Research in Cardiovascular Medicine

: 2020  |  Volume : 9  |  Issue : 4  |  Page : 89--93

Clinical Characteristics, Angiographic Profile, and Hospital Outcomes of Acute Coronary Syndrome in Women Less than 55 Years of Age in a Tertiary Care Hospital of Northern Kerala

Ashraf S Manzil, PC Pramod 
 Department of Cardiology, Academy of Medical Science, Kannur, Kerala, India

Correspondence Address:
Dr. Ashraf S Manzil
Department of Cardiology, Academy of Medical Science, Pariyaram, Kannur - 670 503, Kerala


Background: Despite the fact that the incidence of cardiovascular disease is more pronounced in women, there is a lack of evidence-based studies that investigate the characteristics of acute coronary syndrome (ACS) in Indian women. Aim: The study aimed to assess the clinical characteristics, angiographic profile, and hospital outcomes of ACS in women <55 years of age in a tertiary care hospital of Northern Kerala. Materials and Methods: This was an observational study. In total, 179 women with <55 years of age, who had experienced the first episode of ACS were included in the study. Baseline characteristics including demography, risk factor, clinical presentation, and therapeutic management were reported. Results: Out of 179 female patients, 102 (57%) patients were postmenopausal. The most common risk factors of ACS in our population were found to be dyslipidemia (64.80%), followed by diabetes mellitus (58.10%) and hypertension (41.34%). The most frequent clinical presentation of ACS was non-ST-elevation myocardial infarction (STEMI) (49.16%), followed by STEMI (26.26%) and unstable angina (24.58%). Regarding the severity of disease, single-vessel disease (32%) was more common, followed by double-vessel disease (28%) and triple-vessel disease (24%). Left anterior descending artery (116 patients) was the most frequently involved artery in female patients, followed by right coronary artery (72 patients). Postprocedure complications associated with the study were as follows: hematoma (two patients), pseudoaneurysm (one patient), and takotsubo cardiomyopathy (one patient). Deaths were reported in two patients. Conclusions: The epidemiological trend of ACS, especially in the postmenopausal women, has been continuously rising in developing countries including India. Hence, more emphasis should be given on the identification of risk factors, clinical presentation, and diagnosis in this vulnerable group, which is ultimately beneficial for therapeutic management as well as reduces mortality and morbidity.

How to cite this article:
Manzil AS, Pramod P C. Clinical Characteristics, Angiographic Profile, and Hospital Outcomes of Acute Coronary Syndrome in Women Less than 55 Years of Age in a Tertiary Care Hospital of Northern Kerala.Res Cardiovasc Med 2020;9:89-93

How to cite this URL:
Manzil AS, Pramod P C. Clinical Characteristics, Angiographic Profile, and Hospital Outcomes of Acute Coronary Syndrome in Women Less than 55 Years of Age in a Tertiary Care Hospital of Northern Kerala. Res Cardiovasc Med [serial online] 2020 [cited 2021 Apr 23 ];9:89-93
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Full Text


Coronary artery disease (CAD) is a significant cause of mortality and morbidity in women, representing 1 out of 3 deaths in women without race or ethnicity bias.[1],[2] From 1960 to 1995, the prevalence of CAD in Indian women has risen from 3% to 10% in the urban population, whereas 2%–4% in the rural population.[3] Acute coronary syndrome (ACS), a subcategory of CAD, involves myocardial injury and myocardial infarction (MI) presented with an extensive range of clinical conditions which include unstable angina, ST-elevation myocardial infarction (STEMI), and non–ST-elevation myocardial infarction (NSTEMI). As per epidemiological data, a gender-related discrepancy in mortality rate has been continually reported with ACS. The women with ACS have a higher risk of mortality in the short course of time, even after successful percutaneous coronary interventions.[4],[5] Diabetes mellitus, smoking, hypertension, dyslipidemia, as well as autoimmune and inflammatory diseases such as lupus or rheumatoid arthritis have been established as major cardiovascular risk factors in women. Apart, polycystic ovary, early menopause, and history of preeclampsia may also contribute to the development of ACS in women.[6] However, multiple reported studies hypothesized that women with ACS have a worse prognosis than men those with the disease.[7],[8],[9] Altogether, substantial discrepancies were identified among women and men with ACS in terms of clinical presentation, presence of comorbidities, cardiovascular risk factors, and treatment approach.[4] In the literature, there has been the scarcity of data addressing the clinical characteristics of ACS in Indian women. Here, we aimed to study the clinical characteristics, angiographic profile, and hospital outcomes of ACS in female patients <55 years old.

 Materials and Methods


This observational study was conducted at a tertiary care hospital in India from 2017 to 2018. The study protocol was approved by the institutional ethics committee. The study was conducted in accordance with the Declaration of Helsinki. The female patients with <55 years of age, who had experienced the first episode of ACS, including unstable angina, NSTEMI, and STEMI according to a definition given by the American College of Cardiology and American Heart Association,[10] were included in the study. Notably, data regarding age, CAD risk factor profile, past history of CAD, dyslipidemia, diabetes mellitus, and hypertension were reported in predefined work pro forma. In addition, clinical manifestations included left ventricular (LV) ejection fractions, left ventricular hypertrophies (LVHs), hematologic indices, coronary angiographic findings, and treatment modalities were also noted. Each patient was subjected to a selective coronary angiogram using standard technique within 48 h of admission unless patients were hemodynamically unstable or with deranged renal parameters.

Definitions used in the study

CAD: Significant CAD is defined as a diameter stenosis >50% in each major epicardial artery.[11]

Normal vessels: Normal vessels are described by the complete absence of any disease in the left main coronary artery (LMCA), left anterior descending (LAD), right coronary artery (RCA), and left circumflex (LCX) as well as their main branches (diagonal, obtuse marginal, ramus intermedius, posterior descending artery, and posterolateral branch).

Data analysis

Descriptive statistics were analyzed using SPSS software package (version 15.0, SPSS Inc., Chicago, IL, USA).


Baseline characteristics

A total of 179 female patients under the age of 55 years were included in the study. Of which, 102 (57%) women were in the postmenopausal stage. Age-wise distribution revealed that 12 female patients were in the age group between 30 and 39 years, 34 female patients in 40–44 years' age group, 65 female patients in 45–49 years' age group, and 68 female patients in 50–55 years' age group. [Table 1] demonstrates the most common risk factors associated with occurrence of ACS in our study population. In this study, dyslipidemia (64.8%), diabetes mellitus (58.10%), and hypertension (41.34%) were the most prevalent risk factors. As shown in [Table 2], dyspnea (26.82%) was the most common symptoms found in a majority of female patients. The frequently observed clinical presentations of ACS were found to be NSTEMI (49.16%), followed by STEMI (26.26%) and unstable angina (24.58%). With respect to the severity of disease, single-vessel disease (SVD) (32%) was observed in the most cases, followed by a double-vessel disease (DVD) (28%) and triple-vessel disease (TVD) (24%) [Figure 1]. The graphical presentation of involved coronary arteries in female patients is demonstrated in [Figure 2]. In addition, LV dysfunction was assessed by nonvolumetric echocardiographic analysis, and outcomes showed that 46.42% of the female patients had mid-range LV dysfunction, and 53.57% of the female patients had moderate LV dysfunction. Apart from these, LVH was observed in 109 (60.89%) female patients. LAD arteries were the most commonly involved in female patients (116 patients), followed by RCA (72 patients), whereas LMCA (7 patients) and posterolateral ventricular artery (15 patients) were less commonly involved. Out of 179 female patients, 109 (61%) patients underwent angioplasty during the hospitalization, 44 (25%) patients were managed with drug therapy, and 11 (6%) patients were recommended for coronary artery bypass grafting. For angioplasty, sirolimus-eluting stents were used, and the most common size for proximal LAD stents and distal LAD stents were 3 mm and 2.5 mm, respectively. Similarly, stents of 2.75 mm and 2.5 mm size were used for proximal LCX and distal LCX, respectively. The stents used in proximal RCA were around 3 or 3.5 mm in size. Postprocedure complications associated with this study are displayed in [Table 3]. Hematomas (two patients) were managed with blood transfusion. Unfortunately, deaths reported in two patients despite maximum resuscitative measures.{Figure 1}{Figure 2}{Table 1}{Table 2}{Table 3}


Recent epidemiological data have forecasted that more than half of cardiovascular disease risks will be borne by Indians in the years ahead.[12] The disease also tends to be more aggressive and manifests in women, especially after menopause.

The findings obtained from the INTERHEART study (>52,000 patients with MIs) demonstrated that women have a delay in the manifestation of coronary heart disease symptoms, notwithstanding mortality has raised promptly in women.[13] Ayanian et al.[7] concluded that women needed additional diagnostic and therapeutic procedures. The Global Registry of Acute Coronary Events conducted a study on 26,755 patients from 14 high-income countries. This study postulated that if women with advanced disease have been treated less aggressively, they may have more prone to adverse consequences such as death, MI, stroke, or rehospitalization.[8] Radovanovic et al.[9] reported higher inhospital mortality in female patients. A few pieces of the literature suggested higher adverse effects on elder female patients than the younger one.[14] In the study conducted in Kerala, higher mortality rates were reported in women with STEMI.[15] Two Indian studies, Kerala ACS registry[16] and CREATE,[17] respectively, reported a 22.6% and 23.6% prevalence of ACS. From this detailed literature review, we ultimately hypothesized that risk factors and clinical and angiographic profile in women are much fuzzy. All these studies had been a foundation stone for the present research.

Among Indian women, metabolic risk factors such as dyslipidemia, diabetes mellitus, and hypertension have been mainly blamed as the creator of ACS. The National Family Health Survey has been declared a higher prevalence of obesity in Indian women.[18] Between the ages of 40 and 60 years, the levels of estrogen declines in women which contribute to downregulation of the low-density lipoprotein (LDL) receptors expressed on the liver cells, in turn, result in high LDL cholesterol levels. These high LDL cholesterols are a strong predictor of heart diseases in women younger than 65 years.[19] After menopause, a rise in levels of total cholesterol, very-LDL cholesterol, and triglycerides (TGs) has also been reported.[20] High-density lipoprotein (HDL) cholesterol levels were higher in women as per a national survey report.[19] Stevenson et al.[21] proposed that HDL2 cholesterol subfraction, which is believed to be more cardioprotective than HDL1 or HDL3, demonstrated a remarkable decline after the onset of menopause. Elevated TG concentration is one of the risk factors in women, especially when the HDL cholesterol levels fall below 1.03 mmol/L (40 mg/dL). These probable mechanisms may lead to dyslipidemia and ultimately result in cardiovascular disease in women.

In women, extremely irregular or infrequent menstrual cycles have appeared to be leading cause of diabetes. These menstrual cycles may be related to insulin resistance and thus influence in the development of type 2 (or adult-onset) diabetes.[22] The fact is the relative risk for morbidity and mortality due to cardiovascular disease in women with diabetes ranging from 2 to 5 than those without diabetes.[23] Menopause has no significant relationship with the risk of diabetes as well as further development of CAD.[24]

Hypertension causes LVH as well as the progression of atherosclerosis, which results in CAD.[25] This seems to be a probable mechanism in the development of cardiovascular diseases due to hypertension. As a big concern, Indian women are at much high cardiometabolic risk of CVD, mostly after losing their hormonal protection at menopause.

In this study, the incidence of NSTEMI was found in 49.16% of the cases, STEMI in 26.26% of the cases, and unstable angina in 24.58% of the cases. The Kerala ACS registry[16] reported a 37% prevalence for STEMI, 31% for NSTEMI, and 32% for unstable angina. Kumar et al.[26] reported less prevalence than the former two studies. Women have a lower prevalence of LVH on any blood pressure level, however, the prevalence is increased gradually with older age and after menopause as well. Existing data hint that not only hypertension but also LVH is a strong risk factor for cardiovascular diseases in women.[27]

In this study, the SVD was observed in the majority of patients, followed by double vessel and triple vessel. Correspondingly, Kumar et al.[26] and Tewari et al.[28] reported a higher prevalence of SVD in female patients. The dominant vessels involved in female patients were LAD present in 72 patients. This value is comparable to the study reported by Ezhumalai and Jayaraman.[11]

Several potential limitations associated with the study need to be considered. First, being an observational study, many confounding factors influenced the final outcomes. Second, we have only examined the patients who visited the hospital, so it might not be a true representative of the entire population. Further comprehensive studies that compare clinical characteristics of ACS at different stages in women (reproductive age, menopause, perimenopause, and postmenopause) should be conducted for a complete understanding of ACS in women.


In the Indian scenario, ACS has been an uncommon entity in women, and its treatment is of great challenge for a patient as well as treating physician. Diabetes mellitus, hypertension, and dyslipidemia were the most common risk factors for ACS in our study population. Dyspnea (26.82%) was the most common symptoms associated with ACS in female patients. NSTEMI, STEMI, and unstable angina were the most common clinical presentations in our study population. On angiographic findings, SVD was the most involved vessel, followed by DVD and TVD. LAD involvement was seen in utmost cases. A better understanding of clinical features of ACS may definitely be beneficial for timely diagnosis and precise treatment.

Ethical clearance

The study protocol was approved on April 5, 2017, by the institutional ethics committee with registration number: 185/2017/ACME.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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