Prevalence of ACS and Causal Relation of Hypomagnesaemia

Abstract

Magnesium is an important intracellular cation [1], actually the second most abundant cation after Potassium, which has gained an essential role in normal human homeostasis. Low serum magnesium has been detected commonly in around 12% hospitalized patients and even more commonly in Intensive Care Patients as high as 60 to 65%.

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*Corresponding author: E-mail: gynaroo@dha.gov.ae;
British Journal of Medicine & Medical Research
12(7): 1-5, 2016, Article no.BJMMR.19850
ISSN: 2231-0614, NLM ID: 101570965
SCIENCEDOMAIN international
www.sciencedomain.org
Prevalence of ACS and Causal Relation of
Hypomagnesaemia
Bina Nasim
1
, Ahmed Sajjad
1
, Zafar Khan
1
, Zulfiqar Ali
1
, Anis Sheikh
1
,
Tanvir Yadgir
1
, Wajahat Khan
1
, Omer Sakaf
1
and Ghulam Yasin Naroo
1*
1
Emergency Medicine, Rashid Hospital, Dubai, United Arab Emirates.
Authors’ contributions
This work was carried out in collaboration between all authors. All authors read and approved the final
manuscript.
Article Information
DOI: 10.9734/BJMMR/2016/19850
Editor(s):
(1) Chan-Min Liu, School of Life Science, Xuzhou Normal University, Xuzhou City,
China.
Reviewers:
(1) Mohmed Ashmaig, Health Diagnostics Laboratory, USA.
(2)
Julio Sergio Marchini, Sao Paulo University, Brazil.
Complete Peer review History:
http://sciencedomain.org/review-history/12387
Received 30
th
June 2015
Accepted 23
rd
October 2015
Published 21
st
November 2015
ABSTRACT
Magnesium is an important intracellular cation [1], actually the second most abundant cation after
Potassium, which has gained an essential role in normal human homeostasis. Low serum
magnesium has been detected commonly in around 12% hospitalized patients and even more
commonly in Intensive Care Patients as high as 60 to 65%.
The link of low serum magnesium with acute coronary syndrome is being discussed widely and its
actual role is being scrutinized [2,3].
Recently, Hypomagnesaemia has also been found to play an important role in the pathogenesis of a
variety of clinical disorders including Hypertension, Diabetes Mellitus, Atherosclerosis and Acute
Coronary Syndromes [4-8].
Acute coronary syndrome (ACS) has been defined as a group of conditions due to decreased blood
flow in the coronary arteries. Acute coronary syndrome includes a vast spectrum like: ST elevation
myocardial infarction (STEMI / 30%), non ST elevation myocardial infarction (NSTEMI / 25%), or
unstable angina (U.A. / 38%).These are described according to ECGs and Cardiac Biomarkers of
myocardial necrosis (troponin T, troponin I, and CK MB), in patients presenting with acute cardiac
chest pain (Medscape).
Original Research Article

Nasim et al.; BJMMR, 12(7): 1-5, 2016; Article no.BJMMR.19850
2
Aim:
To look for any association between Hypomagnesaemia and Acute Coronary Syndrome.
Materials and Methods: It’s a retrospective study involving 1198 patients who presented to the
Accident and Emergency department (A & E), Trauma Center, Rashid Hospital, Dubai, with Acute
Coronary Syndrome (ACS) between April 2010 and May 2013.
We reviewed the records of all patients including their clinical history and presentation.
The Magnesium levels of all the patients in the ACS pathway were checked along with, Cardiac
biomarkers - Troponin, CPK and CK MB and Lipid profiles were also analyzed.
A Chi-Square test was performed at 5% level of significance to test the null hypothesis of no
association between cardiac markers, lipid profile and magnesium level.
Inclusion Criteria: All new patients presenting to A & E Department at Rashid Hospital with an
acute coronary syndrome (both NSTEMI & STEMI).
All new patients presenting with non-specific chest pain who test positive for cardiac markers.
All the age groups presenting to A & E Department at Rashid Hospital from 11/04/2010- 30/05/2013
were included. Both the genders were included.
Exclusion Criteria: Patients diagnosed initially with acute coronary syndrome that eventually had
negative cardiac markers.
Results: Out of 1198, 1087(91%) patients were male. 49% were between 50 and 75 years of age
group whereas 46% were between 25 years and 50 years of age. 77% patients were Asians and
17% belonged to Arabic peninsula. The Magnesium level was normal in 1097(92%), low in
63(5.3%). Troponin was negative in 431(36%) and positive in 767(64%) patients with low, medium
and high levels in 338(28.2%), 426(35.5%) and 03(0.3%) respectively.
These results indicate that there is no statistically significant association between Magnesium levels
and Troponin groups (positive and negative) (chi-square with two degree of freedom = 3.30,
p = 0.192).
Conclusion: Our study proves that there is no significant association between Hypomagnesaemia
and Acute Coronary Syndrome.
Keywords: Acute Coronary Syndrome (ACS); ST Elevation Myocardial Infarction (STEMI); Non ST
Elevation Myocardial Infarction (NSTEMI); Unstable Angina (U.A); Atherosclerosis in Risk
Community Study (ARIC); The National Health and Nutritional Examination Survey
(NHANES); The Second Leicester Intravenous Magnesium Intervention Trial (LIMIT-2);
Dubai Health Authority (DHA).
1. INTRODUCTION
Magnesium along with Potassium is the second
most abundant intracellular cation and 4
th
most
abundant cation in the human body. The total
magnesium content in the body of an average
adult is around 25 Gm or 1000 mmol. About 60%
of the body reserve of magnesium is found in the
skeletal bone mass, about 20% is in muscle and
another 20% is in soft tissues and liver. Normal
plasma Magnesium concentration is from 1.7 to
2.5 mg/dl, with about 1/3
rd
bound to protein
(33%) and 2/3
rd
existing as free cation. (12%
complexed with Anions & 55% in free ionized
form).
Magnesium homeostasis is controlled by
absorption that takes place in the upper small
intestine, where nearly 30 to 50% of consumed
magnesium is taken up depending upon the
endogenous magnesium status. The excretion of
magnesium is mainly by the kidneys. Nutritional
sources include green vegetables, cereal, grain,
nuts, legumes, and chocolate. Vegetables, fruits,
meats, and fish have intermediate values.
The pathogenesis of hypertension and diabetes
has been linked to low serum magnesium [4-6].
Recent studies have shown that serum
magnesium is inversely related to
hospitalizations and mortality in patients with
coronary heart disease [9].
According to American heart association (AHA),
serum magnesium level must be >2.0 mg/dl in
patients with acute myocardial infarction as
normal magnesium levels are thought to protect
the myocardium from reperfusion injury.
Supplementation of magnesium is thought to
improve endothelial function, inhibits the function
of platelets, causes dilatation of the coronaries,
reduces the afterload and also suppresses the
release of catecholamines, which prevents the
extension of an infarct.

Nasim et al.; BJMMR, 12(7): 1-5, 2016; Article no.BJMMR.19850
3
1.1 Aims and Objectives
To assess the relationship between low serum
magnesium and Acute Coronary Syndrome.
2. MATERIALS AND METHODS
It’s a retrospective study involving 1198 patients
who presented to the A & E Department, Trauma
Center, Rashid Hospital, Dubai, with Acute
Coronary Syndrome (ACS) between April 2010
and May 2013.
We reviewed the records of all patients including
their clinical history and presentation. The
Magnesium levels of all the patients in the ACS
pathway were checked along with, Cardiac
biomarkers - Troponin, CPK and CK MB and
Lipid profiles were also analyzed. The results
were recorded in a chart to determine a
correlation between patients who have
hypomagnesaemia and acute coronary
syndrome.
A Chi-Square test was performed at 5% level of
significance to test the null hypothesis of no
association between cardiac markers, lipid profile
and magnesium level.
2.1 Normal Reference Ranges
Magnesium- 1.7-2.5 meq/L. Low-<1.7 meq/L,
high->2.5 meq/L.
Troponin-Negative-<0.01 ng/ml, Positive-<0.10
ng/ml-low risk, >0.1 ng/ml- medium or high risk.
CPK- 0-167 iu/L, high- >167 iu/L. CKMB- 0-24
iu/L, high- >24 iu/L.
Cholesterol- 50-200 mg/dl, high->200 mg/dl.
2.1.1 Inclusion criteria
All new patients presenting to A & E Department
at Rashid Hospital with an acute coronary
syndrome (both NSTEMI & STEMI).
All new patients presenting with non-specific
chest pain who test positive for cardiac markers.
All the age groups presenting to A & E
Department at Rashid Hospital from 11/04/2010-
30/05/2013.
Both the genders were included.
2.1.2 Exclusion criteria
Patients diagnosed initially with acute coronary
syndrome that eventually had negative cardiac
markers.
3. RESULTS
A total of 1198 patients’ data with Acute
Coronary Syndrome was analyzed. 1087(90.7%)
were male and 111(9.3%) female. 1141(95.3%)
patients were between 25 to 75 years of age
whereas 49(4.1%) belonged to more than 75
years. 08(0.7%) patients were below 25 years.
1135(94.8%) belonged to Asia including Arab
peninsula. Rest was from Europe (2.8%) and
other regions (2.4%). Cholesterol level was
normal in 618(51.6%) and high in 580(48.4%)
patients. CKMB level was high in 570(47.6%)
and normal in 628(52.4%) patients. The
Magnesium level was normal in 1097(92%), low
in 63(5.3%) and high in 38(3.2%) patients.
Troponin was negative in 431(36%) and positive
in 767(64%) patients with low, medium and high
levels in 338(28.2%), 426(35.5%) and 03(0.3%)
respectively.
These results indicate that there is no statistically
significant association between Magnesium
levels and Troponin groups (positive
and negative) (chi-square with two degree of
freedom = 3.30, p = 0.192).
There is no statistically significant association
between CKMB levels and Magnesium levels
(chi-square with two degree of freedom = 0.93,
p = 0.628).
There is no statistically significant association
between Cholesterol levels and Magnesium
levels (chi-square with two degree of freedom =
4.26, p = 0.119).
4. DISCUSSION
Low serum magnesium has long been
considered as a risk factor for cardiac
arrhythmias but its association has been shown
now with coronary heart disease also. Evidence
from The Atherosclerosis in Risks communities
study (ARIC) [2,6], involving over 15,000 patients
over seven year period showed inverse
relationship between low magnesium and carotid
wall thickness. It also linked low serum
magnesium to hypertension, diabetes and
cardiovascular disease.

Nasim et al.; BJMMR, 12(7): 1-5, 2016; Article no.BJMMR.19850
4
The National health and Nutritional Examination
Survey (NHANES I) [10], follow up study also
showed inverse relationship between Serum
Magnesium and the hospitalization and mortality
in patients with Coronary Heart Disease. It
showed the link of certain dietary risk factors
which are modifiable like dietary magnesium,
alcohol, smoking, lifestyle and exercise, diuretic
use and certain individual characteristics like
race and lipid profile with coronary heart disease.
An important effect of Magnesium is the inhibition
of the production of catecholamine from the
adrenal medulla, thereby suppressing their
arrythmogenic effect and also inhibiting their
vasoconstrictor effect which reduces the
incidence of Unstable Angina and Acute
Myocardial infarction (AMI).
The Second Leicester Intravenous Magnesium
Intervention Trial (LIMIT-2) [11], study, which
was a double blind randomized trial of over 2000
patients, incorporated patients with suspected
Acute Myocardial Infarction who were given
either iv Magnesium or placebo prior to receiving
reperfusion therapy (thrombolysis). And it
showed a reduction in the mortality of elderly
patients and lower incidence of ventricular
arrhythmias.
But the results of the Fourth International Study
of Infarct Survival (ISIS-4) [12], in contrary to the
above studies showed that the 24 hour
intravenous infusion of Serum Magnesium in
patients with Acute Myocardial Infarction given
after thrombolytic agent was administered did not
have any positive effect on the hospitalization or
the mortality of the AMI patients.
5. CONCLUSION
The conclusion of our study is that low serum
magnesium is not a risk factor for acute coronary
syndrome, as there is no statistical significant
relationship between low serum magnesium and
the occurrence of acute coronary syndrome. Our
study also shows that there is no statistical
relationship between hypomagnesemia and high
blood cholesterol levels.
CONSENT
Patient’s record is accessible by authorized
personals only however consent of patients is not
applicable in this study.
ETHICAL APPROVAL
Ethical approval has been obtained from DHA
Medical Research Committee.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
REFERENCES
1. Altura BM, Brodsky MA, Elin RJ, et al.
Magnesium: Growing in clinical
importance. Patient Care. 1994;10:130-
150.
2. Liao F, Folsom AR, Brancati FL. Is low
magnesium concentration a risk factor for
coronary heart disease? The
atherosclerosis risk in communities study.
Am Heart J. 1998;136:480.
3. Taneva E. Hypokaliaemia and
hypomagnesemia during acute coronary
syndrome: A- 661. European Journal of
Anaesthesiology. 2005;22:172.
4. Altura BM, Aimin Z, Altura BT. Magnesium,
hypertensive vascular disease,
atherogenesis, subcellular compartment-
tation of calcium and magnesium and
vascular contractility. Miner Electrolyte
Metab. 1993;19:323-336.
5. Paolisi G, Barbagallo M. Hypertension,
diabetes, and insulin resistance: The role
of intercellular magnesium. Am J
Hypertension. 1997;10:346-355.
6. Ma J, Folsom AR, Melnick SL, Eckfeldt JH,
Sharret AR, Nabulsi AA, et al. Associations
of dietary magnesium with cardiovascular
disease, hypertension, diabetes, insulin
and carotid arterial wall thickness: The
ARIC study. J Clin Epidemiol. 1995;48:
927-40.
7. Singh RB, Rastogi SS, Ghosh S, Niaz MA.
Dietary and serum magnesium levels in
patients with acute myocardial infarction,
coronary artery disease and non-cardiac
diagnoses. J Am Coll Nutr. 1994;13:139-
43.
8. Kafka H, Langevin L, Armstrong PW.
Serum magnesium and potassium in acute
myocardial infarction: Influence on
ventricular arrhythmias. Arch Intern Med.
1987;147:465-9.
9. Woods Kl, Flether S. Long term outcome
after intravenous magnesium sulfate in
suspected acute myocardial infarction, the

Nasim et al.; BJMMR, 12(7): 1-5, 2016; Article no.BJMMR.19850
5
second Leicester intravenous magnesium
intervention trial. LIMIT-2. Lancet; 1994.
10. The role of modifiable dietary and
behavioral characteristics in the causation
and prevention of coronary heart disease
hospitalization and mortality-NHANES
follow up study-1.
11. Woods Kl, Flether S. Long term outcome
after intravenous magnesium sulfate in
suspected acute myocardial infarction. The
second Leicester intravenous magnesium
intervention trial. LIMIT-2. Lancet; 1994.
12. ISIS-4, the Fourth International Study of
Infarct Survival- Lancet; 1995.
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