Acute coronary syndrome in young adults from a Malaysian tertiary care centre

Smoking prevalence, exposure to secondhand smoke, and factors associated with smoking among medical, dental, and pharmacy students in a public university in Malaysia

INTRODUCTION

Smoking among medical, dental, and pharmacy students is an issue in every university worldwide, which will impact future smoking cessation services as they are future healthcare providers. This study investigates the smoking prevalence, exposure to secondhand smoke, and factors associated with smoking among medical, dental, and pharmacy students at a public university in Malaysia.

METHODS

The self-administered online survey utilized in this cross-sectional study was derived from the Global Health Professions Students Survey (GHPSS), which involved medical, dental, and pharmacy students. A total of 328 participants completed a questionnaire from June to August 2022, with a response rate of 91.1%.

RESULTS

The overall smoking prevalence was 4.6% among the medical, dental, and pharmacy students who participated in this study; 46.7% of current smokers were exposed to secondhand smoke at home compared to 17.6% of non-smokers (p=0.011); and 66.7% of smokers were exposed to secondhand smoke in public compared to 40.3% of non-smokers (p=0.043). In all, 99.1% of respondents supported the smoking ban and 46.7% of current smokers supported the smoking ban in discos/bars/pubs, compared to 82.0% of non-smokers (p=0.002). Of the participants, 96.6% received lessons on the danger of tobacco, and 65.5% received smoking cessation training. Among factors associated with current smoking was gender; male students had a 19-fold higher likelihood of smoking than female students (adjusted odds ratio, AOR=19.25; 95% CI: 4.25-87.19, p<0.001). In addition, home exposure to secondhand smoke was four times more common for current smokers (OR=4.11; 95% CI: 1.43-11.79, p=0.009).

CONCLUSIONS

Although smoking prevalence was low among the students in this study, there was a higher percentage of them exposed to secondhand smoke at home and in public.

Smoking and Unstable Plaque in Acute Coronary Syndrome: A Systematic Review of The Role of Matrix Metalloproteinases

Smoking is a risk factor of acute coronary syndrome (ACS) that could increase matrix metalloproteinases (MMPs) levels, leading to unstable coronary artery plaque. The current review aimed to identify the relationship between smoking and MMPs in patients with ACS. Literature search was conducted from inception until March 2022 in three online databases. Risk of bias was assessed using the Newcastle-Ottawa Scale. A meta-analysis was performed, and the odds ratio (OR) together with its 95% confidence interval (CI) were determined. A total of 7,843 articles were identified, and only seven studies were included. Four studies investigated the MMP-3 and MMP-9 related genes and found that smokers with certain MMPs genotypes had high risk of ACS. Smoking also increased the MMPs level in patients with ACS compared with non-smokers. Additionally, a meta-analysis of two studies resulted in an increased odd of ACS in smokers with MMP-3 5A allele versus non-smokers with MMP-3 6A6A allele (OR: 15.94, 95% CI: 10.63-23.92; I2 =55%). In conclusion, the current review highlights the role of MMPs in relation to smoking and ACS. The determination of these roles may help in identifying new ACS markers among smokers and the development of drug-targeted treatment.

In-hospital mortality risk stratification of Asian ACS patients with artificial intelligence algorithm

BACKGROUND

Conventional risk score for predicting in-hospital mortality following Acute Coronary Syndrome (ACS) is not catered for Asian patients and requires different types of scoring algorithms for STEMI and NSTEMI patients.

OBJECTIVE

To derive a single algorithm using deep learning and machine learning for the prediction and identification of factors associated with in-hospital mortality in Asian patients with ACS and to compare performance to a conventional risk score.

METHODS

The Malaysian National Cardiovascular Disease Database (NCVD) registry, is a multi-ethnic, heterogeneous database spanning from 2006-2017. It was used for in-hospital mortality model development with 54 variables considered for patients with STEMI and Non-STEMI (NSTEMI). Mortality prediction was analyzed using feature selection methods with machine learning algorithms. Deep learning algorithm using features selected from machine learning was compared to Thrombolysis in Myocardial Infarction (TIMI) score.

RESULTS

A total of 68528 patients were included in the analysis. Deep learning models constructed using all features and selected features from machine learning resulted in higher performance than machine learning and TIMI risk score (p < 0.0001 for all). The best model in this study is the combination of features selected from the SVM algorithm with a deep learning classifier. The DL (SVM selected var) algorithm demonstrated the highest predictive performance with the least number of predictors (14 predictors) for in-hospital prediction of STEMI patients (AUC = 0.96, 95% CI: 0.95-0.96). In NSTEMI in-hospital prediction, DL (RF selected var) (AUC = 0.96, 95% CI: 0.95-0.96, reported slightly higher AUC compared to DL (SVM selected var) (AUC = 0.95, 95% CI: 0.94-0.95). There was no significant difference between DL (SVM selected var) algorithm and DL (RF selected var) algorithm (p = 0.5). When compared to the DL (SVM selected var) model, the TIMI score underestimates patients' risk of mortality. TIMI risk score correctly identified 13.08% of the high-risk patient's non-survival vs 24.7% for the DL model and 4.65% vs 19.7% of the high-risk patient's non-survival for NSTEMI. Age, heart rate, Killip class, cardiac catheterization, oral hypoglycemia use and antiarrhythmic agent were found to be common predictors of in-hospital mortality across all ML feature selection models in this study. The final algorithm was converted into an online tool with a database for continuous data archiving for prospective validation.

CONCLUSIONS

ACS patients were better classified using a combination of machine learning and deep learning in a multi-ethnic Asian population when compared to TIMI scoring. Machine learning enables the identification of distinct factors in individual Asian populations to improve mortality prediction. Continuous testing and validation will allow for better risk stratification in the future, potentially altering management and outcomes.

Identification of cardiovascular risk factors among urban and rural Malaysian youths

Background

Coronary artery disease (CAD) is one of the major causes of morbidity and mortality worldwide. Early identification of the cardiovascular risk factors (CRF) among youths assists in determining the high-risk group to develop CAD in later life. In view of the modernised lifestyle, both urban and rural residing youths are thought to be equally exposed to various CRF. This study aimed to describe the common CRF including obesity, dyslipidaemia, hypertension, smoking and family history of hypercholesterolaemia and premature CAD in youths residing in urban and rural areas in Malaysia.

Methods

We recruited 942 Malaysian subjects aged 15–24 years old [(males = 257, and urban = 555 vs. rural = 387, (mean age ± SD = 20.5 ± 2.1 years)] from the community health screening programmes organised in both rural and urban regions throughout Malaysia. Medical history and standardised anthropometric measurements were recorded. Laboratory investigations were obtained for fasting serum lipid profiles and plasma glucose levels.

Results

A total of 43.7% from the total study population was either obese or overweight. Youths in the rural were more overweight and obese (49.4% vs. 42.7%, p < 0.044) and have higher family history of hypercholesterolaemia (16.3% vs. 11.3%, p < 0.036) than youths in the urban areas. Low-density lipoprotein (LDL-c) (2.8 vs. 2.7 mmol/L) and total cholesterol (TC) (4.7 vs. 4.5 mmol/L) were significantly higher in urban compared to rural youths (p < 0.019 and p < 0.012). Overall, more youth in this study has CRF rather than not (Has ≥ 1 CRF = 69.9%). Significantly more rural youths have at least one CRF compared to urban youths (rural = 74.2% vs. urban = 66.8%, p = 0.016).

Conclusion

In conclusion, our study showed that a large number of youths had at least one or more CRF. Rural youths have significantly higher BMI with higher family history of hypercholesterolaemia compared to urban youths. However, urban youths have higher LDL-c and TC levels. Other coronary risk factors are not significantly different between urban and rural youths. Rural youths have more CRF compared to urban youths. A larger longitudinal study focusing on this population is important to better understand the effect of the area of residence on CRF in youth.

Cross-Sectional Study of Ethnicity and Chronic Heart Failure: Complex Interplay of Health and Wealth

Objectives: Extrapolating data from international and regional registries on chronic heart failure provides a challenge in Malaysia in view of it being a multicultural country. This study aimed to illustrate the chronic heart failure landscape within northern Kuala Lumpur and identify differences amongst major ethnic groups. Methods: A retrospective, single-centre study was conducted between the 1st January 2013 and 30th April 2016. Patients with left ventricular ejection fraction ≤45% were identified and information was collected on these individuals’ demographics, risk factors, and aetiology. Comparisons were made between three major ethnic groups within Malaysia, and between the author’s database and that of other international registries. Results: 1,181 patients were identified, the majority being Malays (67.3%) and male (81.2%). The mean age was 58.2±11.7 years. The majority had ischaemic risk factors, including previous and current smoking habits (56.7%), coronary artery disease (66.1%), hypertension (71.2%), diabetes (61.8%), and dyslipidaemia (47.9%). There were significant differences noted when looking at rates of dyslipidaemia, diabetes, atrial fibrillation, and chronic kidney disease amongst different ethnicities. The mean left ventricular ejection fraction in Malays was lower (33.1±9.6%) compared to that of Chinese (34.7±8.7%) and Indians (34.9±8.3%). There was marked differences seen in this study’s cohort, compared to three major Asian registries: The 2003 Chong et al. registry, Inter-CHF, and ASIAN-HF. Conclusion: There exists great disparity in chronic heart failure burden amongst populations, and therefore local registries are needed to narrow the gap in knowledge regarding chronic heart failure within Malaysia.

Identification of Haptoglobin as a Potential Biomarker in Young Adults with Acute Myocardial Infarction by Proteomic Analysis

Background

Acute myocardial infarction (AMI) molecular research in young adults is still limited. The aim of this study is to identify AMI proteomic biomarker(s) in young adults.

Methods

This study comprised of two phases namely discovery and verification. In the discovery phase, proteins in the pooled plasma samples from young male adults between 18 and 45 years (10 AMI patients and 10 controls) were separated using two-dimensional electrophoresis. The protein spots that were expressed differently in the AMI patients were identified via matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. The plasma concentrations of these proteins were quantified using enzyme-linked immunosorbent assay during the verification phase (40 AMI patients and 80 controls).

Results

Haptoglobin (Hp), apolipoprotein AI (Apo AI) and apolipoprotein AIV (Apo AIV) were up-regulated in the discovery phase. In the verification phase, the plasma concentration of Hp was significantly higher in AMI patients than the controls (P < 0.001). Logistic regression showed an association between Hp and AMI in young adults (odds ratio [OR] = 1.016, 95% CI: 1.002–1.030, P = 0.025) independent of other AMI risk factors. Hp was significantly correlated with high sensitivity C-reactive protein (hs-CRP) (r = 0.424, P < 0.001).

Conclusion

In young adults with AMI, plasma Hp concentrations were elevated and it is independently associated with AMI. A positive correlation with hs-CRP suggests Hp could be a potential biomarker of AMI in young adults.

Hypertension Is an Independent Predictor of Multivessel Coronary Artery Disease in Young Adults with Acute Coronary Syndrome

Background

Risk factors of multivessel coronary artery disease (CAD) among young acute coronary syndrome (ACS) patients remain elusive now.

Methods

This retrospective study analyzed data from 187 consecutive young (age ≤45 years) ACS patients (75 STEMI, 30 NSTEMI, and 72 unstable angina) hospitalized in our hospital from January 2012 to December 2016. Thirty-six young male patients with normal coronary angiography (CAG) findings (no-CAD), who underwent CAG due to suspected chest pain in this period, served as control group. There were 83 patients with single-vessel disease (SVD) and 104 patients with multiple-vessel disease (MVD) among ACS patients. Patients were followed up for a mean of 267±124 days by clinical visit or telephone calls.

Results

All included patients were male. Prevalence of hypertension (57.2% vs. 30.6%, p=0.002) and smoking (70.6% vs. 52.8%, p=0.049) was significantly higher in ACS patients than in no-CAD patients. Prevalence of hypertension (72.1% vs. 38.6%, p<0.001) and body mass index (BMI) were significantly higher in MVD group than in SVD group. Multivariable analysis revealed that hypertension was an independent risk factor for MVD after adjustment for age, gender, BMI, smoking, family history of premature CAD, hyperlipidemia, left ventricular ejection fraction, and brain natriuretic peptide (odds ratio=3.71, 95% confidence interval=1.84-7.46, p<0.001). Rate of major adverse cardiovascular events (MACE) during follow-up (20.2% vs. 4.8%) was significantly higher in MVD group compared with SVD group.

Conclusions

Hypertension is an independent predictor of MVD and MVD is associated with increased MACE rate compared to SVD in young ACS patients during the short-term follow-up.

Effect of factor XIII levels and polymorphisms on the risk of myocardial infarction in young patients

Factor XIII (FXIII) stabilizes and protects the fibrin network. Its role in myocardial infarction (MI) is still to be clarified. To evaluate the association of FXIII levels with MI in young patients and to investigate how the FXIII-A p.Val34Leu, FXIII-B p.His95Arg, and IVS11, c.1952 + 144 C>G (Intron K) polymorphisms influence FXIII levels and MI risk. Patients with ST elevation MI below 40 years of age (MI, n = 119), age-matched clinical controls (CC, n = 101) without MI and coronary artery disease, and healthy controls (HC, n = 120) were investigated for FXIII activity, FXIII-A₂B₂, FXIII-B concentrations and for the polymorphisms. FXIII activity and FXIII-A₂B₂ antigen were significantly elevated in MI. FXIII activity and antigen were significantly elevated in Arg95, while decreased in Intron K "G" carriers. Smoking had an independent increasing effect on FXIII activity and FXIII-A₂B₂ antigen. Intron K C>G polymorphism significantly decreased the risk of MI in patients with elevated fibrinogen. Among the investigated factors Intron K C>G polymorphism and smoking have the most powerful effect on FXIII levels and on the risk of MI in the young. The effect of smoking on coronary thrombus formation may partially be attributed to its FXIII increasing effect.