 55.0 years (IQR 48.0–65.0). The majority of the patients were aged between 45–60 years (n = 117,50.8%), had underlying Diabetes Mellitus(n = 131,56.9%), hypertension (n = 111,51.6%) and were on treatment with cholesterol-lowering medication before presentation (n = 160, 60.5%).
Table 1
Baseline demographics of the cohort
Characteristics | n | N = 2301 |
Median Age | 230 | 55.0 (48.0–65.0) |
Age Group, n (%) | | |
< 45 years | | 34 (16.0) |
45–60 | | 117(50.8) |
> 60 years | | 79 (37.1) |
ETHNICTY, n (%) | 230 | |
African | | 80 (34.7) |
South Asian | | 101 (43.9) |
Other | | 40 (17.4) |
Caucasian | | 9 (3.9%) |
Sex, n (%) Female Male | 230 | 38 (16.5) 192 (83.5) |
BMI (Kg/m2), Median (IQR) | 230 | 26.5 (25.0–31.0) |
BMI Category Normal Overweight Obesity I Obesity II Obesity III | | 49(21.3) 79 (34.3) 55 (23.9) 32 (13.9) 15 (6.5) |
Admitting Category, n (%) Referral Self | 230 | 85 (37.0) 135 (63) |
Atherosclerotic risk factors DM, n (%) HTN, n (%) Family history of Premature ASCVD, n (%) CKD/ESRD, n (%) Previous ASCVD, n (%) Smoking, n (%) On Cholesterol- lowering medication prior presentation, n (%) | | 131(56.9) 111(51.6) 64(29.8) 27(12.6) 52(24.2) 72(33.5) 130(60.5) |
1: Median (IQR); n (%). BMI: Body Mass Index, DM: Diabetes Mellitus, HTN: Hypertension, CKD: Chronic Kidney Disease, ESRD: End Stage Renal Disease, ASCVD: Atherosclerotic Cardiovascular Disease |
Most patients presented with chest pain (n = 162,72.6%), with the median duration of chest pain before hospital presentation of 12.2 hours (IQR 3.0–24.0 hours). Most patients presented in Killip Class 1 (n = 125,54.3%). Anterior myocardial infarction on ECG was the most common presentation (n = 136,59.1%). A small fraction of patients underwent thrombolysis prior to intervention (n = 17,7.8%). These findings are summarized in Table 2 below.
Table 2
Symptoms and presentation of the Cohort
Characteristic | N = 2301 |
Presenting Complain, n (%) Chest Pain Cardiac arrest on presentation Dyspeptic syndrome Dyspnea Syncope | 167(72.6) 4 (1.7) 12(5.2) 41(17.8) 6(2.6) |
Chest pain Duration, (IQR) < 3 hours, n (%) 3–12 hours, n (%) 12–24 hours, n (%) > 24 hours, n (%) | 12.2 hours (IQR3.0–24.0) 39(23.1) 25(14.9) 22(13.4) 81(48.5) |
KILLIP, n (%) | |
Killip I | 125 (54.3) |
Killip II | 59 (25.6) |
Killip III | 32 (13.9) |
Killip IV | 14 (6.1) |
ECG changes, n (%) Anterior - septal Inferior Anterior- lateral Anterior Inferior- lateral Lateral Complete heart block Posterior- lateral | 67(29.1) 59(25.7) 41(17.8) 28(12.2) 18(7.8) 8(3.5) 5(2.2) 4(1.7) |
Thrombolysis, n (%) Off site On site | 16 (7.8) 12(75) 4(25) |
1: n (%).
The majority of the patients underwent a femoral puncture (n = 142,61.7%), with single vessel disease (n = 151, 65.6%) and atherosclerosis (n = 182,79.1%) as the most common finding and mechanism of obstruction. Left Anterior descending (LAD) artery was the culprit vessel in most cases (n = 112,48.7%). A total of 163(70.8%) patients underwent Primary Percutaneous intervention (PCI)
Table 3
Angiographic findings and interventions
Characteristics | n | N = 2301 |
Access. n (%) Radial Femoral | 230 | 88 (38.2) 142 (61.7) |
Angiographic findings, n (%) Non- Obstructive Coronary Single vessel Disease Single vessel- ISRS Single vessel - stent thrombosis Two vessel disease Triple vessel disease | 230 | 17 (7.9) 142 (61.7) 5 (2.2) 4 (1.7) 37 (16.1) 25 (10.9) |
Culprit vessel, n (%) LM LAD RCA LCX N/A | 230 | 2 (0.87) 112 (48.7) 69 (30) 32 (13.9) 17 (7.9) |
Intervention Done, n (%) Coronary Angiography - No Intervention Primary PCI Thrombotic Aspiration + Primary PCI POBA Primary PCI + PCI of non- IRA Rescue PCI Coronary Angiography - Referral for CABG Unsuccessful PCI | 230 | 17 (7.4) 126 (54.7) 12 (5.2) 7 (3.04) 25 (10.9) 15 (6.5) 17 (7.4) 11 (4.8) |
Mechanism Atherosclerotic Thrombotic SCAD N/A | 230 | 182 (79.1) 29 (12.6) 2 (0.87) 17 (7.4) |
1: n (%). LM: Left Main, LAD: Left Anterior Descending, RCA: Right Coronary artery, LCX: Left Circumflex, PCI: Percutaneous coronary intervention, SCAD: Spontaneous Coronary Artery Dissection.
The in-hospital mortality of the cohort was 5.7%. Patients who died prior to discharge were more likely to have Diabetes Mellitus (n = 12,92.3%), hypertension(n = 12,92.3%), a history of current or previous smoking (n-11,84.6%), and to be on treatment for hyperlipidemia (n = 10,76.9%) (P- value < 0.05). Additionally, an increased need for mechanical ventilation(n = 4,30.8%) and inotropes(n = 8,61.5%) was also noted amongst the non-survivors with statistical significance (P- value < 0.05). A higher BMI and delayed time to presentation was predictive of in-hospital mortality.
Table 4
Comparison of Survivors and non-Survivors
Characteristic | Overall, N = 2301 | Survivors, N = 217 (94.3%) | Non- Survivors, N = 13 (5.7%) | P- Value2 |
AGE, Median (IQR) | 55.0 (48.0–65.0) | 54.1 (48.0–65.0) | 55.5 (49.0–75.0) | 0.77 |
SEX, n (%) | | | | 0.99 |
Female | 38 (10.7) | 37 (10.9) | 1 (7.7) | |
Male | 192 (89.3) | 180 (89.1) | 12 (92.3) | |
Chest Pain Duration, Median (IQR) | 12.0 (3.0–24.0) | 10.5 (3.0–24.0) | 24.0 (24.0–36.0) | 0.05 |
BMI, Kg/m2 (IQR) | 26.5 (IQR 25.0–31.0) | 26.0 (IQR 25.0–31.0) | 39.0 (IQR 36.0–39.0) | < 0.001 |
DM, n (%) | 131 (54.0) | 119 (54.8) | 12 (92.3) | < 0.001 |
HTN, n (%) | 111 (51.6) | 99 (49.0) | 12 (92.3) | 0.002 |
Smoking, n (%) | 72 (33.5) | 61 (30.2) | 11 (84.6) | < 0.001 |
Hyperlipidemia, n (%) | 130 (60.5) | 120 (57.9) | 10 (76.9) | 0.003 |
Killip, n (%) | | | | < 0.001 |
Killip I | 125 (58.1) | 125 (61.9) | 0 (0.0) | |
Killip II | 59 (20.5) | 58 (26.7) | 1 (7.7) | |
Killip III | 32 (13.0) | 23 (10.9) | 9 (46.2) | |
Killip IV | 14 (6.5) | 11 (5.4) | 3 (23.1) | |
Angiographic Findings (%) | | | | 0.48 |
Non- Obstructive Coronary | 17 (7.9) | 17 (8.5) | 0 (0.0) | |
Single Vessel Disease | 142(61) | 136(62.7%) | 6(46.2) | |
Single Vessel Disease - ISRS | 5 (2.3) | 5 (2.5) | 0 (0.0) | |
Single Vessel Disease- Stent thrombosis | 4 (1.9) | 4 (2.0) | 0 (0.0) | |
Two Vessel Disease | 37 (17.2) | 34 (16.8) | 3 (23.1) | |
Triple Vessel Disease | 25 (11.6) | 21 (10.4) | 4 (30.8) | |
Culprit Vessel, n (%) | | | | 0.18 |
N/A | 17 (7.9) | 17 (8.4) | 0 (0.0) | |
LM | 2 (0.9) | 2 (0.9) | 0 (0.0) | |
LAD | 112 (48.7) | 101 (46.5) | 11 (84.6) | |
LCX | 32 (13.9) | 32 (14.7) | 0 (0.0) | |
RCA | 69 (30.) | 67 (30.1) | 2 (15.4) | |
Inotropes, n (%) | 15 (7.0) | 7 (3.5) | 8 (61.5) | < 0.001 |
Mechanical Ventilation, n (%) | 9 (4.2) | 5 (2.5) | 4 (30.8) | < 0.001 |
IABP, n (%) | 3 (1.4) | 1 (0.5) | 2 (15.4) | 0.01 |
LOS, Median (IQR) | 2.0 (2.0–3.0) | 2.0 (2.0–3.0) | 2.0 (0.0–8.0) | 0.74 |
1: Median (IQR); n (%). 2: Wilcoxon rank sum test; Fischer’s exact test; Pearson chi-squared test. BMI: Body Mass Index, DM: Diabetes Mellitus, HTN: Hypertension, LAD: Left Anterior Descending, LCX: Left Circumflex, RCA: Right Coronary artery, IABP: Intra-Aortic Balloon Pump, LOS: Length of Stay
Table 5 below illustrates laboratory investigations for all patients and provides a comparison between survivors and non-survivors. A higher Low-Density Lipoprotein and Triglyceride (TG), with statistical significance (P-value < 0.05), was noted amongst the non-survivors.
Table 5
Laboratory investigations and comparison of survivors and non-survivors
| n | Overall, N = 2301 | Survivors, N = 217 (94.3%) | Non- Survivors, N = 13 (5.7%) | P- Value2 |
Troponin T, Mean (SD) | 224 | 1,073.6 (1,558.3) | 1,045.5 (1,383.4) | 1,496.4 (3,284.1) | 0.46 |
CKMB, Mean (SD) | 188 | 76.2 (88.3) | 75.7 (87.9) | 86.6 (100.1) | 0.58 |
TC, Mean (SD), mmol/l | 212 | 4.7 (1.1) | 4.7 (1.1) | 4.4 (1.1) | 0.10 |
LDL, Mean (SD), mmol/l | 212 | 2.8 (0.9) | 2.2 (0.9) | 2.8 (1.3) | 0.05 |
HDL, Mean (SD), mmol/l | 212 | 1.1 (0.2) | 1.1 (0.2) | 1.0 (0.1) | 0.18 |
TG, Mean (SD), mmol/l | 212 | 1.8 (0.9) | 1.7 (0.9) | 2.5 (1.0) | 0.006 |
HBA1C, Mean (SD)% | 91 | 6.3 (3.8) | 6.3 (3.9) | 6.7 (3.6) | 0.79 |
CRP, Mean (SD) mg/l | 126 | 72.4 (111.5) | 70.4 (110.0) | 136.4 (158.7) | 0.96 |
BUN, Mean (SD)mmol/l | 212 | 5.4 (2.4) | 5.4 (2.4) | 5.5 (2.2) | 0.77 |
Creatinine, Mean (SD)umol/l | 212 | 79.3 (21.4) | 78.9 (19.3) | 84.8 (43.9) | 0.41 |
1: Mean, 2 Wilcoxon rank sum tests. TC: Total Cholesterol, LDL: Low Density Lipoprotein, HDL: High Density Lipoprotein, TG: Triglycerides, CRP: C- Reactive Protein, BUN: Blood Urea Nitrogen.
The Median Left Ventricular Ejection Fraction (LVEF) was 50.23%, and non-survivors had a lower LVEF when compared to survivors. Only 12 patients (5.6%) of the 213 were noted to have LV thrombus on 2D echocardiography.
Table 6
2D Echocardiographic findings prior hospital discharge
Characteristic | Overall, N = 2131 | Survivors, N = 202 | Non-Survivors, N = 11 | P - Value2 |
LVEF, Median (IQR) | 50.23% (40.1–60.2) | 50.6% (45.6–61.3) | 30.5% (31.5–42.5) | < 0.001 |
LV Thrombus, n (%) | 12 (5.6) | 11 (7.7) | 1 (16.7) | 0.40 |
1: Median, n (%), 2 Wilcoxon rank sum tests. LV : Left Ventricle, LVEF : Left Ventricle Ejection Fraction.
We could only retrieve the discharge medication of 217 patients. The majority were discharged on B-blockers (n = 163,75.1%), as seen in Table 6 below. Aspirin and Clopidogrel were the most commonly used Dual Antiplatelet Therapy (DAPT)(n = 112,51.6%)
Table 7
Discharge Medications of the study population
Characteristics | N = 217 (100) |
B- Blocker, n (%) | 163 (75.1) |
ACE-i, n (%) | 67 (30.8) |
ARB, n (%) | 61 (28.1) |
ARNI, n (%) | 25 (11.5) |
MRA, n (%) | 68 (31.3) |
SGLT.2, n (%) | 44 (20.2) |
DAPT, n (%) | |
Aspirin + Clopidogrel | 112(51.6) |
Aspirin + Ticagrelor | 49(22.5) |
Aspirin + prasugrel | 13(5.9) |
Triple antithrombotic Therapy | 36 (16.6) |
1: n (%). B: Beta, ACE-I: Angiotensin converting Enzyme inhibitor, ARB: Angiotensin Receptor Blocker, ARNI: Angiotensin Receptor Neprilysin Inhibitor, MRA: Mineralocorticoid receptor Antagonist, SGLT-2: Sodium Glucose Transport 2, DAPT: Dual Anti platelet.
A higher mean BMI of 36.2 (± 5.7) (OR 1.46, 95% CI 1.17– 2.10), the presence of smoking (OR 41.68, 95% CI 2.60– 240.71), and the use of mechanical ventilation (OR 77.42, 95% CI 1.95– 128.89) were factors associated with in-hospital mortality.
Table 8
Factors associated with in-hospital mortality.
Dependent: OUTCOME | Survivors | Non- Survivors | OR (univariable) | p-value | OR (multivariable) | p-value |
Time from chest pain to Presentation(hours) | | 10.5 (3.0–24.0) | 24.0 (24.0–36.0) | 1.03 (1.00-1.06) | p = 0.069 | 1.04 (0.97–1.14) | p = 0.235 |
BMI | | 27.8 (± 5.2) | 36.2 (± 5.7) | 1.24 (1.13–1.39) | p < 0.001 | 1.46 (1.17–2.10) | p = 0.006 |
HTN | No | 103 (99.0) | 1 (1.0) | | - | | - |
| Yes | 99 (89.2) | 12 (10.8) | 12.48 (2.39-229.57) | p = 0.016 | 6.49 (0.35-631.08) | p = 0.301 |
Smoking | No | 141 (98.6) | 2 (1.4) | | - | | - |
| Yes | 61 (84.7) | 11 (15.3) | 12.71 (3.29–83.76) | p = 0.001 | 41.68 (2.60-240.71) | p = 0.025 |
Inotropes | No | 195 (97.5) | 5 (2.5) | | - | | - |
| Yes | 7 (46.7) | 8 (53.3) | 44.57 (12.06-185.95) | p < 0.001 | 14.22 (0.65-650.87) | p = 0.107 |
Mechanical Ventilation | No | 197 (95.6) | 9 (4.4) | | - | | - |
| Yes | 5 (55.6) | 4 (44.4) | 17.51 (3.80–78.30) | p < 0.001 | 77.42 (1.95-128.89) | p = 0.033 |
IABP | No | 201 (94.8) | 11 (5.2) | | - | | - |
| Yes | 1 (33.3) | 2 (66.7) | 36.55 (3.27-823.35) | p = 0.004 | 26.47 (0.03-130.61) | p = 0.570 |
Triglycerides | Mean (SD) | 1.7 (0.9) | 2.5 (1.0) | 1.94 (1.18–3.16) | p = 0.007 | 3.33 (0.85–18.80) | p = 0.097 |
BMI: Body Mass Index, HTN: Hypertension, IABP: Intra-Aortic Balloon Pump, OR : Odds Ration