Premature coronary artery disease, risk factors, clinical presentation, angiography and interventions: Hospital based registry.

BACKGROUND & AIMS: Premature coronary artery disease (CAD) is endemic in India. We performed a study to identify risk factors, clinical presentation, angiographic findings and interventions in premature CAD. METHODS: Successive patients who underwent percutaneous intervention (PCI) were enrolled from January 2018 to June 2021. Premature CAD was defined as women 45-59 y and men 40-54 y and very premature as women <45 y and men <40 y. Descriptive statistics are presented. Univariate odds ratio (OR) and 95% confidence intervals (95%CI) were calculated to identify differences in various groups. RESULTS: 4672 patients (women 936, men 3736) were enrolled. Premature CAD was in 1238 (26.5%; women 31.9%; men 25.1%) and very premature in 212 (4.5%; women 6.5%, men 4.0%). In premature and very premature vs non-premature CAD, OR (95%CI) for high cholesterol ≥200 mg/dl [women 1.52(1.03-2.25) and 1.59(0.79-3.20); men 1.73(1.38-2.17) and 1.92(1.22-3.03)], non-HDL cholesterol ≥130 mg/dl [women 1.84(1.35-2.52) and 1.32(0.72-2.42); men 1.69(1.43-1.90) and 1.67(1.17-2.34)], LDL cholesterol [men 1.10(0.95-1.25) and 1.04(0.77-1.41)], and tobacco [women 1.40(0.84-2.35) and 2.14(0.95-4.82); men 1.63(1.34-1.98) and 1.27(0.81-1.97)] were higher while hypertension, diabetes and chronic kidney disease were more in non-premature(p < 0.05). Presentation as STEMI was marginally more in women with premature [1.13(0.85-1.51)] and very premature [1.29(0.75-2.22)] CAD and was significantly higher in men [1.35(1.16-1.56) and 1.79(1.29-2.49)]. Location and extent of CAD were not different. CONCLUSIONS: In India, a third of CAD patients presenting for coronary intervention have premature disease. Important risk factors are high total and non-HDL cholesterol and tobacco (men) with greater presentation as STEMI. Extent and type of CAD are similar to non-premature CAD indicating severe disease.

Association of health insurance status with coronary risk factors, coronary artery disease, interventions and outcomes in India.

Objective: Coronary artery disease (CAD) related hospitalization and interventions are associated with catastrophic out-of-pocket health expenditure in India. To evaluate differences in risk factors, disease severity, management and outcomes in uninsured vs insured CAD patients we performed a study. Methods: Successive CAD patients who underwent percutaneous intervention (PCI) at our centre were enrolled from January 2018 to June 2021. Clinical, angiographic and intervention data were periodically uploaded in the American College of Cardiology CathPCI platform. Descriptive statistics are reported. Results: 4672 CAD patients (men 3736, women 936) were included; uninsured were 2166 (46%), government insurance was in 1635 (36%) and private insurance in 871 (18%). Mean age was 60.1 ± 11 years, uninsured <50y were 21.6% vs 14.0% and 20.3% with government and private insurance. Among the uninsured prevalence of raised total and non-HDL cholesterol, any tobacco use, ST-elevation myocardial infarction (STEMI) and ejection fraction <30% were more (p < 0.01). In the STEMI group (n = 1985), rates of primary PCI were the highest in those with private insurance (38.7%) compared to others. Multivessel stenting (≥2 stents) was more among the insured patients. Median length of hospital stay was similar in the three groups. In-hospital mortality was slightly more in the uninsured (1.43%), compared to government (0.88) and privately insured (0.82) (p = 0.242). The cost of hospitalization and procedures was the highest among uninsured (US$ 2240, IQR 1877-2783) compared to government (US$ 1977, IQR 1653-2437) and privately insured (US$ 2013, IQR 1668-2633) (p < 0.001). Conclusions: Uninsured CAD patients in India are younger with more risk factors, acute coronary syndrome, STEMI, multivessel disease and coronary stenting compared to those with government or private insurance. The uninsured bear significantly greater direct costs with slightly greater mortality.

Low use of statins and other coronary secondary prevention therapies in primary and secondary care in India.

OBJECTIVE: To determine the frequency of use of pharmacotherapy with aspirin, beta blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor in patients with stable coronary heart disease (CHD) among physicians at different levels of health care in Rajasthan state, India. METHODS: Physicians practicing at tertiary hospitals and clinics at tertiary, secondary and primary levels were contacted. Prescriptions of CHD patients were audited and descriptive statistics reported. RESULTS: We evaluated 2,993 prescriptions (tertiary hospital discharge 711, tertiary 688, secondary 1,306, and primary 288). Use of aspirin was in 2,713 (91%) of prescriptions, beta blockers 2,057 (69%), ACE inhibitors or angiotensin receptor blockers (ARBs) 2,471 (82%), and statins 2,059 (69%). Any one of these drugs was prescribed in 2,991 (100%), any two in 2,880 (96%), any three in 1,740 (58%), and all four in 1,062 (35.5%) (P < 0.001). As compared to tertiary hospital, prescriptions at tertiary, secondary, and primary levels were lower: aspirin (96% vs 95%, 91%, 67%), beta blockers (80% vs 62%, 66%, 70%), statins (87% vs 82%, 62%, 21%): two drugs (98% vs 96%, 98%, 85%), three drugs (75% vs 58%, 55%, 28%), or four drugs (54% vs 44%, 28%, 7%) (P < 0.01). Use of ACE inhibitors/ARBs was similar while nitrates (43% vs 23%, 43%, 70%), dihydropyridine calcium channel blockers (12% vs 15%, 30%, 47%), and multivitamins (6% vs 26%, 37%, 47%) use was more in secondary and primary care. CONCLUSIONS: There is suboptimal use of various evidence-based drugs (aspirin, beta blockers, ACE inhibitors, and statins) for secondary prevention of CHD in India.