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Trends and Characteristics of Caucasian, Indian &
Pakistani Patients Undergoing Coronary
Angioplasty
St. Mary’s Hospital PTCA Registry
Introduction
• Asians are thought to have higher risk of complications and poorer outcome after PTCA
• However, there is no data comparing the characteristics of Asians to that of Caucasians undergoing PTCA
• There is also no data comparing the characteristic differences that may exist between South Asian originating from different countries or races
• Coronary Artery Bypass Grafting (CABG)
• Percutaneous Transluminal Coronary Angioplasty (PTCA)
Aims
This study examines the differences in risk factors and general trends between Caucasians and Asians patients and between Indians and Pakistanis to determine factors that may explain differences in outcome following PTCA
Methods (1)
• Data sources:– Database: PTCA data was prospectively collected
on a dedicated database from 1986 to 1996
• Data was Validated using– Catheter lab registry notes– Radiography registry notes– Hospital PAZ system– Patient notes
Methods (2) – Database
Variables on database
– Date of birth– Gender– Date of operation– Ethnic origin– Lesion site & size– Number of vessels diseased &
treated– Emergency presentation
– FHx of CAD– History of:
• Hypertension• Stroke• Diabetes• Cholesterol• Uric acid• PVD• Smoking
Statistics (1) Continuous Data
• Unpaired t-test– Unmatched patients
• eg. Age at procedure, vessel diameter
• Paired t-test– Matched pairs (age/sex/year of procedure)
• Mann-Whitney test – Parametric - variances unequal
Statistics (2)Categorical Data
• Chi-squared test– Unmatched patients
• eg. Diabetes, smoking
• McNemar test– Matched pairs
Results(1) - Patient Population
• 3629 entries (3064 patients) – 565 repeats
• 2171 Caucasian patients
• 254 Asians patients
Results (2) – Population
Country of origin
PTCA
NumberTOTAL 3629
England 2593 (428)
(South Asia) (290)
Pakistan 158 (20)
Malta 146
India 132 (16)
Gibraltar 86
Ireland 73
Cyprus 66
Iran 46 (3)
Greece 32
Egypt 27
Poland 24
Dominican Republic
22
Results (3) - Cases Per Year
0
100
200
300
400
500
600
700
800
Pat
ient
s
1985 1987 1989 1991 1993 1995
Data for 1996 is only available for the first 6 months
Results (4) - All Patients
(n=3064)
Age (SD) 59.1 years (10.2)
Males 78.8% (2450)
Diseased vessels (SD) 1.41 (0.61)
Vessel Diameter (SD) 2.63mm (1.10)
Emergency procedure 37.2% (1350)
Results (5) - All Patients
FH of CAD 52.0% (1592)
Hypertension 38.9% (1191)
CVA 1.8% (55)
Diabetes 13.8% (424)
Cholesterol 31.6% (967)
Uric Acid 1.5% (46)
PVD 7.3% (223)
Smoking 34.1% (1046)
Results (6) – UnmatchedCaucasians Asians p-value
Age (SD) 60.4 (10.1) 56.0 (9.56) <0.0001
Male 76.1% 89.8% <0.0001
Diabetes 11.0% 28.2% <0.0001
Uric Acid 1.5% 3.1% 0.047
Diseased vessels
1.38 (0.61) 1.49 (0.65) 0.0024
Vessel width (mm) (SD)
2.66 (1.17) 2.53 (0.85) 0.007
Caucasians
Asians p-value Iran
Age (SD) 60.4 (10.1) 56.0 (9.56)
<0.0001 57.6 (9.6)
Male 76.1% 89.8% <0.0001 90.7%
Diabetes 11.0% 29.4% <0.0001 18.6%
Uric Acid 1.5% 3.1% 0.047 2.3%
Diseased vessels
1.38 (0.61) 1.49 (0.65)
0.0024 1.46 (0.7)
Vessel width (mm) (SD)
2.66 (1.17) 2.53 (0.85)
0.007 2.65 (0.43)
Results (7) – Matched Pairs
Caucasians Asians p-value
Hypertension 35.3% 42.1% 0.036
Diabetes 12.4% 29.4% <0.0001
Diseased vessels(SD)
1.37 (0.60) 1.49 (0.66) 0.012
Vessels treated (SD)
1.17 (0.67) 1.28 (0.84) 0.046
Vessel width (mm) (SD)
2.64 (0.67) 2.53 (0.85) 0.026
Caucasians Iranian p-value
Hypertension 43% 20.9% 0.01
Diabetes 13.9% 18.6% NS
Vessel treated 1.42 1.23 NS
Diseased vessels(SD)
1.54 (0.63) 1.46 (0.7) NS
Chol 32.6 23.2 NS
SMK 27.9 32.6 NS
FH 51.2 39.5 NS
PVD 11.6 2.3 NS
Emergency 23.2 20.9 NS
Matched Caucasian Vs Iran
Results (9) – Trends in Age
30
35
40
45
50
55
60
65
70
Pat
ient
Age
85 86 87 88 89 90 91 92 93 94 95 96
Pakistanis Vs Indians
Pakinstanis(%) (N= 138)
Indians (%)(N= 112)
Hypertension 50.7 31 <0.0001
High Chol 32.6 21.6 0.05
Emergency 56.1 19.3 <0.0001
FH 42.8 56.9 0.02
No DiseasedVessel
1.33 ± 0.59 1.68 ± 0.68 <0.0001
Discussion (1)
• This is one of the first studies looking at ethnic variation in patients attending for coronary angioplasty
Discussion (2) - Asians
• Younger age
• More vessel disease– Hughes et al.(MI - 5.5 years earlier, 3VD)
• Smaller vessels– Dhawan & Bray (quantative angiography)
• Diabetes (29% vs. 11%)– McKeigue et al. (19% vs 4%, known CAD)
Discussion (3)Indians Vs. Pakistanis
• Pakistanis– Hypertension– Cholesterol– Emergency
• Indians– FH of CAD
– More vessel disease (1.68 vs. 1.33)
Discussion (4)Indians Vs. Pakistanis
Inherited factors may have greater role in determining the extent of CAD and factors other than raised cholesterol and hypertension may be involved
Limitations
• Ensuring accuracy of database
• Long-term outcome study
• Coronary artery size
• Changing acceptable level
Conclusions
• Asians patients have significantly greater risk factors than Caucasians
• Pakistanis exhibit more risk factors, but Indians have more widespread disease
• Asians should not be considered a homogenous group
References• Bhopal R et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani,
Bangladeshi, and European origin populations: cross sectional study. BMJ 1999;319:215-220
• Dhawan J, Bray CL. Are Asian coronary arteries smaller than Caucasian? A study on angiographic coronary artery size estimation during life. International Journal of Cardiology 1995;49:267-269
• Dhawan J, Bray CL, Warburton R, Ghambhir DS, Morris J. Insulin resistance, high prevalence of diabetes, and cardiovascular risk in immigrant Asians. Genetic or environmental effect? British Heart Journal 1994;72:413-421
• Farooqi IS, Beevers G, Lip GYH. Insulin resistance, high prevalence of diabetes, and cardiovascular risk in immigrant Asians [letter]. British Heart Journal 1993;73:584
• Hughes LO, Raval U, Raferty EB. First myocardial infarctions in Asians and white men. BMJ 1989 May 20;298:1345-1350
• Khattar RS, Swales JD, Senior R, Lahiri A. Racial variation in cardiovascular morbidity and mortality in essential hypertension. Heart 2000;83:267-271
• McKeigue PM, Shah B, Marmot MG. Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians. Lancet 1991;337:382-386