thesis methodology

1. THESIS REVIEW
“CLINICAL AND ANGIOGRAPHIC PROFILE OF ARMED FORCE PERSONNEL
PRESENTING AS ACS AT A TERTIARY CARE INSTITUTE IN JAMMU AND
KASHMIR”
GUIDE : Prof. (Dr) Hilal Ahmed Rather.

2. INTODUCTION
1. Coronary artery disease (CAD) is leading cause of death worldwide and over three quarters of
these deaths occur in low and middle income countries.
2. Tends to occur at a younger age in Indians with more extensive angiographic involvement.
3. Varies across geography, socio-demography, and ethnicity with a marked inter-regional
heterogeneity across the country.
4. In the state of Jammu and Kashmir, the unusual stress and strain due to the ongoing political
turmoil over last three decades might have modified the epidemiology of CAD.

3. 5. A significant impact of the living conditions and the stress can be reflected on the armed
force personnel working in the state.
6. Cardiovascular risk factors have potentially devastating consequences on the combat
readiness of the military.
7. A significant increase in the volume of patients from this group presenting as ACS at our
center.
8. A serious paucity of data regarding risk factors, angiographic profile and clinical outcomes
in the Armed force personnel undergoing PCI in India that prompted us to perform this
study.

4. Nature of study
This was a prospective cum retrospective observational study.
Primary Objectives:
To assess the clinical and angiographic profile of armed force personnel presenting as acute
coronary syndrome at our center.

5. Secondary Objectives:
 To correlate various demographic, clinical and biochemical variables with the burden of
coronary artery disease in this population group.
To ascertain the clinical outcome which includes mortality and impairment of quality of life at
7 and 30 days post event.
To ascertain the incidence and prevalence of ACS amongst different groups of armed force
personnel including Regular Army, CRPF (central reserved police forces), BSF (border security
forces) and acknowledge any differences whatsoever.
To correlate various stress factors using a validated stress questionnaire with the clinico-
angiographic profile of these patients.

6. Materials and Methods
Study population: All armed force personnel admitted with the diagnosis of acute coronary
syndrome which includes STEMI, NSTEMI and Unstable angina were eligible for inclusion in the
study.
Exclusion criteria:
1.Patients presenting as chronic stable angina
2.Patients with severe renal insufficiency defined as creatinine clearance < 30
An approval to conduct the study has been obtained from the Institutional review board of
SKIMS in the upcoming ethical committee meet.

7. Statistical analysis
• The recorded data has been compiled and entered in a spreadsheet (Microsoft Excel) and
then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA).
• Continuous variables will be summarized in the form of means and standard deviations and
categorical variables as frequencies and percentages.
• For univariate analysis of categorical variables, Chi-square test or Fisher’s exact test, which
ever appropriate, was employed.
• Continuous variables were analysed with the help of Student’s t-test. A p value <0.05 was
considered statistically significant.
• TARGET SAMPLE SIZE: 64

8. PROFORMA
Demography
Name Age Sex Contact no
Affiliation Residence permanent correspondence
Job status
Risk factors: HTN
T2DM
Smoker Pack Years
Alcohol consumption Amount
Other substance use
History AOE
Previous CAD
Family History
Job Profile: Field work Office job
Working hours Night Shift
Stress Questionnaire Score:
Presentation: ACS- STEMI / NSTEMI / UA
TIMI Risk Score

9. ECG
Troponin T
ECHO- EF RWMA
Mechanical complications (VSR/ FWR/ ACUTE MR/ Pericarditis/ Mural thrombus)
Electric complications ( VT/ SVT/ AF/ AIVR)
INVESTIGATIONS
CBC; Hb- TLC- NLR- Plt
Urea Creatinine Albumin CPK Na K
LDL HDL TG Total Cholestrol HBA1C
CAG:
Route
No of vessels with significant lesion
Vessel involved
Culprit artery
Any anomaly
Type of Lesion
PCI
Vessel stented

10. Type of stent
No of stents
Length of stent used
DAPT used Precise-DAPT score
Post procedure complications
Death @ 7 days Death @ 30 days
ISR Stent thrombosis
Referal for CABG

11. PRE-LEMINARY RESULTS
1. Total number of patients: 169 73( prospective)+ (96 retrospective)
2. Males: 168, Females: 1
3. Local: 6, Rest of India- 163.
4. STRTATIFICATION OF PATIENTS AS PER COMPANY AFFILIATION
5. STRATIFICATION AS PER RANK:
NON-COMISSIONAL: 114 (67.4%)
COMISSIONAL: 49 (28.9%)
6. FIELD JOB: 118 (69.8%) DESK JOB: 45 (26.6%)
7. HIGH ALTITUE DEPLOYMENT: 27
s. no Company affiliation Number of
patients
1 Regular army 13
2 BSF 35
3 CRPF 88 (52%)
4 SSB 2
5 ASSAM RIFLES 2
6 Beacon 11
7 LADHAK SQUAD 3
8 AIR FIELD 4
9 ITBP 5

12. MEAN AGE : 47.5747 ±2.598
RISK FACTORS
AVERAGE PACK YEARS : 24.91
S. NO RISK FACTORS NO. OF PATIENTS
1 HTN 83 (49.1%)
2 T2DM 45 (26.6%)
3 FAMILY HISTORY 12 (7%)
4 SMOKING 101 (59.7%)
5 SIGNIFICANT ALCOHOL CONSUMPTION 23 (13.6%)
6 DYSLIPIDEMA 57 (33.7%)

13. PRESENTATION
S.NO Type of MI No of patients
1 AWMI 61 (36%)
2 IWMI 72 (42.6%)
3 HLWMI 4 (2.3%)
4 NSTEMI 27 (15.9%)
5 UA 5 (2.9%)

14. 1.
2. Average time of REVASCULARIZATION: 5.27 h
3. No of patients thrombolysed: 95 (56.2%)
4. PRIMARY PCI: 17 (10%)
5. Average transportation time: 11.21 h
6. Average SAQ Score: 5.8. No of patients with SAQ Score > 7= 29.(17.1%)
Drug used No of Patients
Reteplace 23 (13.6%)
Tenekteplace 39 (23%)
Streptokinase 32 (18.9%)
Alteplace 1 (0.6%)
KILLIP CLASS FREQUENCY
I 65 (38.4%)
II 73 (43.1%)
III 23 (13.6%)
IV 8 (4.7%)

15. Investigations
S. no Investigations Mean values
1 Hb 14.39
2 TLC 10.99
3 NLR 5.74
4 Plt 184.52
5 Urea 38.42
6 Creat 1.24

16. Average blood glucose: 123
Mean HbA1C: 6.45
Lipid profile
lipid
fraction LDL HDL TGS T Chl
Mean Value 139.31 39.46 166.45 215.86
ELECTRIC COMPLICATIONAS
CHB 8 (4.7%)
VT/VF/AIVR 11 (5 +2+ 4) (6.5%)

17. ECHO PARAMETERS
PARAMETER MEAN SD
AO 26.01 4.03
LA 30.24 5.12
LV (d) 44.96 5.6
LV (s) 29.28 4.94
EF 45.6 7.49
Parameters No. Of cases percentage
RWMA 136 80.4
MR ( mild/ mod/ sev) ( 23/ 16 / 4) 13.6/ 9 /4
Diastolic dysfunction
Grade 1
Grade 2
Grade 3
67
83
8
39
49
4
Mechanical complication
( VSR / FWR)
2 FWR / 1 VSR= 3 1.7
LV clot/ PE 3 / 5 1.7 / 2.9

18. Angiographic profile
Out of 169 patients, CAG was performed in 141 (83%) patients.
PCI was performed in 107 (63%) patients. 12 (7%)patients were referred for CABG. 6 (3%) patients had normal
CAG and the rest were put on medical management.
TYPES OF PCI
PRIMARY 17 (10%)
RESCUE PCI 6 (3%)
PHARMACO-INVASIVE 84 ( 49.7%)

19. CAG ROUTE RADIAL ROUTE FEMORAL
ROUTE
TOTAL NO OF
PROCEDURES
No of patients 56 (33.1 %) 85 (50.2%) 141( 83.4%)
VESSEL
INVOLVED
LM LAD DIAGNOL RCA LCX OM
No of
patients
7 66 (39%) 13 53 45 5

20. Culprit artery Type of Lesion
Vessel Disease
No of stents
LM 1
LAD 49
Diagnol 2
LCX 17
RCA 35
OM 3
Lesion Type no. Of patients
A 66 (39%)
B 43 (25%)
C 26 (15%)
No of
stent
1. 2 3 POBA DEB GP IIb/IIIa
TOTAL (
130)
86
(50.8%)
19(11.2%) 2 (1.7%) 8 (4.7%) 2 (1.1%) 47
(27.8%)
SVD 67 (39%)
DVD 51 (30%)
TVD/LM-TVD 17 (10 %)
Normal Angio 6 (3%)

21. IVUS WAS USED IN 22 PATIENTS AND OCT GUIDANCE WAS USED IN 2 PATIENTS. FFR WAS USED IN 2 PATIENTSS
MORTALITY: A TOTAL OF 13 DEATHS ( 5 + 8) WITH A DEATH RATE OF 7.6% WAS NOTED. PROCEDURAL MORTALITY
WAS NOTED IN 1.1 % OF PATIENTS AND PERI-PROCEDURAL COMPLICATIONS OCCURED IN 5.3 % OF PATIENTS
COMPLICATION DATA
VARAIABLE TOTAL
DEATHS
NON-PROCEDURAL
PROCEDURAL
13
10
2(1.1 %)
PUMP FAILURE
REFRACTORY ARRYTHMIA
VSR/FWR
5
2
3
SUCCESS RATE 98.1%
DROP IN TIMI FLOW (SLOW FLOW)
FLOW LIMITING DISSECTION
2
0
SIDE BRANCH OCCLUSION
CORONARY PERFORATION
3
0
STENT THROMBOSIS
No reflow
REFRACTORY SHOCK
2
1
0
PERIPROCEDURL – MI
STROKE / CIN
1
1/1