Prevalence of diabetes and other cardiovascular risk factors in an Iranian population with acute coronary syndrome.

Abstract

Coronary artery disease is the leading cause of death in industrialized countries and most patients with diabetes die from complications of atherosclerosis. The objective of this study was to determine the presence of diabetes mellitus and other conventional coronary heart disease risk factors (cigarette smoking, hypertension and hyperlipidemia) in patients with acute coronary events in an Iranian population.
The study included 514 patients with unstable angina or myocardial infarction (MI) out of 720 patients admitted to CCU ward of a general hospital from March 2003 to March 2005. History of diabetes, hypertension and cigarette smoking, demographic indices, coronary heart disease and diabetes mellitus treatment, myocardial enzymes, serum triglycerides (TG) and cholesterol and fasting and non fasting blood glucose levels and HbA1C of diabetics were recorded of admission sheets. The data were structured to appropriate one way ANOVA, T tests, and chi square test with SPSS 13 product for windows.
Out of all patients 35.8% were female, 30% were diabetics (Duration 13.4 +/- 8.7 years), 42% were smoker and 91% were hypertensive. Twenty four percent had MI and 76% had unstable angina. MI was significantly higher in diabetic patients (36.4% vs. 19.2%, P < 0.001). Location and extension of MI and myocardial enzymes did not differ between diabetics and non-diabetic patients. Diabetic patients were older than non diabetics (65 +/- 11.6 vs. 59.7 +/- 12.5 years, p < 0.05). Five (66.7%) out of 9 patients with fatal MI were diabetics (Odds Ratio = 2.98). Age, duration of diabetes and HbA1c levels, did not differ between diabetic patients with or without MI. Hypertension and current smoking was significantly higher in patients with MI compared to patients with unstable angina (p < 0.05). Serum TG, HDL-C, LDL-C and total cholesterol level did not differ between patients with MI and unstable angina. Diabetic patients compare to non diabetic patients were more hypertensive (96% vs. 88.7%, p < 0.005) and had higher serum triglyceride (TG over 200 mg/dl, 35.1% vs. 26.4, p <0.05). Diabetes was more frequent among women than men (36.4% vs. 26.4%, p < 0.05). Women were older than men (65 +/- 11.6 vs. 59.2 +/- 13 years, p < 0.005) and had higher total serum cholesterol (200 +/- 41.8 vs. 192 +/- 42.5 mg/dl, p < 0.05) and HDL-C levels (49.7 +/- 22 vs. 40 +/- 13 mg/dl, p < 0.005). Ninety seven percent of all patients had at least one of cardiovascular risk factors (hypertension, smoking, diabetes, high cholesterol and low HDL-cholesterol levels).
In this study 19 out of 20 patients with acute coronary event have at least one of conventional cardiac risk factors. Diabetes and hypertension are leading risk factors, which may directly or indirectly interfere and predict more serious complications of coronary heart disease.

Full text

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BioMed Central
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Cardiovascular Diabetology
Open Access
Original investigation
Prevalence of diabetes and other cardiovascular risk factors in an
Iranian population with acute coronary syndrome
Alireza Esteghamati1, Mehrshad Abbasi*2, Manouchehr Nakhjavani3,
Abbas Yousefizadeh4, Amelita P Basa5 and Hamid Afshar6
Address: 1Associate Professor, Faculty of Medicine, Tehran University of Medical Sciences. Keshavarz Blvd, Tehran, Iran, 2Endocrine Department,
Vali-asr Hospital, Tehran University of Medical Sciences, Keshavarz Blvd, Tehran 14197-33147, Iran, 3Professor, Internal Medicine, Head of
Endocrine Division, Vali-asr Hospital, Tehran University of Medical Sciences, Keshavarz Blvd., Tehran 14197-33147, Iran, 4Internal Medicine
Department, Bank-Melli Hospital, Jomhouri Blvd, Tehran, Iran, 5Endocrine Dept, VA Medical Center/Baylor College Of Medicine, Houston, TX,
USA and 6Cardiology Dept. Ochsner Clinic Foundation, New orleans, LA, USA
Email: Alireza Esteghamati - Esteghamati@sina.tums.ac.ir; Mehrshad Abbasi* - mehrshad_abbasi@Yahoo.com;
Manouchehr Nakhjavani - nakhjavanim@sina.tums.ac.ir; Abbas Yousefizadeh - Abbasyousefizadeh@yahoo.com;
Amelita P Basa - amyloubasa@yahoo.com; Hamid Afshar - hamidafshar@yahoo.com
* Corresponding author
Abstract
Background: Coronary artery disease is the leading cause of death in industrialized countries and most patients
with diabetes die from complications of atherosclerosis. The objective of this study was to determine the
presence of diabetes mellitus and other conventional coronary heart disease risk factors (cigarette smoking,
hypertension and hyperlipidemia) in patients with acute coronary events in an Iranian population.
Methods: The study included 514 patients with unstable angina or myocardial infarction (MI) out of 720 patients
admitted to CCU ward of a general hospital from March 2003 to March 2005. History of diabetes, hypertension
and cigarette smoking, demographic indices, coronary heart disease and diabetes mellitus treatment, myocardial
enzymes, serum triglycerides (TG) and cholesterol and fasting and non fasting blood glucose levels and HbA1C
of diabetics were recorded of admission sheets. The data were structured to appropriate one way ANOVA, T
tests, and chi square test with SPSS 13 product for windows.
Results: Out of all patients 35.8% were female, 30% were diabetics (Duration 13.4 ± 8.7 years), 42% were
smoker and 91% were hypertensive. Twenty four percent had MI and 76% had unstable angina. MI was significantly
higher in diabetic patients (36.4% vs. 19.2%, P < 0.001). Location and extension of MI and myocardial enzymes did
not differ between diabetics and non-diabetic patients. Diabetic patients were older than non diabetics (65 ± 11.6
vs. 59.7 ± 12.5 years, p < 0.05). Five (66.7%) out of 9 patients with fatal MI were diabetics (Odds Ratio = 2.98).
Age, duration of diabetes and HbA1c levels, did not differ between diabetic patients with or without MI.
Hypertension and current smoking was significantly higher in patients with MI compared to patients with unstable
angina (p < 0.05). Serum TG, HDL-C, LDL-C and total cholesterol level did not differ between patients with MI
and unstable angina. Diabetic patients compare to non diabetic patients were more hypertensive (96% vs. 88.7%,
p < 0.005) and had higher serum triglyceride (TG over 200 mg/dl, 35.1% vs. 26.4, p <0.05). Diabetes was more
frequent among women than men (36.4% vs. 26.4%, p < 0.05). Women were older than men (65 ± 11.6 vs. 59.2
± 13 years, p < 0.005) and had higher total serum cholesterol (200 ± 41.8 vs. 192 ± 42.5 mg/dl, p < 0.05) and
HDL-C levels (49.7 ± 22 vs. 40 ± 13 mg/dl, p < 0.005). Ninety seven percent of all patients had at least one of
cardiovascular risk factors (hypertension, smoking, diabetes, high cholesterol and low HDL-cholesterol levels).
Conclusion: In this study 19 out of 20 patients with acute coronary event have at least one of conventional
cardiac risk factors. Diabetes and hypertension are leading risk factors, which may directly or indirectly interfere
and predict more serious complications of coronary heart disease.
Published: 17 July 2006
Cardiovascular Diabetology 2006, 5:15doi:10.1186/1475-2840-5-15
Received: 27 June 2006
Accepted: 17 July 2006
This article is available from: http://www.cardiab.com/content/5/1/15
© 2006 Esteghamati et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Background
The most important complication of Type 2 diabetes Mel-
litus (DM) is coronary heart disease (CHD) which
presents with increased mortality and morbidity com-
pared to the non-diabetic population. In the Framingham
Heart Study, the presence of diabetes doubled the age-
adjusted risk for cardiovascular disease in men and tripled
it in women. Diabetics comprise as many as 20 percent of
those who require percutaneous transluminal coronary
angioplasty (PTCA) & coronary artery bypass graft surgery
(CABG). Coincidence of co-morbidities put diabetic
patients in higher risk for CHD and its mortality. Moreo-
ver diabetes itself is considered as a CHD risk factor or
even CHD equivalent [1]. Patients with diabetes and with-
out previous myocardial infarction (MI) have as high a
risk of MI as persons without diabetes and with a previous
MI, and that the cardiovascular risk factors of both groups
should be treated equally aggressively. Major epidemio-
logical studies raised concerns about the importance of
DM as an independent and important CHD risk factor [2].
The aim of this study was to determine the prevalence of
diabetes and CHD risk factors in patients with acute coro-
nary syndrome (ACS).
Methods
We studied the patients who were admitted in CCU ward
of a general hospital between March 2003 and March
2005 with ACS. Information was obtained from the
archived data sheets about patient demographic charac-
teristics and medical history concerning their age, sex, his-
tory of diabetes, duration of diabetes, hypertension,
smoking, previous hospital admissions, previous ACS,
treatment modalities of coronary heart disease and diabe-
tes, and revascularization. Laboratory data including
myocardial enzymes, serum triglycerides and total choles-
terol, high-density lipoprotein cholesterol (HDL-C), low-
density lipoprotein cholesterol (LDL-C) levels, fasting and
non-fasting blood glucose levels (FBS and BS respectively)
and glycated hemoglobin (HbA1C) were collected. Diag-
nosis, type of MI, management and interventional proce-
dures, and in-hospital outcomes were also recorded. The
criteria for the diagnosis of MI, type of MI, and unstable
angina were based on clinical presentation, biochemical
makers of acute ischemic injury, and electrocardiographic
findings. Patients were classified as diabetics based on the
review of medical records. Dyslipidemia was defined
according to ATPIII. Information regarding diabetes treat-
ment modalities (insulin versus oral hypoglycemic agents
and/or diet) was also collected.
Five hundred and fourteen out of 720 patients who were
admitted to the CCU during interested period were
included in the study. Patients with congestive heart fail-
ure, cardiomyopathy and severe comorbids and patient
who were admitted due to known valvular disease were
excluded. The data were structured to appropriate one way
ANOVA, T tests, and chi square test with SPSS 13 product
for windows
Results
Out of 514 patients 125 (24.3 %) had MI and 389(75.7%)
had unstable angina. Data concerning the prevalence of
conventional risk factors in patients with myocardial inf-
arction and unstable angina is shown in table 1. Patients
with MI compared to those with unstable angina had
higher FBS (158.6 ± 93.6 vs. 116.6 ± 49.9 mg/dl; p <
0.005), BS (189.4 ± 118.4 vs. 139.4 ± 69.3 mg/dl; p <
0.005), and HbA1c (10 ± 2.4 vs. 9.1 ± 3%; p < 0.05). There
was no significant difference between patients with MI
and unstable angina regarding age (62.2 ± 12.4 vs. 61 ± 13
years) and duration of diabetes (14.5 ± 8.7 vs.12.9 ± 8.7
years). Two third (330, 64.2%) of patients were male. The
frequencies of risk factors in different genders are summa-
rized in table 2.
Myocardial infarction was more frequent in diabetic
patients (one out of three, 36.4%) compared to non-dia-
betic patients (one out of five, 19.2%, p < 0.005, OR =
2.4). They were more hypertensive than non-diabetic
patients (96.1% vs. 88.6, p <0.005) but smoking fre-
quency was the same as non-diabetic patients. Diabetics
patients with MI had significantly higher BS (274.7 ±
130.8 vs. 216 ± 89.6 mg/dl, p < 0.005), FBS (222 ± 109.3
vs.167.3 ± 75.6 mg/dl, p <0.01) and HbA1c (10 ± 2.4 vs.
9.1 ± 3%, p < 0.05) than diabetic patients with unstable
angina. Comparing diabetic with non-diabetic patients,
serum total Cholesterol, LDL-C and HDL-C were the
same. There were also the same in hypertensive and nor-
motensive patients.
Diabetic patients had higher serum TG levels than non
diabetic patients (179 vs. 161 mg/dl, p < 0.05). The age of
diabetic patients with or without MI was the same as non-
diabetic patients.
Hypertensive patients had higher MI compared to normo-
tensive patients (25.7% vs.10.6%, p < 0.05). Frequency of
MI was higher in smokers than non-smokers (30.6% vs.
19.8%, p <0.005). Smoker patients were younger than
non-smoker patients (58.9 ± 13.6 vs. 63 ± 12 years, P <
0.005). Serum HDL-cholesterol level was lower in smoker
patients than non-smoker patients (39 ± 10.5 vs. 46.8 ±
20.4 mg/dl, p < 0.005). Accumulation of multiple risk fac-
tors in patients with MI and unstable angina is shown in
graph 1. Frequency of MI in patients with three risk factors
(DM, HTN, and smoking) was significantly higher than
patients with no risk factors, one or two risk factors. Fre-
quencies of different types of MI in our patients are listed
in table 3.

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Nine patients died in hospital, which included 5 patients
with extensive MI, 2 patients with anterior MI and 2
patients with inferior MI; 5 of them were diabetics
(75.6%). BS and HbA1c of patients who died were higher
than patients with MI who survived (p < 0.05 and p <
0.005 respectively).
Discussion
Diabetes, hypertension, smoking and dyslipidemia, are
common in patients with ACS. In this study type 2 diabe-
tes was fairy common in patients with acute coronary
events as is shown in the San Antonio Heart Study. Unlike
other cardiovascular risk factors such as high serum lipid
levels, cigarette smoking, and blood pressure, which are
either declining or under progressively better medical
management and control, and unlike cardiovascular mor-
tality, which is also declining, obesity and type 2 diabetes
are exhibiting increasing trends [3].
Moreover CHD is the leading cause of morbidity and mor-
tality in patients with diabetes mellitus and Diabetes is a
poor prognostic factor in ACS [4,5]. Our data also shows
that patients with diabetes more likely experience acute
MI than patients without diabetes in acute coronary
events.
Our data concerning higher prevalence of MI and female
sex predominance in ACS patients with DM is consistent
with report from multinational observational Global Reg-
istry of Acute Coronary Events (GRACE),[6]. According to
GRACE approximately 1 in 4 patients with ACS presented
with a history of diabetes. They were more often women
(as in GUSTO-IIb study [7] and Lowel et al [8])and they
were also more likely to die during the acute hospitaliza-
tion with a greater prevalence of comorbidities and coro-
nary risk factors [9]. They were older and less likely to be
current cigarette smokers. Other studies showed that dia-
betic patients with ACS are younger [1,10] and less likely
to be current cigarette smoker [11,12]. In this study 1 out
of 3 patients with ACS were diabetic and diabetes was
more common in females but MI, ACS, and in-hospital
mortality frequency were the same in both sexes. Diabet-
ics were older and more hypertensive but as current
smoker as non-diabetic patients.
Based on Framingham Study the relative impact of diabe-
tes is substantially greater for women than for men.
Whereas non-diabetic women have lower relative CHD
risk compared to non-diabetic men, cardiovascular mor-
tality and morbidity was actually about as great for dia-
betic women as for diabetic men [13] as we found in this
study. Although it is suggested that the excess relative risk
of CHD mortality in women vs. men with diabetes might
disappear after adjusting for classic CHD risk factors [14]
Tight control of BP in diabetic patients reduces all diabe-
tes-related end points and occurrence of stroke, Heart fail-
ure and retinopathy but do not interfere with MI,
peripheral vascular disease and renal failure [15]. Up to
70% of adult patients with type 2 diabetes have hyperten-
sion [16]. The relationship between blood pressure and
cardiovascular events in type 2 diabetes is noted in pro-
spective studies [17]. Taken together, these studies suggest
that an increase in systolic BP is associated with increased
cardiovascular events. This is supported by an epidemio-
logic analysis of UKPDS data in which each 10 mmHg
increase in systolic blood pressure increased the risk of MI
Table 2: The frequencies of risk factors in different genders. *
indicates P < 0.005 and + indicates p < 0.05.
Female(%)Male(%)
MI
DM+
HTN*
Smoking*
Cholesterol+
Tg
LDL
HDL*
Age*
40(21.7)
67(36.4)
179(97.3)
19(10.3)
199.9+-41.8
188.4+-88.3
114+-36
49.7+-21.9
65+-11.6
85(25.8)
87(26.4)
288(87.3)
197(59.7)
192.1+-42.5
170.6+-97.3
112.3+-37.4
40.2+-13.3
59.6+-13
Table 1: The prevalence of conventional risk factors in patients with myocardial infarction and unstable angina. * indicates that the
difference between patients with UA (unstable angina) and MI (myocardial infarctions) is significant.
Patients with UAPatients with MIAll patients
DM*
Hypertension+
Smoking*
History of previous ACS
Hypertriglyceridemia
Hypercholesterolemia
High LDL
Low HDL
total
98(25.2)
347(89.2)
150(38.6)
51(13.3)
200(51.4)
157(40.4)
123(64.1)
150(78.1)
389(75.7)
56(44.6)
120(96)
66(52.8)
17(13.6)
52(41.6)
58(46.4)
34(63)
33(61.1)
125(24.3)
154(30%)
467(90.9)
216(42)
68(13.3)
252(49)
215(41.8)
157(63.8)
183(74.4)
514

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by 11%. We also showed that hypertension is common in
ACS patients especially in our diabetic patients and it
increases the risk of MI.
Serum cholesterol, blood pressure, and smoking are mod-
ifiable risk factors and are key points to influence and
effect on CHD mortality and risk in diabetes [18]. Dyslip-
idemia is regarded as highly predictive cardiovascular dis-
ease (CVD) risk factor [19] but in our study patients with
ACS and DM did not have higher serum cholesterol com-
pared to non-diabetics with ACS. This may be due to treat-
ment of patients with cholesterol lowering agents as
shown in GRACE.
We showed that diabetic patients with poor blood glucose
control as indicated by higher HbA1c and/or higher BS
and FBS had more MI and also non diabetics with ele-
vated blood glucose levels were more likely to have MI. It
is possible to simply attribute high FBS/BS to greater stress
imposed by MI, but according to analysis of the Paris Pro-
spective study and the British Regional Heart Study, mor-
tality of non-diabetics with isolated 2-h post-challenge
hyperglycemia is higher than non-diabetic normoglyc-
emic [20,21]. It is suggested that prediabetic subjects have
an atherogenic pattern of risk factors (possibly caused by
obesity, hyperglycemia, and especially hyperinsulinemia)
which may be present for many years and may contribute
to the risk of macrovascular disease [22]. Furthermore in
Honolulu Heart Program the age-adjusted and risk factor-
adjusted relative risks for CHD, deaths from CHD, and
total deaths were higher in the asymptomatic hyperglyc-
emic and known diabetics compared to low- normal eug-
lycemics [23]. On the other side, it is reported that
intensive blood glucose control which significantly
reduced HbA1c compared to conventional treatment do
not reduce significantly risk of diabetes-related death, all-
cause mortality, and risk of MI [24]. Hyperinsulinemia
and hyperglycemia might affect through their comorbidi-
ties as hypertension, dyslipidemia, and central body fat
distribution [25,26].
Our study is compatible with previous findings which
showed no significant differences in localization of MI
and development of Q wave in diabetics and non-diabetic
patients [27]
Survival rate after myocardial infarction decreases in type-
2 diabetic patient [28], and even diabetes and MI are sim-
ilarly strong predictors of total mortality [29]. It seems
that diabetes independently darkens the prognosis of MI
and it is reported that at every risk factor level, the abso-
Frequency of myocardial infarction (MI) in patients with mul- tiple risk factors
Figure 1
Frequency of myocardial infarction (MI) in patients with mul-
tiple risk factors. *indicates significant difference in frequency
of MI between patients with smoking (Sm), hypertension
(HTN), and diabetes (DM) with other groups. # indicates sig-
nificant difference in frequency of MI in patients with HTN
plus DM compared to patients with HTN and to patients
without risk factor. ¶indicates significant difference in fre-
quency of MI between patients with Sm plus DM compare to
those with HTN.
Sm HTN DM HTN DMSm DM HTNNo Risk
Cumulative Risk Factors
200
150
100
50
0
Count
ua
mi
dx
25.4%
30%
Textbox
16.6%
48.3%
*
#
¶
Table 3: Frequencies of different types of myocardial infarction in patients. There were no differences between distribution of MI
between those with and without diabetes. Data of 8 patients is missing.
MI distribution Non diabetics N(%) Diabetics N(%)All Patients N(%)
Anterior
Antrolateral
Antroseptal
Inferior ± Posterior
Lateral
Septal
Extensive
Total Q wave
Non Q wave
19(30)
1(1.6)
8(12.5)
24(37.5)
2(3.1)
0
1(1.6)
55(86)
9(14)
10(18.9)
2(3.7)
11(20.7)
17(32.1)
1(1.9)
1(1.9)
5(9.4)
47(88.7)
6(11.3)
29(24.8)
3(2.6)
19(16.2)
41(35)
3(2.6)
1(0.8)
6(5.1)
102(87.2)
15(12.8)

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lute risk of age-adjusted coronary death rate is three times
greater for diabetic men than non-diabetic men [30,31].
Our study is concordant with these findings but a limita-
tion of our study was that we only collected the records of
in-hospital mortality and based on low mortality rate
therefore we can not come to any conclusion about the
effect of diabetes on mortality of ACS. Due to our study
setting which included patients with relatively regular fol-
low up our results could not be easily generalized to gen-
eral populations. Furthermore the present study suffers of
the limitations of other single center, uncontrolled regis-
try, cross sectional studies, which debilitated us to gener-
alize our results and test the causal association among
variables. Finally, we did not have the data concerning
central obesity, insulin resistance, and minor and new car-
diovascular risk factors including albuminuria, homo-
cystinemia, C-reactive protein (CRP), and adiponectin.
Strength of our study is our Iran population sample,
which allows comparison between reportedly encoun-
tered data of developed countries and a different ethnicity
of a developing country. We would like to highlight the
different findings in different genders which might
uncover substantial differences between CVD risks males
and females.
Conclusion
Diabetes is common in patients with ACS and is a herald
for more severe complications as MI and mortality. This
increased risk is partly attributed to hypertension, smok-
ing and dyslipidemia, which are common in patients with
ACS. In this study, frequency of hypertension, hypercho-
lesterolemia and smoking in diabetics were the same as
non-diabetics, thus diabetes itself play an independent
role in increasing CVD risk. Hyperglycemia increases the
risk of MI even in non diabetic patients with ACS.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
AR conceived and designed the study, carried out the data
collection, participated in literature review and edited the
manuscript. MA conducted the statistical analyses and lit-
erature review, drafted the manuscript, and participated in
data collection. MN provided expertise and oversight
throughout the process. AY participated in data collection.
APB and HA reviewed drafts. All authors read and
approved the final manuscript.
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