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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 76-83

Prevalence of Coronary Artery Disease in Rheumatic Heart Disease and Comparison of Demographic and Coronary Artery Disease Profile with Atherosclerotic Coronary Artery Disease


1 Department of Cardiology, S.P. Medical College and Hospital, Bikaner, Rajasthan, India
2 Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Web Publication12-Sep-2016

Correspondence Address:
Dinesh Choudhary
Department of Cardiology, S.P Medical College and Hospital, Bikaner, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-8568.190322

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  Abstract 

Aim: In India, coronary angiography (CAG) is usually performed in rheumatic heart disease (RHD) patients before valve replacement surgery if there is any suspicion of coronary artery disease (CAD) or the patient is aged >40 years. The aims of the present study were (1) to find the prevalence of CAD, CAD patterns and its association with various CAD risk factors in RHD patients and (2) to study the association of inflammation seen in RHD with prevalence of CAD. Materials and Methods: The records of 1204 RHD patients who underwent CAG before surgery from 2001 to 2010 were evaluated. Patients of RHD with significant CAD (≥50% stenosis) were compared with age- and sex-matched patients of RHD with no CAD and atherosclerotic CAD patients. All RHD patients with embolic acute coronary artery syndrome were excluded from the study. Results: One-hundred and nine (9.05%) RHD patients had significant CAD (males 65.1% and females 34.9%). The mean age was 52.8 ± 8.6 years (52.3 ± 8.9 years for males and 53.6 ± 8 years for females). Involvement of mitral valve was seen in 66.1%, aortic valve in 7.3% and both valves in 26.6% in these patients. Single-vessel disease, double-vessel disease or triple-vessel disease was present in 58.7%, 27.5% and 13.8%, respectively. Left main coronary artery was involved in 4.6% of the cases. Left anterior descending (LAD) was the most common vessel involved (68.9%), followed by right coronary artery (44.1%) and left circumflex artery (42.3%). Univariate analysis showed that polymorphonuclear leucocyte count was significantly higher (P = 0.037; odds ratio: 1.03 with 95% confidence interval: 1.001–1.056) in RHD CAD patients than the atherosclerotic CAD patients. Conclusion: The prevalence of CAD in patients with RHD is similar to other Indian studies but lower than the Western countries. Single-vessel involvement, mostly LAD, is more common among these patients. CAD risk factor is less common than the atherosclerotic patients. CAD in these patients may be attributed to the inflammatory state seen with RHD.

Keywords: Coronary artery disease, rheumatic heart disease, risk factors


How to cite this article:
Choudhary D, Chaurasia AK, Rohan V A, Arulkumar A, Kumar S M, Harikrishnan S, Sanjay G, Ajithkumar V K, Titus T, Tharakan J A. Prevalence of Coronary Artery Disease in Rheumatic Heart Disease and Comparison of Demographic and Coronary Artery Disease Profile with Atherosclerotic Coronary Artery Disease. Adv Hum Biol 2016;6:76-83

How to cite this URL:
Choudhary D, Chaurasia AK, Rohan V A, Arulkumar A, Kumar S M, Harikrishnan S, Sanjay G, Ajithkumar V K, Titus T, Tharakan J A. Prevalence of Coronary Artery Disease in Rheumatic Heart Disease and Comparison of Demographic and Coronary Artery Disease Profile with Atherosclerotic Coronary Artery Disease. Adv Hum Biol [serial online] 2016 [cited 2019 Jul 22];6:76-83. Available from: http://www.aihbonline.com/text.asp?2016/6/2/76/190322


  Introduction Top


Rheumatic heart disease (RHD) is a major health burden in India. Around 25%–30% of all cardiac visits to hospitals are related to RHD.[1] The incidence is 0.7–4.5/100 children with even higher prevalence among young children.[1],[2],[3] There is minimal prevalence of RHD in patients with myocardial infarction (MI) in both clinical and autopsy studies.[4],[5],[6] In few studies, frequent association of RHD was seen with the occurrence of coronary artery disease (CAD) with poor prognosis.[7],[8],[9] Hence, coronary angiogram is usually performed if there is suspicion of CAD or compulsory if it is performed after a certain age before valvular heart surgeries. The American College of Cardiology/the American Heart Association recommends routine pre-operative coronary angiography (CAG) in patients with valvular heart disease before valve surgery in men aged ≥35 years, in pre-menopausal women aged ≥35 years who have coronary risk factors and in post-menopausal women.[10] In India, CAG is usually performed routinely in RHD patients before valve replacement surgery if there is any suspicion of CAD or the patient is aged >40 years. Many studies have been done to observe the prevalence of CAD in various countries, association of the risk factors with CAD in RHD patients, whether CAG is needed before valve surgery, if yes, at what age (?).[7],[8],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] There are no large studies to see the association of inflammation (found in RHD) in causation of CAD in RHD patients. The present study has tried to find this association along with the prevalence of CAD in RHD patients and comparison of demographic and CAD risk factor profile of RHD patients with CAD in non-RHD patients.


  Materials and Methods Top


The study population included South Indian patients with RHD who underwent CAG before scheduled valve surgery. The study involved a retrospective–prospective analysis of records of 1204 patients of RHD who underwent CAG before valve surgery between January 2001 and December 2010. Among them who had significant CAD (stenosis ≥50%) (Group A) were compared with similar number of age- and sex-matched patients of RHD without CAD (Group B) and CAD in non-RHD patients (Group C) selected randomly in the same period. All RHD patients with embolic acute coronary syndrome (who had previous history of thromboembolism and left atrial thrombus, recanalised coronaries) were excluded. Patients having other inflammatory disorders such as COPD, connective tissue disorders, active infection or fever were excluded. All patients with associated congenital heart disease, constrictive pericarditis, ischaemic mitral regurgitation, bicuspid aortic valve and degenerative aortic valve disease were excluded from the study.

CAG was performed via a femoral or radial approach. The degree of coronary artery stenosis was estimated visually as the obstructed proportion of each vessel, expressed as a percentage of the vessel diameter. The indicators of atherosclerosis included the presence or absence of any clinically significant CAD, defined as a ≥50% stenosis (by quantitative CAG) of any coronary artery or any major vessel of ≥1.5 mm in diameter. Multivessel disease was defined as the presence of clinically significant stenosis in two or more vessels.

Hypertension (HTN) was defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or self-reported use of antihypertensive medications. Diabetes mellitus (DM) was diagnosed by the self-reported use of antidiabetic drugs by patients or defined according to the American Diabetic Association guidelines as follows: (1) Symptoms of DM plus random blood glucose concentration ≥11.1 mmol/L (200 mg/dL) or (2) fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) or (3) 2 h plasma glucose ≥11.1 mmol/L (200 mg/dL) during an oral glucose tolerance test. Dyslipidaemia was defined as total cholesterol ≥200 mg/dl, low-density lipoprotein (LDL) cholesterol level ≥100 mg/dl or high-density lipoprotein (HDL) cholesterol <40 mg/dl in males and <50 mg/dl in females or triglyceride (TG) level ≥150 mg/dl.

The current smoking habit was considered a conventional risk factor of CAD. Body mass index (BMI) was calculated as weight (kg) divided by height square (m 2).

Statistical analysis

Statistical analysis was performed using SPSS 14 software (SPSS Inc., Chicago, Illinois, USA). Categorical data were analysed using Chi-square or Fisher's exact test. Continuous data were analysed by t-tester ANOVA/F-tests and presented as mean ± standard deviation. Univariate analysis was performed to find out the predictors of the CAD in RHD patients. P < 0.05 was considered statistically significant.


  Results Top


Group A, Group B and Group C in tables are shown for RHD with CAD, RHD with no CAD and CAD in non-RHD patients, respectively.

The prevalence of CAD in RHD patients who underwent CAG before surgery was 9.01% (109/1204). Males were 65.1% and females were 34.9% in RHD with CAD group as shown in [Table 1]. The mean age of the patients was 52.8 ± 8.6 years overall: 52.3 ± 8.9 years for males and 53.6 ± 8 years for the females as shown in [Table 2]. These patients were compared for age- and sex-matched patients of RHD with no CAD group and patients with CAD without RHD group.
Table 1: Number (%) of male and females in rheumatic heart disease with coronary artery disease patients

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Table 2: Mean age of rheumatic heart disease with coronary artery disease patients (years±standard deviation)

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As shown in [Table 3], mitral valve was involved in 66.1%, aortic valve in 7.3% cases and both valves in 26.6% cases in Group A while in Group B these were 56.9%, 9.2% and 33.9%, respectively, with no statistically significant differences (P > 0.05). There was no significant difference between the presence of significant aortic stenosis (AS), aortic regurgitation (AR) and mitral stenosis (MS) in both groups but mitral regurgitation was more common in Group B (87.2% vs. 71.6%; P < 0.01).
Table 3: Comparison of dominant valve disease and p-aminohippuric acid in various groups

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[Table 4] shows comparison of various clinical features among the groups. Angina was significantly more in Group C while dyspnoea and palpitation were more common in the RHD patients. Patients were more symptomatically in worse New York Heart Association (NYHA) class (NYHA Heart Failure Classification) in the RHD group in comparison to the CAD in non-RHD patients.
Table 4: Comparison of clinical features in various groups

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[Table 5] shows comparison of risk factors for CAD in various groups. Smoking was significantly more in Group C and Group A in comparison with Group B, but there was no significant difference between Groups A and C. DM, HTN and dyslipidaemia (DLP) were significantly more in Group C than Groups A and B and more in Group A than Group B. There was no significant difference in post-menopausal status in all three groups. BMI was significantly more in Group C than that of Groups A (22.2 ± 3.5) and B (21.3 ± 3.6).
Table 5: The comparison of risk factors based on groups

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[Table 6] shows that values for haemoglobin, total cholesterol, HDL, TGs and LDL were not significantly different among three groups, but polymorphs and creatinine were significantly more in Group A than Group C. Erythrocyte sedimentation rate (ESR) was also high but not significant (22.4 ± 20.7 vs. 19 ± 15.3; P = 0.173). [Table 7] shows percentage of digoxin and statins used in various groups. [Table 8] shows that EF (ejection fraction) was significantly less in Group A than Group C. Atrial fibrillation, non-specific ST-T changes and left ventricular hypertrophy with strain were more common in electrocardiogram (ECG) of RHD patients while normal ECG and ECG suggestive of old MI were more commonly seen in the atherosclerotic patients as shown in [Table 9].
Table 6: The comparison of laboratory investigations in various groups

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Table 7: The comparison of drugs based on groups

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Table 8: Comparison of echocardiography variables based on groups

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Table 9: Comparison of electrocardiogram variables based on groups

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[Table 10] shows that in Group A, single-vessel disease (SVD), double-vessel disease (DVD) and triple-vessel disease (TVD) were seen in 58.7%, 27.5% and 13.8%, respectively, while in Group C patients, it was 29.4%, 35.8% and 34.9%. Left main coronary artery (LMCA) was involved in 4.6% vs. 2.8% in both groups, respectively. In RHD patients, most commonly involved vessel was left anterior descending (LAD) (68.9% overall and 29.4% alone), followed by right coronary artery (RCA) (44.1%) and left circumflex artery (LCx) (42.3%).
Table 10: Comparison of involvement of coronaries in various groups

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[Table 11] and [Table 12] show univariate analysis of different groups based on selected variables for predictors of CAD in RHD patients. Univariate analysis showed that SVD was significantly more in Group A patients (P = 0.00; odds ratio: 5.067 with 95% confidence interval: 2.43–10.55) when referenced to TVD in comparison to Group C patients which had significantly more TVD. Two-vessel disease (P = 0.087) or LMCA involvement (P = 0.65) showed no significant difference between two groups. Diabetes (P = 0.001), HTN (P = 0.001), dyslipidaemia (P = 0.001), family history of CAD (P = 0.002) and BMI (P = 0.01) were significantly less in Group A patients. Smoking rates were also less but not statistically significant (P = 0.29).
Table 11: Result of univariate analysis of rheumatic heart disease with coronary artery disease as compared to rheumatic heart disease no coronary artery disease by selected variables for predictors of coronary artery disease in rheumatic heart disease patients

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Table 12: Result of univariate analysis of rheumatic heart disease with coronary artery disease as compared to non-rheumatic heart disease coronary artery disease patients by selected variables for predictors of coronary artery disease in rheumatic heart disease patients

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[Table 13] shows that risk factors were also significantly less in patients with SVD in RHD group as compared to SVD patients in non-RHD CAD patients group except smoking and post-menopausal status in females (DM, P < 0.01; HTN, P < 0.001; DLP, P < 0.01; family history of CAD, P < 0.01 and smoking, P > 0.05).
Table 13: Comparison of risk factors for single-vessel disease in the groups

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  Discussion Top


The records of 1204 RHD patients who underwent CAG before surgery from 2001 to 2010 were analysed. Patients of RHD with significant CAD (≥50% stenosis: As used in most of the similar studies) were compared for age- and sex-matched patients of RHD with no CAD and atherosclerotic CAD patients. All RHD patients with embolic acute coronary artery syndrome were excluded. One-hundred and nine (9.05%) RHD patients had significant CAD (males 65.1% and females 34.9%: male:female ratio of 1.86). In Western countries, this prevalence ranged from 16% to 50%.[7],[8],[15],[16] Only one study from Spain done by Rangel et al. showed the prevalence of 8%. In South East Asian countries like China, the prevalence was found to be 11%[20] but in Pakistan it was on higher side 31.3% [Table 14].[21] In previous Indian studies, the prevalence found between 7% and 12%.[23],[24],[25]
Table 14: Reported prevalence of coronary artery disease with rheumatic heart disease in South East Asian countries

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The male:female ratio of 1.86:1 matched with other studies which showed ratio between 1.6:1 and 2.6:1.[14],[15],[25] Only one study from China done by Li et al. showed ratio of 3:1.[20] The mean age of RHD patients who had CAD was 52.8 ± 8.6 years (52.3 ± 8.9 for males and 53.6 ± 8 for females). The mean age of CAD in RHD patients was around 55–60 years in Western studies [13],[14],[16] and one study from China [20] but comparable to other Indian studies [23],[24],[25] and a study from Pakistan.[21] Hence, it is fair enough in India to advise CAG in patients of RHD planned for surgery who are above 40 years of age and definitely in patients with age >40 years with coronary risk factors as significant association was seen with CAD risk factors and CAD in the present study.

In the present study, the prevalence was similar to other Indian studies but lower than the Western countries [Table 15]. This may be due to higher age group in the Western countries and partly may be due to the demographic, clinical and environmental characteristics of the different populations such as race, dietary habits and physical activity.
Table 15: Reported prevalence of coronary artery disease with rheumatic heart disease in countries other than South East Asia

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Involvement of mitral valve was seen in 66.1%, aortic valve in 7.3% and both valves in 26.6% in these patients. Shaikh et al.[21] also found that mitral valve involvement was more than the aortic and double valve involvement in RHD patients who underwent CAG before surgery and found to have CAD. This can be explained because of high prevalence of mitral valve disease in RHD patients. Univariate analysis showed a significant inverse association between MR and prevalence of CAD (P = 0.005). Narang et al.[25] showed a significant inverse association between AR and CAD and no significant association with MR and CAD. It can be concluded that regurgitation lesions are probably less commonly associated with CAD in comparison to AS and MS. Strong association of stenotic lesions with CAD has been found in various studies.[15],[25] This may be attributed to more prolonged and ongoing inflammatory process responsible for stenotic lesion leading to microvascular changes and endothelial dysfunction. Less CAD in regurgitation lesions may be due to larger vessels seen in these lesions. However, still, more studies are needed in this aspect.

The presence of angina was significantly more common in Group A than the Group B patients. Other studies [8],[13],[18] also found that the presence of angina is a good predictor of the CAD in RHD patients. SVD, DVD or TVD was present in 58.7%, 27.5% and 13.8%, respectively. SVD was more commonly seen in other studies also.[14],[25] LAD was the most common vessel involved (overall 68.9% and 29.4% in isolated cases), followed by RCA (44.1%) and LCx (42.3%). Rangel et al.[14] also found that LAD was most commonly involved artery, followed by RCA and LCx. Li et al.[20] also found that LAD was the most commonly involved vessel (in 38.12% cases).

Risk factors such as smoking, DM, HTN and DLP were good predictors of the CAD in RHD patients but not the family history of CAD or BMI. This association was seen in the previous studies also.[16],[17],[18],[19],[20],[24] Mean cholesterol, HDL, TGs and LDL levels were not significantly different in CAD and no CAD patients in RHD. It may be due to non-availability of lipid profile for all the patients, and so the comparison may not be reliable.

Univariate analysis showed that polymorphonuclear leucocyte count was significantly higher in Group A than Group C patients. ESR was also higher in these patients but not statistically significant. Univariate analysis showed that SVD was significantly more in Group A patients in comparison to Group C patients which had significantly more TVD. Two-vessel disease or LMCA involvement showed no significant difference between two groups. Diabetes, HTN, dyslipidaemia, family history of CAD and BMI were significantly less in Group A patients. Smoking was also less but not statistically significant (P = 0.29). These risk factors were also significantly less in patients with SVD in Group A as compared to SVD patients in Group C except smoking which was less but not significant. In the present study, the mean age of CAD in RHD patients was 52.8 years which is lower than the mean age of atherosclerotic CAD in India (57.5 years)[26] and in Kerala registry (60.2 years). Hence, concluding the above discussion, CAD in these patients may be partly attributed to the inflammatory state seen with RHD. However, still more studies are required to explain this association.

Study limitation

The main limitations of the study were its retrospective nature and single centre study. To study the association of inflammation with the prevalence of CAD, only polymorphonuclear cell counts and ESR may not be sufficient, as C-reactive protein (CRP) levels are usually not done in CAG before valvular surgery. Lipid profiles were not available for all the patients. Information regarding history of DLP and self-reported use of the lipid-lowering drugs was mainly used for the presence or absence of DLP. Hence, available mean values for different lipids were not reliable and not significant for prediction of CAD in RHD patients.


  Conclusion Top


The prevalence of CAD in patients with RHD is similar to other Indian studies but lower than the prevalence in Western countries. Single-vessel involvement, mostly LAD, is more common among these patients. CAG should be performed in patients >40 years of age who are undergoing for valvular surgery, and it is mandatory in this age group if patients have CAD risk factors.

CAD risk factors are less common in RHD CAD group than the patients in non-RHD CAD group. CAD in these patients may be attributed to the inflammatory state seen with RHD though further studies are required in this regard with well-proven inflammatory markers of CAD such as high-sensitivity CRP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15]



 

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