Summary
Background
Traditional risk factors are strong predictors of the incidence of coronary artery disease (CAD), but their association with disease severity remains controversial and could differ across ethnic groups.
Aims
In this study, we assessed the prevalence of cardiovascular risk factors (CRFs) in Afro-Caribbean patients with documented CAD, and sought to identify which of these factors are related to disease severity.
Methods
We retrospectively studied 420 consecutive patients with CAD. Disease severity was determined from the results of invasive coronary angiography, based on the presence or absence of multiple (two or three) diseased vessels and the myocardial jeopardy (MJ) score.
Results
In the studied population (mean age 64.7 ± 12.4 years), hypertension, diabetes and dyslipidaemia were the most frequent modifiable CRFs, present in 75.9, 47.8 and 37.8% of patients, respectively. Multiple logistic regression analysis showed that diabetes, male sex and personal cardiovascular history significantly increased the risk of multivessel CAD: odds ratios (ORs) of 1.53 (1.01–2.33; P = 0.048), 1.61 (1.02–2.55; P = 0.043) and 1.68 (1.11–2.56; P = 0.015), respectively. Obesity was an independent negative predictor, with an OR of 0.48 (0.29–0.79; P = 0.004). Other traditional CRFs (hypertension, dyslipidaemia, smoking, age and family history of vascular disease) were not associated with CAD severity. For high-risk lesions (MJ score ≥8), both diabetes and hypertension were independent predictors of disease severity, whereas obesity was no longer a protective factor.
Conclusion
Diabetes emerged as the strongest modifiable risk factor predictor of multivessel disease in Afro-Caribbean patients, whereas obesity was an independent protective factor. The underlying mechanisms of these associations should be relevant to disease prevention.
Résumé
Contexte
Les facteurs de risque cardiovasculaire (FDRCV) classiques sont de puissants prédicteurs d’une coronaropathie mais leur lien avec la sévérité des lésions coronaires est controversé et pourrait varier selon les groupes ethniques.
Objectifs
Évaluer la prévalence des FDRCV chez des sujets afro-caribéens et rechercher les facteurs associés à la sévérité des lésions coronaires.
Méthodes
Nous avons analysé rétrospectivement 420 dossiers consécutifs de patients coronariens. La sévérité des lésions a été appréciée à la coronarographie selon l’existence ou non de lésions pluritronculaires (2 ou 3 vaisseaux atteints) et selon un score de risque myocardique ( myocardial jeopardy score ).
Résultats
Dans la population étudiée (d’âge moyen 64,7 ± 12,4 ans), l’hypertension, le diabète et une dyslipidémie étaient les FDRCV modifiables les plus fréquemment observés avec une prévalence respective de 75,9, 47,8 et 37,8 %. Dans l’analyse de régression logistique multivariée seuls le diabète, le sexe masculin et les antécédents coronariens étaient prédictifs de lésions pluritronculaires avec des odds ratio (OR) de 1,53 (1,01–2,33 ; p = 0,048), 1,61 (1,02–2,55 ; p = 0,043) et 1,68 (1,11–2,56 ; p = 0,015), respectivement. L’obésité était un facteur prédictif négatif avec un OR de 0,48 (0,29–0,79 ; p = 0,004). En considérant les lésions coronaires à haut risque (score de risque myocardique ≥ 8), seuls le diabète et l’hypertension étaient des facteurs prédictifs indépendants de sévérité.
Conclusion
Le diabète est apparu comme le facteur de risque modifiable le plus fortement lié aux lésions pluritronculaires chez les sujets afro-caribéens alors que l’obésité était un facteur protecteur indépendant. La connaissance des mécanismes sous-jacents à ces associations revêt un intérêt majeur pour la prévention des coronaropathies.
Background
Among cardiovascular diseases, coronary artery disease (CAD) is one of the leading causes of mortality and morbidity. The association between conventional risk factors (such as advanced age, male sex, family history of CAD, hypertension, dyslipidaemia, diabetes, smoking and obesity) and the presence of CAD and adverse clinical events is universal and well established . However, the correlation between these risk factors and the severity of coronary atherosclerosis, assessed by angiography, is less consistent, with studies reporting conflicting results . Several studies have also suggested that the distribution and relative effects of risk factors, as well as disease presentation and prognosis, may differ across ethnic groups .
The Guadeloupian population comprises about 80% Afro-Caribbeans, 10% Indians, 5% Caucasians and 5% other ethnic groups. Cardiovascular diseases are responsible for one third of all deaths in Guadeloupe, where a high prevalence of cardiovascular risk factors (CRFs) has been described in the population, including hypertension, diabetes and obesity . However, very few data are available about the distribution of CRFs in patients with CAD in this population, and their impact on the severity of the disease has never been evaluated.
Therefore, the aims of our study were to investigate the prevalence of CRFs in Afro-Caribbean patients with documented CAD, and to determine which of these factors are associated with the extent of atherosclerosis, assessed by coronary angiography.
Methods
Study population
We reviewed the medical records of 543 consecutive Afro-Caribbean patients who had undergone coronary angiography for suspected CAD between January 2009 and May 2012 at the University Hospital of Pointe-à-Pitre. The medical records were standardized and were in the form of a detailed questionnaire on risk factors that makes it possible to distinguish missing data from absence of a given factor. The same paper form was used for all patients. Based on the coronary angiography results, 81 patients with normal coronarography were excluded, as were 42 patients with incomplete data on major CRFs.
Area of investigation
Guadeloupe is a 1628 km 2 island situated in the eastern Caribbean; it is a French overseas department of approximately 402,000 inhabitants, with wide availability of health services and easy access to hospital. The University Hospital of Pointe-à-Pitre is the only coronarography centre on the island.
Sociodemographic and clinical data, including age, sex, weight, height, history of hypertension, diabetes, dyslipidaemia, current smoking status, previous cardiovascular disease and family history of early atherosclerotic CAD, were collected. Body mass index (BMI) was calculated as weight/height 2 (kg/m 2 ). Obesity was defined as BMI ≥30 kg/m 2 .
Afro-Caribbean ethnic origin was determined when the patient defined him/herself and his/her first-degree relative as Afro-Caribbean. The final study population consisted of 420 patients.
Coronary angiography
Selective coronary angiographies were performed with the Judkins technique, using a femoral or radial approach. At least four positions on the left coronary artery and two positions on the right coronary artery were considered.
Significant vessel disease was defined as ≥50% narrowing of the diameter of at least one major (≥2.5 mm diameter) epicardial vessel. The vessel diameter and degree of lumen narrowing were calculated by quantitative coronary angiography. All images were calibrated to the lumen of a guide catheter (5–6 F). CAD severity was measured as: the presence of multiple (two or three) diseased vessels; or one diseased vessel or insignificant stenosis. For a more precise measure of the lesion burden and its potential functional and prognostic impacts, we used the myocardial jeopardy (MJ) score system described by Dash et al., which is a validated tool with which to estimate the amount of myocardium at ischaemic risk . For this score, the coronary arterial circulation is considered to involve six-vessel segments: left anterior descending artery, diagonal branches, septal branches, circumflex coronary artery, obtuse marginal branches and posterior descending artery. Each vessel involved directly or indirectly in a lesion (>70% diameter narrowing) proximal to its origin is assigned 2 points. Thus, in our study population, this score ranged from 0 to 12, based on the number of segments involved. Patients with a previous coronary artery bypass were excluded from the evaluation of the MJ score because this method has not been validated in these patients.
Statistical analysis
Quantitative data are presented as means ± standard deviations and qualitative data as numbers (percentages). For comparisons, the patients were categorized into two groups according to the presence of none or one diseased vessels or multiple (two or three) diseased vessels.
The distributions of the data were tested for normality to determine the use of parametric or non-parametric tests. For univariate analyses, differences in the means were detected using Student’s or the Wilcoxon test, as appropriate, and differences in proportions with the χ 2 test.
We used logistic regression analysis to study the associations between CRFs and the severity of CAD as the dependent variable. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The risk factors studied were age, sex, obesity, hypertension, diabetes, dyslipidaemia, family cardiovascular history and personal cardiovascular history. Adjustments were made by age and all the significant covariates at the level of P < 0.2 in the univariate analysis. A multiple logistic regression was also performed for high MJ scores (defined as a score value higher than the 75th percentile).
IBM SPSS Statistics software, version 19, was used for the data analysis. All tests were two-sided and a P -value <0.05 was deemed to be statistically significant.
Results
In all, 420 patients were included in the study. These patients, who had undergone pathological coronarography, were mainly men (67.8%) and had a mean age of 64.7 ± 12.4 years. The characteristics of the patients are presented in Table 1 .
| All ( n = 420) | Two- or three-vessel disease | Multivariable logistic regression | |||||
|---|---|---|---|---|---|---|---|
| Yes ( n = 222) | No ( n = 198) | P | Odds ratio | 95 % CI | P | ||
| Age (years) | 64.7 ± 12.4 | 65.2 ± 12.0 | 64.2 ± 12.8 | 0.42 | – | – | – |
| Male sex | 284 (67.8) | 159 (71.6) | 125 (63.1) | 0.07 | 1.61 | (1.02–2.55) | 0.043 |
| Obesity | 89 (21.5) | 35 (15.8) | 54 (28.0) | 0.003 | 0.48 | (0.29–0.79) | 0.004 |
| Hypertension | 318 (75.9) | 169 (76.1) | 149 (75.6) | 0.90 | – | – | – |
| Diabetes | 200 (47.8) | 116 (52.5) | 84 (42.6) | 0.04 | 1.53 | (1.01–2.33) | 0.048 |
| Dyslipidaemia | 158 (37.8) | 84 (38.0) | 74 (37.6) | 0.93 | – | – | – |
| Smoking | 52 (14.2) | 28 (14.2) | 24 (14.3) | 0.98 | – | – | – |
| Personal cardiovascular history | 170 (40.5) | 104 (46.8) | 66 (33.3) | 0.005 | 1.68 | (1.11–2.56) | 0.015 |
| Family cardiovascular history | 35 (8.5) | 16 (7.3) | 19 (9.8) | 0.37 | – | – | – |
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