Demographic profile and prevalence of risk factors and their correlation with STEMI, NSTEMI and premature CAD in documented CAD patients

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1 Demographic profile and prevalence of risk factors and their correlation with STEMI, NSTEMI and premature CAD in documented CAD patients 1 3 Sharad Gupta, DM, Vitull K. Gupta, MD, Rupika Gupta, MD, Sonia Arora, MBBS, Varun Gupta MBBS. 1 Consultant Interventional Cardiologist, Max Super Speciality Hospital, Bathinda, Punjab, India Assistant Professor, Department of Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India 3 Consultant Pathologist, Lal Path Labs, Bathinda, Punjab, India Consultant Diet and Nutrition, Kishori Ram Hospital and Diabetes Care Centre, Kishori Ram Road, Basant Vihar, Bathinda, Punjab, India MBBS Final Student, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India Abstract Introduction: Worldwide, cardiovascular disease (CVD) is estimated to be the leading cause of death and loss of disability-adjusted life years. Coronary artery disease (CAD) has assumed epidemic proportions in India. It has been well established that it is always better to prevent disease than to cure it. Several conventional and un-conventional risk factors have been documented in Indian population, but the real impact of these risk factors on prevalence of CAD still remains unclear. Aims and objectives: Our study is an attempt to reappraise the demographic and biochemical profile of patients with CAD and to correlate the risk factor profile with STEMI, NSTEMI and premature CAD patients. Material and methods: The proposed study was prospectively conducted in a tertiary care centre. Patients meeting the inclusion criteria were studied with detailed history, physical examination and investigations according to the protocol of the study along with angiographic assessment of coronary lesions. Results: We studies 33 patients including males and 0 females. Mean age of subjects with STEMI was lower that amongst NSTEMI which was not significant statistically (p=0.103). Hypertension, diabetes and metabolic syndrome were significantly higher amongst NSTEMI subjects than STEMI subjects. Smoking was more significantly associated with STEMI and no association with periodontitis, dyslipidemia, central obesity and tobacco chewing was seen. Conclusion: Our study has explored the relationship of various risk factors with UA/NSTEMI, STEMI and premature CAD patients which needs to be further substantiation by larger multi centric studies which would help device preventive strategies focusing individual risk factors in relation to target population. Key Words Angiographic assessment Risk factors Indian population NSTEMI STEMI Coronary artery disease Introduction Worldwide, cardiovascular disease (CVD) is estimated to be the leading cause of death and loss of disability-adjusted life years. Coronary artery disease (CAD) has assumed epidemic proportions in India. The Global Burden of Diseases (GBD) study reported the estimated mortality 1 from CAD in India at 1. million in the year 000. It has been predicted that by the year 00 there will be an increase by almost % in the global CVD burden. The situation in India is more alarming. Reddy reported that mortality from CVD was projected to decline in developed Received: ; Revised: -0-1; Accepted: Disclosures: This article has not received any funding and has no vested commercial interest Acknowledgements: None 1 J. Preventive Cardiology Vol. 1 No. May 01

2 Prevalence of Risk Factors in CAD patients countries from 190 to 01 while it was projected to almost double in the developing countries. It has been predicted that by 00 there would be 11% increase in CV deaths in India. This increase is much more than % for China, 10% for other Asian countries and 1% for 1 economically developed countries. Several conventional and non conventional risk factors have been implicated for CAD. From an epidemiological perspective, a risk factor is a characteristic or a feature of an individual or population that is present early in life and is associated with an increased risk of developing future disease. Not all coronary events occur in individuals with multiple conventional risk factors, however, and in some individuals abnormalities of inflammation, hemostasis, and/or thrombosis appear to contribute decisively. In particular, nearly half of all myocardial infarctions (MI) or stroke occurs among individuals without hyperlipidemia. The major conventional risk factors include hypertension, diabetes, smoking, hyperlipidemia and obesity. The non conventional risk factors include hscrp, lipoprotein (a), homocysteine, fibrinogen, D-dimer, tissue plasminogen activator (t-pa) and plasminogen activator inhibitor (PAI- 1). It has been well established that it is always better to prevent disease than to cure it. The amazing success story of reverting the CAD epidemic in western world is mainly due to aggressive modification of risk factors and lifestyle changes. Several conventional and un-conventional risk factors have been documented in Indian population, but the real impact of these risk factors on prevalence of CAD still remains unclear. It is also not very clear whether there is any correlation of these risk factors with angiographic severity of CAD. Very few studies in India have evaluated the correlation with ST elevation myocardial infarction (STEMI), non-st elevation myocardial infarction (NSTEMI) and premature CAD patients. Thus, by accurate risk stratification, cost effective strategies could be implemented which have beneficial impact on CAD morbidity and mortality. Aims and objectives Our study is an attempt to reappraise the demographic and biochemical profile of patients with CAD and to correlate the risk factor profile with STEMI, NSTEMI and premature CAD patients. Material and methods The proposed study was prospectively conducted in a tertiary care centre. Informed consent was taken from patients for the study participation. Inclusion criteria Patients with acute coronary syndrome (ACS) including unstable angina (UA), NSTEMI and STEMI were serially enrolled. For the diagnosis of UA, patient had to have at least one of the following: angina usually lasting for 0 minutes, onset within one month or angina occurring with a crescendo pattern. The patient also had at least one of the following: ST segment depression 0. mm or T inversion 0.3 mv in any two leads. For the diagnosis of NSTEMI, apart from the above criterion, the patient had elevated Troponin T as a marker of myocyte necrosis. For the diagnosis of STEMI patients needed to have symptoms consistent with MI (chest discomfort with or without radiation to arm(s)/jaw/back/epigastrium, weakness, diaphoresis, nausea, light headedness) of greater than 30 minutes duration, with ECG changes of STEMI i.e. ST elevation of at least 0.1 mv in contiguous precordial leads or limb leads or new/presumably new LBBB. Exclusion criteria Recent or ongoing infection or fever, chronic inflammatory disorders e.g. rheumatoid arthritis; SLE and where diagnosis of CAD was not confirmed. Study design 1. Detailed history and physical examination of all patients who were enrolled in the study.. Routine blood investigation e.g. Hb, TLC, DLC, blood urea, serum creatinine, serum Na+ / K+, random blood sugar. 3. Measurements-height, weight, body mass index (BMI) and waist to hip ratio were calculated for each patient. Body mass index was calculated as weight/height (kg/m ). Patients with BMI >30 kg/m were considered obese. Waist and hip circumferences were measured with a non-stretchable standard tape measure with the subject standing at the narrowest point between the costal margin and iliac crest, and hip circumferences at the level of the widest diameter around the buttocks. Central obesity was defined as waist to hip ratio >0.9 for males and >0. for females.. Assessment of risk factors including hypertension, diabetes, smoking, family history of CAD was done. Diabetes was defined as deranged fasting blood glucose level 1 mg/dl or a patient who was already on treatment for diabetes. Hypertension was defined as or more blood pressure readings of 10 mm Hg systolic or 90 mm Hg diastolic, or a patient who was already on anti-hypertensive medication. Smoking was defined as the regular smoking of tobacco in any form J. Preventive Cardiology Vol. 1 No. May 01 1

3 Gupta S, et al currently or within the last 1 year. Similarly, tobacco chewing was defined as consumption of tobacco orally currently or within last 1 year. A positive family history of premature CAD was defined as the presence of documented CAD in a first-degree relative (male < years, female years). Premature CAD was defined as occurrence of CAD at age years.. Fasting lipid profile (serum concentration of total cholesterol, triglycerides and HDL cholesterol) were measured by using commercial kits from Boehringer Mannheim. LDL cholesterol was calculated by using the Friedwald equation: LDL cholesterol = total cholesterol- [(Triglycerides/) + HDL] Dyslipidemia was defined by presence of any one of the following: LDL >130 mg/dl, TG 10 mg/dl or HDL <0 mg/dl in men and <0 mg/dl in women.. We defined metabolic syndrome by using the NCEP ATP III criteria for the diagnosis of metabolic syndrome. It is a cluster of 3 of the following vascular risk factors: (waist circumference > 10 cm in men or > cm in women, fasting triglycerides 10 mg/dl, HDL-cholesterol < 0 mg/dl in men or < 0 mg/dl in women, hypertension defined as blood pressure 130/ mm Hg or use of blood pressure medication, and IFG 110 mg/dl).. The analysis of hs-crp by turbidimetry immunoassay using QUANTA Reagent kit (latex) manufactured by Tulip corporation, USA. Values of 1 mg/l, 1 to 3 mg/l and > 3 mg/l were labeled as low risk, intermediate risk and high risk respectively.. For calculation of socio-economic status modified Kuppuswamy s scale was used which included education (maximum points); profession (maximum 10 points) and income (maximum 1 points). Total points 10 points Socio-economic class Lower 11- points Middle -9 points Upper 9. Complete dental examination was done by a trained dentist to look for definitive evidence of periodontitis. Complete exams consisted of suppuration index, plaque index (PI), gingival index (GI), pocket depth (PKT), bleeding index (BI), attachment loss measurements (AL), and tooth mobility. Missing and deciduous teeth were also, recorded. 10. Angiographic assessment of coronary lesions was done. Selective coronary angiography in multiple views was performed by standard technique to both the extent and severity of disease. Significant CAD was defined as at least 0% reduction in the diameter of major epicardial coronary arteries i.e. left anterior descending (LAD), left circumflex (LCx) or right coronary artery (RCA) and their branches; or 0% luminal narrowing of the left main coronary artery (LMCA). Patients were classified as having single-vessel disease (SVD), double-vessel disease (DVD) or triple vessel disease (TVD) accordingly. Presence of significant CAD in LMCA was classified as DVD. Statistical analysis The data was analyzed using Statistical Package for Social Sciences (SPSS) Version 1.0. Proportions were compared using Chi-square test while mean values were compared using Independent t test. The confidence limit of the study was kept at 9% hence a p value less than 0.0 was considered statistically significant. Results We studied 33 patients including males and 0 females. Demographic profile and prevalence of risk factors among study subjects is shown in table 1. Table 1: Demographic Profile and Prevalence of Risk Factors Among Study Subjects (n=33) Sr.no. Risk factors No. of patients Percentage 1 Mean age Gender: Male Female 3 Diagnosis: STEMI UA /NSTEMI Socioeconomic status: Lower Middle Upper.3± J. Preventive Cardiology Vol. 1 No. May 01

4 Prevalence of Risk Factors in CAD patients Table 1: Demographic Profile and Prevalence of Risk Factors Among Study Subjects (n=33) Sr.no. Risk factors No. of patients Percentage Premature CAD 1. Hypertension Diabetes Dyslipidemia Smoker Tobacco chewer Obesity (BMI >30 kg/m ) Central obesity Periodontitis Metabolic syndrome 1. 1 Family history of CAD hs-crp 1 mg/l 1-3 mg/l >3 mg/l Angiographic severity (n=) SVD DVD TVD The mean age of females was significantly higher as compared to males (p). Among the various risk factors; hypertension, diabetes and metabolic syndrome were significantly higher amongst females as compared to males. In contrast males had higher proportion of smokers as compared to females. No statistically significant difference was seen between two genders for tobacco chewers, dyslipidemia, central obesity and periodontitis. hs-crp levels 1 mg/l were more commonly seen amongst males (p=0.01) while >3 mg/l were more commonly seen amongst females (p=0.009). Single vessel disease was more commonly seen amongst males (p=0.00) while triple vessel disease was more commonly seen amongst females (p=0.001). Gender wise prevalence of risk factors and angiographic severity CAD is expressed in table. Mean age of subjects with STEMI was.±11. years as compared to 0.0±10. years amongst NSTEMI, however the difference between two groups was not significant statistically (p=0.103). Hypertension, diabetes and metabolic syndrome were seen to be significantly higher amongst NSTEMI subjects as compared to STEMI subjects. However, habit like smoking was more significantly associated with STEMI. No association with periodontitis, dyslipidemia, central obesity and tobacco chewing was seen. Higher hs-crp levels (>3 mg/l) were seen to be associated with STEMI whereas no significant association with angiographic severity of disease could be seen, though SVD was more commonly seen amongst STEMI subjects. Prevalence of risk factors and angiographic severity of CAD in patients of UA/NSTEMI and STEMI is shown in table 3. A significant positive association of premature CAD was seen with dyslipidemia (p=0.01), family history of CAD (p=0.00), smoking (p) and tobacco chewing (p=0.001). No association of premature CAD was seen with hypertension (p) and diabetes (p=0.011). No association with central obesity, metabolic syndrome and periodontitis could also be seen. Among patients with premature CAD, the prevalence of SVD was significantly J. Preventive Cardiology Vol. 1 No. May 01 1

5 Gupta S, et al Table : Gender wise Prevalence of Risk Factors and Angiographic Severity CAD Sr.no. Variables Females (n=0) Males (n=) X P 1 Mean age.3±..± Hypertension Diabetes Smoker 1.31 Tobacco chewer Dyslipidemia Central obesity Metabolic syndrome Periodontitis hs-crp 1 mg/l >1-3 mg/l >3 mg/l Angiographic severity SVD DVD TVD (n=3) 1 1 (n=0) higher (p) whereas among those in higher age groups, the incidence of DVD and TVD was higher. Comparison of different risk factors between patients with Premature CAD ( years) and those with age > years is shown in table. Discussion Epidemiological studies have revealed that the prevalence of CAD in India is increasing along with the prevalence of conventional risk factors for CAD. Present health transition from predominance of infections to the preponderance of cardiovascular disorders, such as hypertension, diabetes, and CAD is now responsible for 3% of all deaths. Indians have one of the highest rates of heart disease in the world. The disease also tends to be more aggressive and manifests at a younger age. In the present study, the mean age of presentation was.3±11. years which is comparable to the data from the CREATE Registry (mean age.±1.1 years). The mean age was higher than that reported in South Asian cohort (3 years) of the INTERHEART study and was lower than in the Western countries and other regions (mean age is years). McKeigue et al, Balarajan et al, Enas et al and 1 Joshi et al in their respective studies observed that South 1 Asians had a lower age at presentation of first AMI and that the younger age of first AMI among the South Asian cases appears to be largely explained by the higher prevalence of risk factors in native South Asians. In the present study, males (.%) outnumbered females (1.%). The skewed gender distribution of the study population can be attributed to the gender bias and atypical presentation which is also a feature in INTERHEART study and its south Asian cohort (overall male %, and south Asian cohort %). Also,.% and 3.3% study population were males in the CREATE Registry and a published data,13 from North India, respectively. The mean age of presentation was higher in females (.3±. years) as compared to males (.±11.30 years). Hypertension, diabetes and metabolic syndrome were significantly more common risk factors in females whereas males were more likely to be smokers. This finding of our study was similar to the findings of INTERHEART study, which reported that hypertension and diabetes were associated with a greater odds ratio and PAR in women compared with men. No significant difference between the two genders for tobacco chewing, dyslipidemia, central obesity and periodontitis was found in this study. Higher hs-crp levels were significantly more J. Preventive Cardiology Vol. 1 No. May 01

6 Prevalence of Risk Factors in CAD patients Table 3: Prevalence of Risk Factors and Angiographic Severity CAD in Patients with STEMI and UA/NSTEMI Sr.no. Variables STEMI (n=) UA/ NSTEMI (n=3) X P 1 Mean age.± ± Hypertension.0 3 Diabetes Smoker Tobacco chewer Dyslipidemia Central obesity Metabolic syndrome Periodontitis hs-crp 1 mg/l >1-3 mg/l >3 mg/l Angiographic severity SVD DVD TVD Table : Comparison of different risk factors between patients with Premature CAD ( years) and those with age > years. Sr.no. Risk Factor Premature CAD ( years (n=) 3 Hypertension Diabetes Dyslipidemia Central obesity Metabolic syndrome 3 0 CAD In > years age (n=) X P Family history of CAD Smoker Tobacco chewer Periodontitis Angiographic severity SVD DVD TVD J. Preventive Cardiology Vol. 1 No. May 01 19

7 Gupta S, et al in females than in males and this result is similar to the earlier published data. With the present knowledge about gender differences associated with CRP and evidence that CRP as a predictor of incident cardiovascular events may differ in men and women, altering clinical practice and research methods to allow for gender-specific interpretations of CRP may be warranted. Further research is needed to find optimal gender-specific CRP cutoffs that 1 most accurately predict cardiovascular risk. SVD was more common in males than in females, which could be attributed to the younger age at presentation in males than females, more likelihood of being smokers and less likelihood of being hypertensive, diabetic and to have metabolic syndrome. Maximum number of patients in the present study belonged to the middle class (1.%), whereas 30.9% were from low socioeconomic class and only.% patients were from the upper socioeconomic class. This observation of ours was similar to the report from the CREATE Registry which also reported that most patients were from lower middle (.%) and poor (19.%) social classes. Hypertension, a conventional risk factor is implicated in CAD. In our study, 0.% of the patients were hypertensive. The prevalence of hypertension in the present study was nearly the same as reported in CREATE Registry (3.%). The prevalence of hypertension in south Asian cohort of INTERHEART study (1.%) was comparatively lower than in our study. The higher prevalence of diabetes and hypertension could be explained by the comparatively higher development and increasing epidemic of CAD in India. In the present study the prevalence of diabetes was 30.3%, which was exactly the same as reported in the CREATE Registry (30.%), but was higher than the reported prevalence (10.%) in a similarly aged population from, South Asian countries in the INTERHEART study. Native Indians living in India now constitute the largest population of diabetics in the world. Tobacco smoking is a known modifiable risk factor for CAD. The prevalence of tobacco smoking was high in the present study (0.%). The prevalence of tobacco chewing in our study was 3.1%. The prevalence of smoking and tobacco chewing was significantly higher in patients presenting with premature CAD than in elderly patients with CAD. Overall, the mean age of smokers presenting with CAD was younger as compared to non smokers with CAD. Also, STEMI was more common than UA/NSTEMI in smokers than non smokers. Data from the INTERHEART study also suggested that the risk of smoking is greater in the young than in the old, and the risk of AMI is even higher in those who both chew and smoke tobacco. Dyslipidemia was found in.9% of our study population. In the INTERHEART study also,.1% of subjects from the South Asian region were dyslipidemic. No significant difference was found in the prevalence of dyslipidemia between men and women suggesting that dyslipidemia is equally prevalent in both genders. In our study population, the prevalence of obesity using BMI as the criteria was 11.9%. Using waist hip ratio as the criteria the prevalence of obesity was found to be 33.% which is less than the prevalence seen in south Asian cohort of INTERHEART study (.%). Lakka et al reported that abdominal obesity is an independent risk factor for acute coronary syndrome in middle-aged men. They also reported that in combination with smoking, the risk of coronary events increases by. times. The epidemic of obesity is a huge and rapidly growing public health hazard. Abdominal obesity (i.e., central obesity) with increased waist circumference is an important component of the insulin resistance-hyperinsulinemia syndrome, and has been found to be more frequent in persons of Indian 1 origin. The prevalence of metabolic syndrome in our study was 1.%. A study from Andhra Pradesh had reported the prevalence of metabolic syndrome to be 1.%. Different studies from the western countries have reported a much higher prevalence (0-0%) of metabolic syndrome in patients with CAD. We did not find any significant difference in the prevalence of metabolic syndrome in patients with premature CAD compared to those in higher age groups (P = 0.). Statistically significant difference was observed between the patients of NSTEMI subjects as compared to STEMI subjects (P = 0.00). In one study it was reported that patients with metabolic syndrome were younger and more likely to be 1 females. Another study reported that patients with metabolic 19 syndrome were more likely older and to be women. In our s t u d y, s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e (P = ) was observed in prevalence of metabolic syndrome among males (%) as compared to females (1%). It was found that 30.3% of our study population had evidence of periodontitis. We found a statistically significant positive correlation between periodontal disease and CAD. Both the incidence and prevalence of CAD are increased in patients who are affected with periodontal disease. A meta-analysis of cohort studies indicated that there was 1. times increased risk (9% CI , P <.0001) for CAD in the edentulous patients (<10 teeth). The results also indicated that an inverse relationship between the number of teeth and the relative 0 risk of CAD may exist. In our study no statistically significant difference was seen between two genders 10 J. Preventive Cardiology Vol. 1 No. May 01

8 Prevalence of Risk Factors in CAD patients (P = 0.0) and STEMI or NSTEMI (P = 0.) or with premature CAD (P = 0.) for periodontitis. The prevalence of premature CAD ( years) was 1.%. The presence of dyslipidemia, smoking, tobacco chewing and positive family history of CAD were significant risk factors in the younger age group in our study. These findings of ours were similar to the literature published in 1-3 the past. Hypertension and diabetes were found to be more significant risk factors in the older age groups. Data from the INTERHEART Study suggests that first MI attack occurred in.% of Asian women and 9.% of men at age less than 0 years, which is - to 3.-fold higher than in the West European population and is third highest of all the regions studied worldwide. Asians in general and Indians in particular are at increased risk of MI at a younger age (<0 years), irrespective of whether they have migrated to other countries or are resident Asians. Among patients with premature CAD, the prevalence of SVD was significantly higher (p) whereas among those in higher age groups, the incidence of DVD and TVD was higher. High hs-crp levels were significantly raised in patients with premature CAD. It was found that the number of patients with a diagnosis of STEMI was much higher than those presenting with a diagnosis of UA/NSTEMI in patients with raised hs-crp (.% vs..%). CREATE Registry by Xavier et al observed that a diagnosis of STEMI was more common in Indians amounting to 0% of all patients presenting with ACS, whereas in reports from developed countries by Budaj et al, Hasdai et al, and Mandalzweig et al found that in developed countries, STEMI accounts to less than 0% of patients presenting with ACS, including the European Heart Surveys. This suggests that patients admitted to Indian hospitals with acute coronary syndromes are likely to have worse, - prognosis than those in other countries. It was found that patients with STEMI were slightly younger at presentation (mean age.±11. years) than those with UA/NSTEMI (mean age 0.0±10. years). We observed that patients with UA/NSTEMI were more likely to be hypertensive, diabetic and to have metabolic syndrome than those with STEMI. A higher rate of smoking in STEMI patients was found than patients with UA/NSTEMI. These findings were similar to the observations in the CREATE Registry. No statistically significant difference between the two groups in terms of prevalence of other risk factors, including tobacco chewing, dyslipidemia, central obesity and periodontitis was observed. SVD was more common in patients with STEMI than those with UA/NSTEMI, no difference for the prevalence of DVD and TVD in the two groups was observed. Conclusion From the present study, we conclude that hypertension, diabetes and metabolic syndrome were significantly more common risk factors in females and those presenting with UA/NSTEMI whereas smoking was predominant risk factor in males, those with premature CAD and in those presenting with STEMI. Mean age was younger for patients presenting with STEMI as compared to those presenting with UA/NSTEMI. A significant positive association of premature CAD was seen with dyslipidemia, family history of CAD, smoking and tobacco chewing. No association of premature CAD was seen with hypertension, diabetes, central obesity, metabolic syndrome and periodontitis. Among patients with premature CAD, the prevalence of SVD was significantly higher whereas among those in higher age groups, the incidence of DVD and TVD was higher. No difference was found in the prevalence of dyslipidemia, tobacco chewing, central obesity and periodontitis between the two genders and those presenting with either STEMI or UA/NSTEMI. A higher prevalence of TVD on angiography was found in diabetics, those with metabolic syndrome and higher hs- CRP levels. SVD was more prevalent in younger age group, smokers and those presenting with STEMI. Our study has explored the relationship of various risk factors with UA/NSTEMI. STEMI and premature CAD which needs to be substantiated by larger multicentric studies which would help device preventive strategies focusing individual risk factors in relation to target population. References 1. Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet 199; 39: Reddy KS. Cardiovascular diseases in India. 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9 Gupta S, et al modifiable risk factors associated with myocardial infarction in countries (the INTERHEART study): case-control study. Lancet 00; 3: McKeigue PM, Marmot MG. Mortality from coronary heart disease in Asian communities in London. BMJ. 19; 9: Balarajan R. Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales. BMJ. 1991; 30: Enas EA, Yusuf S, Mehta J. Prevalence of coronary artery disease in Asian Indians. Am J Cardiol. 199; 0: Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K et al. Risk Factors for Early Myocardial Infarction in South Asians Compared With Individuals in Other Countries. JAMA. 00; 9: Kumar N, Sharma S, Mohan B, Beri A, Aslam N, Sood N, Wander GS. Clinical and Angiographic Profile of Patients Presenting with First Acute Myocardial Infarction in a Tertiary Care Center in Northern India. Indian Heart J 00; 0: Lakoski SG, Cushman M, Criqui M et al. Gender and C-reactive protein: Data from the Multiethnic Study of Atherosclerosis (MESA) cohort. Am Heart J 00; 1: Teo KK, Ounpuu S, Hawken S, Valentin V et al. Tobacco use and risk of myocardial infarction in countries in the INTERHEART study: a case-control study. Lancet 00; 3: -. 1.Lakka HM, Lakka TA, Tuo Milelito, Salonan JT. Abdominal obesity is associated with increased risk of acute coronary events in men. European Heart Journal 00; 3: Latheef SAA, Subramanyam G. Prevalence of Coronary Artery Disease and Coronary Risk Factors in an Urban Population of Tirupati. Indian Heart J 00; 9: Steinberg BA, Fonarow GC, Hernandez AF et al. Metabolic Syndrome in Patients with CAD: Is it More than Obesity? Analysis of 9, Hospitalizations in Get with the Guidelines. Circulation 00; 11 (1): Zeller M, Steg PG, Ravisy J, Laurent Y et al. Prevalence and Impact of Metabolic Syndrome on Hospital Outcomes in Acute Myocardial Infarction. Arch Intern Med. 00; 1: Bahekar A, Singh S, Saha S, Molnar J, Rohit Arora. The prevalence and incidence of coronary heart disease is significantly increased in periodontitis: A meta-analysis. Am Heart J 00; 1: Gupta R, Gupta VP, Sarna M, et al.. Prevalence of coronary heart disease and risk factors in an urban Indian population: Jaipur Heart Watch-. Indian Heart J 00; :9-..Achari V, Thakur AK, Sinha AK. The Metabolic Syndrome - Its Prevalence and Association with Coronary Artery Disease in Type Diabetes. JIACM 00; (1): Kaul U, Dogra B, Manchanda SC, et al. Myocardial infarction in young Indian patients: risk factors and coronary arteriographic profile. Am Heart J 19; 11: 1-..Budaj A, Brieger D, Steg PG, et al. Global patterns of use of antithrombotic and antiplatelet therapies in patients with acute coronary syndromes: insights from the Global Registry of Acute Coronary Events (GRACE). Am Heart J 003; 1: Hasdai D, Behar S, Wallentin L, et al. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 00; 3: Mandelzweig L, Battler A, Boyko V, et al. The second Euro Heart Survey on acute coronary syndromes: Characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 00. Eur Heart J 00; : -93. Address for correspondence Dr. Vitull K. Gupta : vitullgupta000@yahoo.com 1 J. Preventive Cardiology Vol. 1 No. May 01