|Year : 2018 | Volume
| Issue : 4 | Page : 310-315
Prevalence of metabolic syndrome in angiographically confirmed coronary artery disease
Alan Mobarek Mahmood1, Mousa Haji Ahmed1, Jamal Bashir Mohammad2
1 Cardiac Center, Azadi Teaching Hospital, Duhok, Kurdistan, Iraq
2 Department of Internal Medicine, College of Medicine, University of Duhok, Duhok, Kurdistan, Iraq
|Date of Web Publication||20-Dec-2018|
Alan Mobarek Mahmood
Azadi Teaching Hospital, Duhok, Kurdistan
Source of Support: None, Conflict of Interest: None
Background: Coronary artery disease (CAD) is one of the most common causes of death in the developed world with the high prevalence of cardiac risk factors and associated morbidity. These risk factors were mostly contributed in the metabolic syndrome. Objective: The study aimed to determine the prevalence of metabolic syndrome among patients with angiographically documented CAD and its relation with the severity of CAD. Materials and Methods: In the current cross-sectional study, a total of 320 patients aged 18 years and older of both genders and diagnosed with CAD by medical and clinical examinations and angiography findings were included in the study. Patients with normal angiographic or nonsignificant coronary stenosis and those with acute coronary syndrome were excluded from the study. Results: The prevalence of metabolic syndrome in patients diagnosed with CADs was 68.4% in this study. The numbers and severity of coronary arteries involved were importantly increased through increasing the numbers of the components of the metabolic syndrome that the patient have it. The majority of the patients with right coronary artery (67.6%), circumflex artery (63.2%), left anterior descending (66.7%), and multivessel (69.8%) had metabolic syndrome with no significant difference (P = 0.913). Moreover, the most of the patients with one vessel (66.4%), two vessels (68.2%), three vessels (72.2%), and four vessels (66.7%) were metabolic syndrome (P = 0.846). Between the individual components, diabetes mellitus (DM) was the most significant risk factor accounts for the number and severity of the CAD in all CAD patients. Conclusions: The prevalence of metabolic syndrome is high among patients with angiographically documented CAD. Patients having metabolic syndrome have more severe and more complex CAD.
Keywords: Comorbidity, coronary artery disease, metabolic syndrome
|How to cite this article:|
Mahmood AM, Ahmed MH, Mohammad JB. Prevalence of metabolic syndrome in angiographically confirmed coronary artery disease. Med J Babylon 2018;15:310-5
|How to cite this URL:|
Mahmood AM, Ahmed MH, Mohammad JB. Prevalence of metabolic syndrome in angiographically confirmed coronary artery disease. Med J Babylon [serial online] 2018 [cited 2019 Mar 23];15:310-5. Available from: http://www.medjbabylon.org/text.asp?2018/15/4/310/248034
| Introduction|| |
The metabolic syndrome (syndrome X, insulin resistance syndrome) consists of a constellation of metabolic abnormalities that confer increased risk of cardiovascular disease (CVD) and diabetes mellitus (DM). The term “metabolic syndrome” was first used in the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) to describe the co-occurrence of obesity, dyslipidemia, hypertension (HT), and abnormal glucose metabolism (Expert Panel on Detection and Treatment of High Blood Cholesterol in 2001).
However, the association of metabolic disorders and cardiovascular risk factors had been recognized for many decades., In his American Diabetes Association Banting lecture in 1988, Reaven used the term “syndrome X” to describe the relationship of insulin resistance, HT, type 2 diabetes (T2D), and CVDs. Other investigators have referred to the clustering of metabolic and cardiovascular risk factors as the “insulin resistance syndrome.”
Coronary artery disease (CAD) is one of the most common causes of death in the developed world, the high prevalence of cardiac risk factors and associated morbidity have been reported in Iraqi adult population, these risk factors were mostly contributed in the metabolic syndrome, and it became a growing health problem in Iraq due to alteration in lifestyle, low physical activity, the epidemic of obesity and insulin resistance. Although in Iraq, little studies were found to identify the prevalence of the metabolic syndrome in patients having CAD, and the majority of them accomplished among inpatients presenting with ACS before attending angiography catheterization, meanwhile they were an unconfirmed CAD.
Worldwide the prevalence of metabolic syndrome varies in part reflecting the age, ethnicity of their population and the diagnostic criteria applied, in general increases with age. The highest recorded prevalence was among native Americans 60% of women and 45% in men ages 45–59 years meeting criteria of the NCEP ATP III were as in the US, is less common in African–American men and more in Mexico–American woman based on data from the National Health and Nutrition Examination Survey 2003–2006. In France, studies of a cohort of 30–60 years have shown <10% prevalence for each sex although 17.5% of people 60–64 years of age were affected.
In a recent 2016 Iranian study among 200 CAD patients, the prevalence of metabolic syndrome was 49.5% women and 40% men, In Turkey reported a prevalence of 33.9%, The population for this analysis were 2108 men and 2151 women., In Tunisia, metabolic syndrome prevalence was 45.5% based on the IDF criteria and 24.3% according to the (ATP III) definition which included 3435 adults. In Palestinians, in East Jerusalem, metabolic syndrome was found in 115 (33.6). In Northern Jordan, the prevalence of metabolic syndrome was 36.3%.
The aim of this study was to determine the prevalence of metabolic syndrome among patients with angiographically documented CAD and its relation with the severity of CAD.
| Materials and Methods|| |
The cross-sectional prospective study enrolled all patients whom underwent elective coronary angiography in Azadi Heart Center/Duhok, Iraq, between September 2017 and May 2018.
The patient's ages were between 18 years and older of both genders, diagnosed with CAD by medical and clinical examinations and angiography findings. Patients with normal angiographic or nonsignificant coronary stenosis and those with acute coronary syndrome were excluded from the study.
Metabolic syndrome was diagnosed according to the ATP III criteria, including three or more of the following metabolic abnormalities: abdominal obesity (waist circumference [WC] >102 cm in men and >88 cm in women), high blood pressure (≥130 mmHg systolic or ≥85 mmHg diastolic), hypertriglyceridemia (>150 mg/dl, 1.7 mmol/L), low high density lipoprotein cholesterol (HDL-C) (<40 mg/dl, 1.03 mmol/L) in men and (<50 mg/dl, 1.29 mmol/L) in women, high fasting glucose (fasting serum glucose (>110 mg/dl).
Diagnosis of patients with CAD was based on the result of coronary angiography, in which >50% stenosis regarded as significant vessel disease (VD), while those below this rate had been excluded from this study.,,
The descriptive purposes of the study, including the prevalence of metabolic syndrome in CAD patients were determined in frequency and percentage. The continuous normally distributed characteristics of patients were determined in mean and standard deviation (SD). The difference of metabolic syndrome among angiography findings was examined in Chi-squared and Fishers' exact test. The predictors of angiography findings were examined in univariant analysis of variance. The null hypothesis was rejected in P < 0.05. The statistical calculations were performed using Statistical Package for the Social Sciences version 24 (SPSS, IBM Company, Chicago, USA).
| Results|| |
The demographic and clinical characteristics of the 320 CAD patients (180 males and 140 females; aged 32–85 years, the mean age 57.74, SD: 9.96) with and without metabolic syndrome are presented in [Table 1]; of these, 68.4% had metabolic syndrome; (56.3% males vs. 52.1% females) (P < 0.05).
|Table 1: Prevalence of metabolic syndrome in coronary artery disease patients|
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The majority of patients had abnormal high density lipid cholestetol (HDL-C), Triglyceride (TG), Waist circumference (WC), and were known diabetes mellitus DM or impaird fasting blood sugars (FBS ) and hypertension (HT). For HDL.C (81.7% males and 73.6% females), for TG; (78.50%), WC; (77.9% females and 49.4 males), HT; (56.3% males and 43.8% females) while DM; 52% [Table 1].
Again the mean and percentages of WC, BMI, BP, FBS, TG, and low-density lipoprotein cholesterol (P < 0.0001) in CAD patients with metabolic Syndrome were significantly higher, and HDL-C levels (P < 0.0001) were significantly lower than in those without Metabolic Syndrome. Low serum HDL (36.28 ± 7.76 vs. 47.23 ± 9.64, P < 0.001), high serum TG (227.89 ± 71.57 vs. 140.22 ± 56.36, P < 0.0001), HT; 187 (85.8%) versus 25 (24.8%), P (<0.0001), DM; 153 (70.2%) versus 15 (14.9%), P (<0.0001), and they were the most significant risk factors for CAD in metabolic patients versus nonmetabolic ones [Table 2] and [Figure 1].
|Table 2: Baseline characteristics of metaboli and nonmetabolic patients (n=320)|
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|Figure 1: Prevalence of individual components of metabolic syndrome. *Gender represents males 1|
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The majority of the patients with right coronary artery (RCA) (67.6%), circumflex artery (CX) (63.2%), left anterior descending (LAD) (66.7%), and multivessel (69.8%) had metabolic syndrome with no significant difference (P = 0.913). Moreover, the most of the patients with 1 vessel (66.4%), two vessels (68.2%), three vessels (72.2%), and four vessels (66.7%) were metabolic syndrome (P = 0.846) [Table 3] and [Figure 2].
|Figure 2: Prevalence of metabolic syndrome in angiography findings (vessel number)|
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The numbers and severity of coronary arteries involved were importantly increased through increasing the numbers of the components of the metabolic syndrome that the patient have it [Table 4], although not reaching the significant values, here the individual components such as obesity, HT, DM, dyslipidemias, smoking, and family history played there role in the pathogenicity of the nonmetabolic categorized CAD patients.
|Table 4: Severity of coronary artery disease according to components of metabolic syndrome|
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Between the individual components, DM was the most significant risk factor accounts for the number and severity of the CAD in all CAD patients as follow: 2VD; (63 [37.5%] vs. 44 [29.1%], 3VD; (48 [28.6%] vs. 31 [20.5%]), (P = 0.045), multi-VD (MVD); (114 [67.9%] vs. 78 [51.7%]), (P = 0.029) as compression between diabetic and nondiabetic patients, respectively [Table 4], [Table 5], [Table 6].
| Discussion|| |
In this study, the prevalence of metabolic syndrome in angiographically confirmed CAD patients was 68.4% which is similar to studies in other regions of the world like in study by Achari et al., in which prevalence was 64.2% in Indian population, while in Iranian adults the prevalence of metabolic syndrome among CAD patients was 49.5%. Furthermore, in Pakistani patients, the prevalence was much more less 37%.
Hence, the prevalence of Met S varies widely, depending on the type of study (hospital-based vs. population-based study), baseline characteristics of the study population (e.g., ethnicity, age, and history of ACS) and criteria used to define Met S. Furthermore, these differences could be due to lifestyle-related factors such as unhealthy food habits, urbanization, economic growth, physical inactivity and increased stress, high percentage of body fat, and abdominal obesity.
The individual components of the metabolic syndrome whether alone or in combination with risk factors have variable effects on CAD risk with some of them having the highest risk for CAD, however, each component acts as an independent risk factor for CAD, but all of them interact synergistically, and thus lead to increased risk of CAD.
The prevalence of metabolic syndrome and its individual components with various rates in CAD patients has been reported in earlier studies, the abdominal obesity, dyslipidemia, HT, and hyperglycemia most often were reported as the metabolic syndrome components, and the severity of CAD increased with the number of components.,,,
In Shanghai, a study performed and showed that among individual components of metabolic syndrome, low HDL, high FBG, and high BP had the highest OR for coronary heart disease, these three parameters had significant increases in number of disease vessel.
In Korean population, a study showed that metabolic syndrome was independently linked to coronary parameters including obstructive plaque and coronary artery calcium score in the nondiabetic CAD patients, low HDL-C levels were markedly associated with CAD among the individual components of metabolic syndrome in these patients.,
However, there were no exact prevalence of metabolic syndrome in Iraq and or Kurdistan region, have been done before, and exactly in angiographic profile CAD patients, our results were near the results done in the Middle East countries.,
Unfortunately, in our study, the premature CAD was obvious in which the mean age were (57.77 ± 9.23) and (57.70 ± 11.44) for metabolic and nonmetabolic patients respectively, and the females were older than males by (4 years) [Table 2].
Concerning the gender, in our study, the prevalence of metabolic syndrome in female patients who present with CAD was higher when compared with overall cohort studies,,, had shown a higher prevalence of metabolic syndrome in female presenting with ACS.
Among the individual components of metabolic syndrome, nearly all components, DM, HT. hypertriglyceridemia (TG), and HDL-C, central obesity (WC), were significantly abnormal (P < 0.0001), as compared with nonmetabolic syndrome patients.
Females were more diabetic, hypertensive, obese, hypertriglyceridemia, less or passive smokers, and older. While males were more smokers, thinner, and younger in ages due to cultural habits.
Nonmetabolic patients were mostly males, more smokers, and mostly were diabetic, hypertensive, and had low (HDL-C), and had a family history of CAD.
Regarding the association of high-level glucose, some studies have shown markedly associated with CAD. A study reported that the prevalence of CHD in diabetic patients with metabolic syndrome was significantly higher than in those without metabolic syndrome.
The severity, the pattern of the lesion and characteristics type of coronary vessel involved in both metabolic and nonmetabolic syndrome patients, were studied, and it revealed that MVD; (2VD), (3VD), were more prevalent in metabolic syndrome group than those without metabolic syndrome (57.4% vs. 42.6%).
Similar observations had been reported by other studies. Kip et al. reported statistically significant prevalence of severe CAD in patients with Met S (47% as compared to 25% in patients without Met S). Yavuz et al. reported significantly higher number of patients with Met S having severe CAD as compared to patients without Met S (91% vs. 62%) in a multicenter study also reported significantly higher prevalence of severe CAD in European American and African American patients having Met S as compared to patients without Met S (71% and 57% vs. 29% and 43%).
LAD artery was mostly diseased followed by (RCA) and (CX) nearly equally in both groups. Complex coronary lesions (diffuse and tubular) were more in metabolic syndrome group as compared to simple (discrete) lesions in nonmetabolic syndrome group. Our angiography findings were in accordance with observations.,
| Conclusions|| |
The prevalence of metabolic syndrome is high among patients with angiographically documented CAD. Patients having metabolic syndrome have more severe and more complex CAD.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.
Albrink MJ, Krauss RM, Lindgrem FT, von der Groeben J, Pan S, Wood PD. Intercorrelations among plasma high density lipoprotein, obesity and triglycerides in a normal population. Lipids 1980;15:668-76.
Sarafidis PA, Nilsson PM. The metabolic syndrome: A glance at its history. J Hypertens 2006;24:621-6.
Reaven GM. Banting lecture 1988. Role of insulin resistance in human disease. Diabetes 1988;37:1595-607.
DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care 1991;14:173-94.
Fiuza M. Metabolic syndrome and coronary artery disease. Rev Port Cardiol 2012;31:779-82.
Al-Rubaye FG. Frequency of metabolic syndrome in a sample of adult diabetics in Baghdad. Iraqi J Community Med 2011;24:12-6.
Malani PN. Harrison's principles of internal medicine. JAMA 2013;308:1813-4.
Sanisoglu SY, Oktenli C, Hasimi A, Yokusoglu M, Ugurlu M. Prevalence of metabolic syndrome-related disorders in a large adult population in Turkey. BMC Public Health 2006;6:92.
Kozan O, Oguz A, Abaci A, Erol C, Ongen Z, Temizhan A, et al.
Prevalence of the Metabolic syndrome among Turkish adults. Eur J Clin Nutr 2007;61:548-53.
Bouguerra R, Alberti H, Smida H, Salem LB, Rayana CB, El Atti J, et al.
Waist circumference cut-off points for identification of abdominal obesity among the Tunisian adult population. Diabetes Obes Metab 2007;9:859-68.
Abu Sham'a RA, Darwazah AK, Kufri FH, Yassin IH, Torok NI. MetS and cardiovascular risk factors among palestinians of East Jerusalem. East Mediterr Health J 2009;15:1464-73.
Khader Y, Bateiha A, El-Khateeb M, Al-Shaikh A, Ajlouni K. High prevalence of the Metabolic syndrome among Northern Jordanians. J Diabetes Complications 2007;21:214-9.
Miller JM, Dewey M, Vavere AL, Rochitte CE, Niinuma H, Arbab-Zadeh A, et al.
Coronary CT angiography using 64 detector rows: Methods and design of the multi-centre trial CORE-64. Eur Radiol 2009;19:816-28.
Cury RC, Ferencik M, Achenbach S, Pomerantsev E, Nieman K, Moselewski F, et al.
Accuracy of 16-slice multi-detector CT to quantify the degree of coronary artery stenosis: Assessment of cross-sectional and longitudinal vessel reconstructions. Eur J Radiol 2006;57:345-50.
Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, Budoff MJ, et al.
SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr 2009;3:122-36.
Achari V, Thakur A, Sinha AK. The metabolic syndrome – Its prevalence and association with coronary artery disease in type 2 diabetes. J Indian Acad Clin Med 2006;7:32-8.
Montazerifar F, Bolouri A, Mahmoudi Mozaffar M, Karajibani M. The prevalence of metabolic syndrome in coronary artery disease patients. Cardiol Res 2016;7:202-8.
Wierzbicki AS, Nishtar S, Lumb PJ, Lambert-Hammill M, Turner CN, Crook MA, et al.
Metabolic syndrome and risk of coronary heart disease in a Pakistani cohort. Heart 2005;91:1003-7.
Lopes NH, Paulitsch FS, Pereira AC, Góis AF, Gagliardi A, Garzillo CL, et al.
Impact of Metabolic syndrome on the outcome of patients with stable coronary artery disease: 2-year follow-up of the MASS II study. Coron Artery Dis 2008;19:383-8.
Amarasinghe S, Sandrasegarampillai B, Arasaratnam V. Metabolic syndrome among Jaffna Tamil community, Sri Lanka. Indian J Endocrinol Metab 2015;19:663-6.
Hajian-Tilaki K. Metabolic syndrome and its associated risk factors in Iranian adults: A systematic review. Caspian J Intern Med 2015;6:51-61.
Moussouami SI, Bouhika EJ, Nsompi F, Kayilou JM, Mbemba F, Massamba A. Prevalence and risk factors of cardiovascular diseases in the Congo-Brazzaville Pygmies. World J Cardiovasc Dis 2016;6:211.
Zhang Y, Hong J, Gu W, Gui M, Chen Y, Zhang Y, et al.
Impact of the Metabolic syndrome and its individual components on risk and severity of coronary heart disease. Endocrine 2009;36:233-8.
Won KB, Chang HJ, Kim HC, Jeon K, Lee H, Shin S, et al.
Differential impact of metabolic syndrome on subclinical atherosclerosis according to the presence of diabetes. Cardiovasc Diabetol 2013;12:41.
Won KB, Chang HJ, Sung J, Shin S, Cho IJ, Shim CY, et al.
Differential association between metabolic syndrome and coronary artery disease evaluated with cardiac computed tomography according to the presence of diabetes in a symptomatic Korean population. BMC Cardiovasc Disord 2014;14:105.
Agoşton-Coldea L, Mocan T, Rusu LD, Pais R, Albu A, Rusu ML, et al.
The impact of the metabolic syndrome on the patients with acute coronary syndrome. Rom J Intern Med 2008;46:55-62.
Al Suwaidi J, Zubaid M, El-Menyar AA, Singh R, Rashed W, Ridha M, et al.
Prevalence of the metabolic syndrome in patients with acute coronary syndrome in six middle Eastern countries. J Clin Hypertens (Greenwich) 2010;12:890-9.
Gupta A, Gupta R, Sarna M, Rastogi S, Gupta VP, Kothari K. Prevalence of diabetes, impaired fasting glucose and insulin resistance syndrome in an Urban Indian population. Diabetes Res Clin Pract 2003;61:69-76.
Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Metabolic syndrome in Urban Asian Indian adults – A population study using modified ATP III criteria. Diabetes Res Clin Pract 2003;60:199-204.
Alexander CM, Landsman PB, Teutsch SM, Haffner SM; Third National Health and Nutrition Examination Survey (NHANES III); National Cholesterol Education Program (NCEP). NCEP-defined Metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years and older. Diabetes 2003;52:1210-4.
Kip KE, Marroquin OC, Kelley DE, Johnson BD, Kelsey SF, Shaw LJ, et al.
Clinical importance of obesity versus the metabolic syndrome in cardiovascular risk in women: A Report from the Women's Ischemia syndrome Evaluation (WISE) study. Circulation 2004;109:706-13.
Yavuz B, Kabakci G, Aksoy H, Tulumen E, Deveci OS, Aytemir K, et al.
Determining the relationship between metabolic syndrome score and angiographic severity of coronary artery disease. Int J Clin Pract 2008;62:717-22.
Anuurad E, Chiem A, Pearson TA, Berglund L. Metabolic syndrome components in African-Americans and European-American patients and its relation to coronary artery disease. Am J Cardiol 2007;100:830-4.
Henry P, Makowski S, Richard P, Beverelli F, Casanova S, Louali A, et al.
Increased incidence of moderate stenosis among patients with diabetes: Substrate for myocardial infarction? Am Heart J 1997;134:1037-43.
Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-30.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]