Coronary Angiographic Findings among Diabetic Patients In Basrah Cardiac Centre A Cross Sectional Study

Background: Diabetes mellitus is associated with the increased prevalence of atherosclerosis and coronary heart disease. Diabetes mellitus highly affects patients who have already experienced an unstable angina or myocardial infarction. Diabetes mellitus is also expected to increase in the coming decades among people worldwide. Aim: This study aims at exploring comparatively the correlation between electrocardio-graphic and coronary angiographic findings in both diabetic and non-diabetic patients with ischemic heart disease (IHD), also to determine the severity and extent of coronary artery disease in diabetic compared to nondiabetic. Methods: This was a cross sectional study, enrolled 100 patients from the Cardiac Catheterization Center in Al-Sadder Teaching Hospital, Basrah, Iraq during the period between January and May 2012. Fifty diabetic and 50 non-diabetic consecutive patients were selected. Every selected patient underwent an ECG and coronary angiography depending on at least one indication. Results: A significant correlation was found between diabetes and ischemic angiographic findings and diabetic patients has more extensive and diffuse disease than non-diabetic. Conclusions: Diabetic patients are more susceptible to ischemic heart disease than non-diabetic, Therefore diabetic patients with suspected CAD are highly recommended to have coronary angiography.


Diabetes Mellitus
Diabetes mellitus represents a chronic disease that approximately inflicts 150 million people worldwide. [1]It is expected to increase in the coming decades among people. [2]It is stated that diabetic people are at risk of having atherosclerosis and Coronary Artery Disease (CAD).DM is the leading cause of death in the world and is associated with a 2-to 8-fold higher morbidity and mortality from cardiovascular disease.Remarkably, 65% to 75% of patients with DM die of cardiovascular disease. [3,4]In the present study, the respondents were classified according to their medical reports into two groups: diabetic and nondiabetic.A patient was considered diabetic if he/she was taking insulin or oral hypoglycemic agents, or met the criteria of the National Diabetes Data Group and WHO criteria for diagnosing DM.These criteria includes following:  FBS > 7.0 mmol/L (126 mg/dL);  Symptom of DM plus RBS > 11.1 mmol/L (200 mg /dL); or  Twohour plasma glucose > 11.1 mmol/L (200 mg/dL) during an OGGT. [5]ronary Angiography Coronary Angiogram (CA) should be considered a diagnostic test used in combination with complementary noninvasive tests.Identification of CAD and assessment of its extent and severity are the most common indications for cardiac catheterization in adults, coronary arteriography provides the most reliable anatomic information for determining the appropriateness of medical therapy, percutaneous coronary intervention (PCI), or coronary artery bypass surgery (CABG) and subsequently become one of the most widely used invasive procedures in cardiovascular medicine [6] The American College of Cardiology and the American Diabetes Association Consensus Development Conference has established guidelines for screening diabetic individuals for CAD.For more illustration for the guidelines, consider (Table -1).[7] Patients can be screened for CHD if they suffer from:

Table 1. Indications for CAD Testing in Diabetic Patients
1.
Typical or atypical cardiac symptoms 2.
Peripheral or carotid occlusive arterial disease 4.
Sedentary lifestyle, age ≥35 years, and plans to begin a vigorous exercise program

5.
Two or more of the risk factors listed below inaddition to diabetes: a) Total cholesterol ≥240 mg/dl (6.2 mmol/l), LDL cholesterol ≥160 mg/dl (4.2 mmol/l), or HDL cholesterol<35 mg/dl (0.9 mmol/l); b) Blood pressure >140/90 mm Hg; c) Smoking; or d) Family history of premature CHD The American Heart Association defined high blood pressure as systolic pressure ≥140 mm Hg or diastolic pressure ≥ 90 mm Hg, or if someone uses antihypertensive medication, or being told at least twice by a physician or other health professional that he/she has hypertension. [8]im of Study: this study aims at exploring comparatively the correlation between electrocardio-graphic and coronary angiographic findings in both diabetic and nondiabetic patients with ischemic heart disease (IHD), also to determine the severity and extent of coronary artery disease in diabetic compared to non-diabetic.the precordial leads for men and 1.5 mm for women (who tend to have less ST elevation) and greater than 1mm in other leads. [9]on-ST elevation ACS: A non-ST elevation ACS is manifested by ST depressions and/or T wave inversions without ST segment elevations or pathologic Q waves.The classification of CAD was done in according to the American Heart Association, were the patient considered to have a significant lesion in the coronary artries if the lesion was <70 and more except for the Left Main Stem (LMS), which was considered significant if its lesion is 50% or more.The patient underwent coronary angiography based on the indication mentioned in (Table -1).Family history of premature CAD (male first degree relative < 55 years and female first degree relative < 65 years.

Statistical Analysis
Statistically speaking, the data has been analyzed using the SPSS version 17 for windows Software.The results of all quantitative data were expressed as mean ± SD.Pearson's Chi square tests were used for assessing qualitatively the correspondence between CAD in diabetic and non-diabetics groups.

RESULTS
The mean age in both diabetic and non-diabetic groups was almost equal (57.9 ± 9.8 and 59.6 ± 9.7, respectively).Risk factors were reported in 41(82%) patients in the diabetic group, compared to only 34 (68%) in the non-diabetic group, (Table -2).Electrocardiographic findings were abnormal in 32 (64%) in the diabetic group, versus 18 (36%) in the non-diabetic group.The P value was 0.2 for diabetic, which is insignificant.The abnormal angiographic findings were 43 (86%) in diabetic and 28(56%) in the non-diabetic which was a strong statistical correspondence between diabetes and the abnormal angiography findings, the cornerstone of the study (Table-2).Nine (18%) in the diabetic group showed a lesion in the left main stem whereas only 3 (6%) showed a similar lesion in the non-diabetic (P value was less than 0.001), ( Table -4).

DISCUSSION
This study revealed that the abnormal angiographic lesions were significantly greater in the diabetic patients than in non-diabetic.Furthermore, the main finding of this study was that diabetic patients had a more severe and an extensive CAD than the non-diabetic one.The abnormal angiographic findings in DM were 43 in diabetic and 28 in non-diabetic which is highly significant.This proved that there was a significant correlation between diabetes and abnormal coronary angiographic finding. [10,11]Table -3), showed single vessel disease in our study, was higher in the non-diabetic group, than in the diabetic patients.It was further noticed that double & triple vessel diseases were highly prevalent among diabetes patients.This confirme the fact that diabetic patients have extensive coronary artery disease, a finding that is compatible with those obtained by the previous larger multicenter studies. [12]Similar result reached by Natali et al, [13] were diabetic patients had more frequently three vessel disease and less frequently the single-vessel disease.Additionally, risk factors in our study (hypertension, family history of IHD, smoking, gender and age) had no difference in 2 groups who have an abnormal angiographic finding.Such a result is not in line with the one obtained by previous studies which maintained that hypertension was more common in diabetic patients. [14]Krishnaswami and colleagues [15] studied the coronary arterial lesions seen by angiography in 1666 consecutive male patients, it was found that there were significant relations between CAD severity and diabetes, and this is with agreement with other results.In comparism with coronary angiography, our study showed that the sensitivity of ECG for detection of ischaemic heart disease was high (67.44%)8] CONCLUSIONS AND RECOMMENDATIONS People with diabetes have an increased prevalence of atherosclerosis and coronary artery disease (CAD).Further, the incidence of having an extensive and diffuse disease is more common in patients with diabetes.Therefore diabetic patients with suspected CAD are highly recommended to have coronary angiography.The latter provides the clinician with valuable information regarding the confirmation of the presence or absence of coronary artery disease, the prognosis of patients with CAD and the determination between following a drug therapy, coronary stenting or surgical bypass graft.
A cross sectional study enrolled 100 patients from Cardiac Catheterization Center in Al-Sadder Teaching Hospital, Basrah, Iraq, during the period between January and May 2012.Fifty diabetic and 50 non-diabetic consecutive patients were selected.The data were analyzed in October 2012.Every selected patient underwent an ECG and coronary angiography depending on at least one indication in addition to full history and clinical examinations.The first group, the diabetic, it includes 33 males and 17 females.As for the non-diabetic group, it consists of 39 males and 11 females.Electrocardiographic (ECG) was done for all patients and the electrocardiogram (ECG) is a mainstay in the initial diagnosis of patients with suspected ACS.It allows initial categorization of the patient with a suspected MI into one of three groups based on the pattern: ST elevation MI (ST elevation or new left bundle branch block) non-ST elevation ACS, with either NSTEMI or UA (ST-depression, T-wave inversions, or transient ST-elevation) Undifferentiated chest pain syndrome (nondiagnostic ECG).ST Elevation Myocardial Infarction: ECG criteria for the diagnosis of ST elevation MI, which include 2 mm of ST segment elevation on