CLINICAL RESEARCH AND METHODS

Risk factors of clinical types of Acute Coronary Syndrome

Fathi El-Gamal (1)

Raffal Alshaikh (2)
Aseel Murshid (2)
Saleh Zahrani (2)
Shahad Alrashed (2)
Abdullah Alnahdi (2)
Taghreed Alawi (2)
Abdulrahim Aljudaibi (2)

(1) Family Medicine Department, Ibn Sina National College for Health Sciences (ISNC), Jeddah, KSA
(2) ISNC, Jeddah, KSA

Corresponding author:
Prof. Fathi M. El-Gamal, MB ChB, MSc, MD, PhD (UK)
Department of Family Medicine,
Ibn Sina National College. Al Mahjer Street. Jeddah, Kingdom of Saudi Arabia.
Tel: 6356555-6355882 / Fax: 6375344 – P.O. Box 31906 Jeddah 21418
Email: drfathimhelgamal1996@hotmail.com

Received: November 2019; Accepted: December 2019; Published: January 1, 2020.

Citation: Fathi M. El-Gamal et al. Risk factors of clinical types of Acute Coronary Syndrome. World Family Medicine. 2020;
18(1): 156- 162. DOI: 10.5742MEWFM.2020.93740

Abstract
Objective: to explore clinical patterns and risk Key words: Acute Coronary Syndrome, risk factors,
factors of Acute Coronary Syndrome (ACS). Saudi Arabia

Results: A great proportion of the patients with ACS

had an age range of 46 – 59 years (47.3%), and
28.2% were younger than 46 years old. Among the
cases of ACS, S-T elevation myocardial infarction
(STEMI) were 23.7%, non- S-T elevation myocar-
dial infarction (NSTEMI) were 29.5% and unstable
angina (UA) were 46.8%. Chest pain (82.7%), and
shortness of breath (24.7%) were the most common
complaints among patients with ACS. Sweating
was encountered among 9.7% of the patients. Risk
factors for ACS included smoking (OR:8.95;95%
CI:4.022, 19.914, and p < 0.000), and male gender
(OR:0.414;95% CI:0.190, 0.902, and p < 0.026).
STEMI was significantly associated with increased
mean values of Na level (mean 142.1mEq/L), and
young age (mean 48.5 years). NSTEMI was asso-
ciated with increased value of random sugar level
(mean 201.1 mg/dL). UA was associated with in-
creased mean values of systolic and diastolic blood
pressures (means 155, and 94 mmHg respectively)
and increased Uric acid level (6 mg/dL). In agree-
ment with a recent study, the present study didn’t
find hypercholesterolemia as a significant risk factor
for ACS after allowing for possible risk factors.

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of females [27 (14.3%)]; and about one third of the patients

Introduction
with ACS were current smokers [62 (33.3%)]. These
findings were significantly higher among patients with ACS
Cardiovascular Diseases (CVD) are the leading cause
compared to controls (p <0.000). Among patients with
of morbidity and mortality worldwide. (1) Coronary artery
ACS: 32.3% had treatment for diabetes mellitus, 45.2%
disease (CAD) is the most common CVD and accounts
had treatment for hypertension and 15.1% had treatment
for morbidity and mortality of millions all over the world.
for ischemic heart disease. However these differences
Acute coronary syndrome (ACS) represents a major
were not significantly different from those of the control
health problem mainly among middle aged and elderly
group (p > 0.05). Among the cases of ACS, STEMI was
populations, although it also affects younger age groups
23.7%, NSTEMI was 29.5%, and UA was 46.8%. Table
and imposes marked limitations on their life style (2-4).
1 shows that smoking subjects are 9 times more likely to
Urbanization in most of the countries has resulted in
suffer from ACS (OR: 8.95; 95%CI: 4.022, 19.914, and p <
increased obesity and smoking habit, and development of
0.000) compared to non-smoking subjects, after allowing
diabetes mellitus, dyslipidemia, and hypertension, which
for other risk factors. Male subjects are 2.14 times more
provide risk factors for rising occurrence of CAD (5, 6).
likely to suffer from ACS (OR: 0.414; 95%CI: 0.190, .0902,
Saudi Arabia, with the major transformation and adoption
and p < 0.026) compared with females after allowing for
of a western life style, has suffered from increased
other risk factors. Subjects with hypertension are 1.8
prevalence of risk factors for CVD. (6, 7). Among the
times more likely to suffer from ACS (OR: 0.546; 95%CI:
concern of the 2030 vision of Saudi Arabia is to promote
0.296, 1.007, and p < 0.053) compared with normal
the health care systems through scrutinizing risk factors
subjects. Subjects with Diabetes mellitus are 1.726 times
for the main health problems to deliver community based
more likely to suffer from ACS (OR: 1.726; 95%CI: 0.886,
preventive measures and improve access to health care
3.360) compared with normal subjects; however this
systems. Our objectives include identifying the pattern of
difference was not statistically significant (p < 0.108).
clinical presentation, and exploring the risk factors of the
Dyslipidemia was irrelevant to ACS, when other factors
different clinical types of ACS.
were controlled.

Method Table 2 shows that the males were more encountered

among the ACS patients with STEMI or NESTMI, while
A cross sectional study was conducted where the files of the females were more encountered among the ACS
186 patients with ACS admitted to the cardiac wards of two cases with UA (p < 0.05). Smoking habit was more
general hospitals: one in the North of Jeddah city and one in common among the patients with STEMI (47.7%) and
the southern region were reviewed during the period 2017- NSTEMI (43.6%) compared to those with UA(21.8%).
2018. The diagnosis of ACS was based on patient’s history These differences were statistically significant (p<0.05).
of chest pain, physical examination, electrocardiography, Cases with STEMI (43.2%) and with NSTEMI (40.0%) had
radiologic tests, and serial high sensitivity Troponins. ACS treatment for DM significantly more than the patients with
was further categorized into unstable angina (UA), non- UA(21.8%). No significant differences were found between
ST-segment elevation myocardial infarction (NSTEMI), the three groups regarding treatment for hypertension or
and ST-segment elevation myocardial infarction (STEMI) ischemic heart disease (IHD) where p<0.05.
(8). Data regarding the underlying risk factors such as a
positive family history, smoking, hypertension, fasting lipid Table 3 shows that STEMI was significantly associated with
profile for dyslipidemia, liver and kidney profile, random increased mean values of Na level compared to NSTEMI
and fasting glycemic profile and uric acid levels were and UA (142.1mEq/L, 139.11mEq/L, and 140.21mEq/L
obtained. Demographic characteristics, complications respectively). STEMI was significantly associated with
and outcome were also revised. Patients with congenital young age (mean =48.5 years), compared to NSTEMI, and
or valvular heart disease were excluded. A number of UA (54.3, and 52.5 respectively). NSTEMI was associated
195 inpatients at the same hospitals, without current or with increased value of random sugar level (201.1 mg/
past ACS, and who were admitted for causes other than dL), Compared with STEMI and UA, UA was associated
cardiac diseases were employed as controls. with increased mean values of systolic and diastolic
blood pressures (155, and 94 mmHg respectively) and
Statistical analysis: Data was analyzed using SPSS (IBM increased Uric acid level (6 mg/dL), compared to STEMI
P/C version 23). The Multi-nominal Logistic regression and NSTEMI.
was used; Odds ratio and 95% confidence intervals for the
different risk factors were calculated. Level of significance Table 4 shows that chest pain was the most common
for this study was 0.05. complaint among patients with ACS (81.7%) particularly
among those with STEMI (97%). Dyspnea was a
Results presenting complaint in 24.7% of the patients with ACS,
particularly those with UA (29%). Palpitation and headache
The majority of patients with ACS were 46 – 59 years old were complaints among 7.5% of patients with ACS, mainly
(47.3%); 28.2% were younger than 46 years old, while among those with UA (12.6% and 13.8% respectively).
24.2% were older than 59 years. The percentage of males
among ACS patients [159 (85.5%)] was greater than that

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Table 1: Multi-nominal logistic regression of different risk factors and ACS

Table 2: Types of ACS and personal and medical disorders

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Table 3: Analysis of variance for the blood chemistry and age among different types of ACS

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Table 4: Presenting symptoms among patients with different forms of ACS

compared to non-smoking subjects, after allowing for other

Discussion
risk factors. Smoking is regarded as a strong risk factor
for myocardial infarction. Numbers of studies have shown
ACS encircles a wide range of clinical disorders that
a strong positive correlation between atherosclerosis,
are shared by more than one physiologic derangement:
smoking and myocardial infarction. Smoking leads to
an acute or sub-acute imbalance between the oxygen
premature atherosclerosis and cardiac death. One in every
demand and supply of the myocardium. ACS includes UA
5 deaths in the United States each year is due to cigarette
and evolving MI which is usually divided into STEMI and
smoking. Risk is more in women who smoke and who are
NSTEMI. (5). Each year in the United States of America,
taking birth control pills (19-22). Chest pain was the most
approximately 1.36 million hospitalizations are required for
common complaint among patients with ACS (81.7%)
ACS (9). The prevalence of ACS in the Middle East differs
particularly among those with STEMI (97%). Dyspnea
from one country to another. For instance, it was 6% in
was a presenting complaint in 24.7% of the patients with
Saudi Arabia (in 2004), 8.3% in Egypt (in 2001) and 13%
ACS, particularly those with UA (29%). Palpitation and
in Lebanon (in 2008). However, by 2030, this prevalence
headache were complaints among 7.5% of patients with
is expected to rise due to increasing rates of hypertension,
ACS, mainly among those with UA (12.6% and 13.8%
DM, overweight, obesity, physical inactivity, smoking and
respectively). This is in line with other studies (23-26).
dyslipidemia (10) Premature ACS remains a significant
The risk factors for coronary artery disease (CAD) include
cause of morbidity and mortality worldwide. In 2012,
hypercholesterolemia, hypertension, and diabetes mellitus
CAD was the cause of death in 1894 Canadians younger
(DM). (9, 10). In the present study, when multivariate
than 55 years. Further, ACS remains a significant cause
logistic regression was used to allow for different factors,
of lost work productivity, unemployment, and disability in
diabetes mellitus, hypertension and dyslipidemia were not
this young age category (11). In this study, 28.2% were
significant risk factors for ACS.
under the age of 46. This is in line with another study (12).
Several previous reports have revealed the existence of
Ralapanawa et al in 2014 reported 25.7% ACS in Sri lanka
gender differences in terms of presentation of symptoms,
to be STEMI, 36.7% to be NSTEMI, and 37.7% to be UA
validity of diagnostic tests, in-hospital medication, drug side
(23). Hersi et al.in 2007 reported 41.5% ACS in Saudi
effects, clinical outcomes, complications, and management
Arabia to be STEMI, 36.5% to be NSTEMI, and 22.1% to
of ACS(13-16). The percentage of women diagnosed with
be UA (24); while our study in 2018 showed 23.7% of ACS
ACS can range from 33% to 45% (17). This is in line with
to be STEMI, 29.5% to be NSTEMI and 46.8% UA.
findings from the present study where the percentage of
males was 85.5% while that of females was 14.3%; in
Medagama et al, showed no significant difference in age
addition male subjects were 2.14 times more likely to suffer
distribution of patients with all groups of ACS, with the
from ACS compared with females. These sex differences
majority being between 51 and 70 years of age.(25) Sharma
in occurrence of ACS, might be explained by differences
et al showed a higher mean age of 60.07 ± 10.47 years
in anatomic, physiologic, biologic, and psychological
amongst NSTEMI patients compared to 57.76 ± 11.44 years
characteristics among them(14, 18). In the present study
for STEMI patients with no significant statistical difference.
smoking subjects were 9 times more likely to suffer from
(26). Ralapanawa et al, showed a slightly higher mean age
ACS (OR: 8.95; 95%CI: 4.022, 19.914, and p < 0.000)

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for UA (62.2 years) and NSTEMI (61.9 years) compared List of abbreviations

to STEMI (59.2 years) but without a statistical significance ACS: Acute coronary syndrome
(P = 0.246) (22). In line with these findings we found that STEMI: S-T elevation myocardial infarction
mean age for STEMI (48.8 ±9.8 years) was significantly NSTEMI: Non-ST elevation myocardial infarction
lower than the mean age for NSTEMI (54.3 ± 11.4 years) UA: Unstable angina
and mean age for UA (52.5 ± 11.47 years). In the present CAD: Coronary artery disease
study we found that patients with STEMI and NSTEMI IHD: Ischemic heart disease
were more commonly males , smokers and having DM DM: diabetes mellitus
compared to the patients with UA; on the other hand SPSS: Statistical package for Social Sciences
females were significantly more encountered among the Od: Odds Ratio
patients with UA. CI: Confidence interval

Treatment for hypertension and IHD was similar in Declarations

all groups with ACS. The patients with NSTEMI had Ethics approval and consent to participate
increased value of random sugar level compared with Ethical clearance was obtained from the institutional review
the patients with STEMI and UA. These are in line with board (Protocol identifier 006MP25082019; Application
previous studies (23-26). Hyponatremia, defined as a of human ethics committee approval -2-, 17/12/2016).
serum sodium concentration ([Na+]) <135 mmol/L, is the Permission was obtained from the directors of the outpatient
commonest electrolyte disorder encountered in clinical clinics for collecting data from the records. Data collection
practice. Previous studies had found that hyponatremia is procedure was anonymous.
closely related to the prognosis of heart failure (26), and
stroke (27). In the present study we found that the patients Acknowledgements
with NSTEMI and UA had significantly decreased mean The authors would like to thank the Dean of the College
value of Na level compared to the patients with STEMI. The of Ibn Sina, and the directors of both hospitals, for their
underlying mechanism may be relevant to the release of material support.
vasopressin, activation of the renin-angiotensin system and
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