|Year : 2022 | Volume
| Issue : 2 | Page : 176-179
Profile of acute coronary syndromes in serving personnel presenting to a field cardiology center without cath lab facilities
A Jayachandra1, Rajat Datta2, Ajay Swamy3, Neel Kanth Issar4, Saikat Sarkar5, Vivek Aggarwal6
1 Department of Cardiology, Base Hospital, New Delhi, India
2 Department of Cardiology, AHRR, Director General, Armed Forces Medical Services, New Delhi, India
3 Department of Cardiology, CHAF, Bengaluru, Karnataka, India
4 Department of Internal Medicine, 11 Air Force Hospital, Ghaziabad, Uttar Pradesh, India
5 Department of Internal Medicine, Military Hospital, Shimla, Himachal Pradesh, India
6 Department of Internal Medicine, AFMC, Pune, Maharashtra, India
|Date of Submission||12-Mar-2022|
|Date of Decision||26-Mar-2022|
|Date of Acceptance||04-Apr-2022|
|Date of Web Publication||10-Aug-2022|
Dr. Sqn Ldr Neel Kanth Issar
Department of Internal Medicine, 11 Air Force Hospital, Hindan, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Acute coronary syndrome (ACS) is common in serving personnel and requires prompt diagnosis and treatment. This retrospective study was done to see the profile of ACS in serving personnel presenting to a tertiary hospital without cardiac catheterization laboratory (CCL) facilities. Methods: ACS was diagnosed based on an electrocardiogram (ECG), clinical features, and cardiac biomarkers. History of comorbidities, risk factors, and preceding exertion was taken. Immediate medical management was done as per the standard guidelines, and follow-up angiography was done at a dependent cardiology center with CCL. Results: A total of 75 personnel reported with ACS. The mean age of personnel was 42.01 ± 8.59 years. Acute ST-elevation myocardial infarction (STEMI) was noted in 48% (36/75) of the patients, 32% (24/75) had non-STEMI, and 20% (15/75) had unstable angina (UA). Low ejection fraction was more common in patients with STEMI (P ≤ 0.001). History of preceding exertion was noted in 55 personnel. Eighteen patients with STEMI were thrombolysed. Angiographically significant lesions were noted only in 30.6% (23/75) individuals with ACS. Conclusion: ACS is common in deployed serving personnel. The most common precipitators were immediate preceding exertion and smoking. Morbidity and mortality due to ACS can be decreased by digital transmission of ECG, prehospital thrombolysis, graded physical exertion, and counseling about a healthy diet.
Keywords: Acute coronary syndrome, combat zone, exertion, serving personnel
|How to cite this article:|
Jayachandra A, Datta R, Swamy A, Issar NK, Sarkar S, Aggarwal V. Profile of acute coronary syndromes in serving personnel presenting to a field cardiology center without cath lab facilities. J Mar Med Soc 2022;24:176-9
|How to cite this URL:|
Jayachandra A, Datta R, Swamy A, Issar NK, Sarkar S, Aggarwal V. Profile of acute coronary syndromes in serving personnel presenting to a field cardiology center without cath lab facilities. J Mar Med Soc [serial online] 2022 [cited 2022 Nov 29];24:176-9. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/2/176/353656
| Introduction|| |
Acute coronary syndromes (ACSs) in young males are a common occurrence in developing countries such as India and occur almost exclusively in males and a decade earlier than the developed countries. Serving personnel of the armed forces have to work in isolated remote areas under extremely uncertain stressful conditions. There is a robust food supply system already existing in armed forces in a combat zone; however, due to inclement weather and difficult terrain, there is an interruption in the supply of fresh fruits and vegetables despite local outsourcing. Cultural Indian dietary preferences are typically rich in calories, and this gets complicated in a combat zone by the belief of individuals to consume energy-dense foods which are high in carbohydrates and trans fats. This combination of increased stress, traditional dietary patterns, and unaccustomed exertion makes personnel more prone to ACS. This ACS becomes more life-threatening as a majority of the personnel in a combat zone are deployed in remote and difficult terrain with very limited access to physician care. Globally, there has been a recent surge in cases of ACS in serving personnel, including sudden cardiac death. Prompt recognition and initiation of early treatment is of utmost importance to reduce the morbidity and mortality in our serving personnel. Prompt digital transmission of electrocardiograms (ECGs) and empowering the medical officers to initiate early treatment will help to reduce morbidity, mortality, and sudden cardiac death.,, We present a demographic and clinical profile of serving personnel in combat zone presenting with ACS to a tertiary hospital without cardiac catheterization laboratory (CCL) facilities. The objective of the study was to assess the clinical profile and risk factors in serving personnel of ACS.
| Methods|| |
A retrospective study was done on serving personnel presenting to a field tertiary care hospital without CCL facilities between 2015 and 2017. ACS was diagnosed based on ECG, clinical features, and cardiac biomarkers. A detailed history of preexisting morbidities, risk factors, and immediately preceding exertion was also taken. Exertion was further classified according to the distance of running preceding the cardiac event. All the ECGs of individuals from outstation units were digitally transmitted to a physician/cardiologist to facilitate prompt initiation of treatment.
All the patients diagnosed with ACS were subclassified according to the ACC/AHA guidelines into ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina (UA). All the patients with STEMI within the window period were thrombolysed with an available thrombolytic agent. High-risk patients with thrombolysis in myocardial infarction (TIMI) risk score >3 and out of window period for thrombolysis were given a third intravenous antiplatelet therapy. Echocardiography and risk stratification was done for all the patients. All the patients were transferred to service CCL after stabilization for coronary angiography. Revascularization was done at dependent CCL if indicated. Data were collated and analyzed in IBM statistics SPSS software Version 22.0 (IBM Corp., Armonk, NY, USA). The study was approved by the Institutional Ethical Committee.
| Results|| |
A total of 75 serving personnel presented with ACS between January 2015 and May 2017. All individuals were male with a mean age of 42.01 ± 8.59 years. Of 75 total patients, 16 patients were from local units and 49 patients were referred or evacuated from other peripheral locations. The predominant mode of evacuation from peripheral hospitals was road transport in an ambulance, whereas only four were heli-evacuated by medical officers or paramedics. Only one of them had returned from a 48-h trip to high altitude by helicopter. Acute STEMI was noted in 48% (36/75) of the patients, 32% (24/75) had NSTEMI, and 20% (15/75) had UA [Table 1]. In STEMI, 22 personnel had anterior wall myocardial infarction (AWMI), 12 had inferior wall myocardial infarction (IWMI), and 2 had both AWMI and IWMI. There was only one mortality noted in a patient who presented with ACS (NSTEMI) with cardiogenic shock. Ejection fraction (EF) was less than 40% in 14/75 patients and >55% in 43 patients. Low EF was more common in patients with STEMI with a significant P < 0.001 [Table 2]. More than 50% of the individuals having AWMI had an EF of <40%.
|Table 1: Type of acute coronary syndrome in serving personnel presenting to a peripheral cardiology center|
Click here to view
|Table 2: Association of left ventricular ejection fraction with the type of acute coronary syndrome|
Click here to view
History of exertion was noted in 55 cases of 75. History of 5 km run was noted in 56% (42/75), 2.4 km run was seen in 13.3% (10/75), and 1.6 km run was noted in 4% (3/75). No preceding exertion was there in 26.6% (20/75) cases. Most of these individuals were undergoing an organized physical proficiency run of various distances in a combat zone. This ACS after exertion usually occurred within 1 ho of successful completion of the desired level of physical activity in the morning. There was no history of any preceding angina before the current cardiac episode. There was no seasonal variation noted, with 37 cases having ACS during the winter season from October to March and 38 cases from April to September.
From local units, 09/16 patients of ACS had STEMI, of which 7 could be thrombolysed within the window period, whereas 26/69 patients from other peripheral locations had STEMI, of which only 11 could be thrombolysed. Patients who were thrombolysed had a better EF as compared to nonthrombolysed patients, as shown in [Table 1]. The most common thrombolytic agent used was tenecteplase in 13 patients, followed by reteplase in 4 and streptokinase in 1 patient. All the patients were stabilized and referred to a tertiary care center for an angiogram. Angiographically significant lesions were noted only in 30.6% (23/75) of the cases. Others had either nonobstructive lesions or recanalized coronaries.
Smoking was the most common risk factor noted in our study, with 78.6% (59/75) individuals giving a history of smoking. A history of diabetes was present in four cases and a history of hypertension was noted in three cases. Four personnel with ACS required a third injectable antiplatelet agent in the form of Aggrastat (tirofiban). Of 75 individuals with ACS, 53 were found to have noncritical/recanalized coronaries. Significant coronary artery disease (CAD) on coronary angiography was found in 22 cases, of which one required coronary artery bypass graft (CABG) subsequently and the rest underwent angioplasty. Multivessel percutaneous coronary intervention (PCI) was done in two cases.
| Discussion|| |
Of the 157 patients treated at our center for ACS, 75 were deployed personnel. ACS in deployed military personnel is a common occurrence as they have multiple hidden cardiovascular risk factors despite appearing physically fit. Coronary heart disease is considered as one of the most common causes of release from service. Military combat is an important and significant cardiovascular risk, as seen in a systematic review and meta-analysis done by Boos et al. There is a lot of research about CAD in Indian serving personnel exposed to high altitude areas., However, there are very limited data available about ACS in Indian serving personnel posted to nonhigh-altitude combat zone. There are multiple factors that predispose individuals in a combat zone to high risk of CAD, which include diet, stress, and unaccustomed physical exertion. Indian army has a robust food supply and storage facility, but providing fresh fruits and vegetables is a major challenge, especially in a combat zone, due to the perishability of the food material. Hence, there is increased dependence of tinned, canned, and fried food such as poories. The traditional Indian diet is rich in carbohydrates and trans fats. Dietary habits in a combat zone need to be modified with the aim to promote healthy and nutritious dietary practices rich in fiber and vitamins. In armed forces, healthy food practices can be promoted by improving the food environment and supply chain even in the remote and inaccessible areas by regular stocking or local outsourcing and storage facility for fruits and vegetables. These healthy diet practices, in turn, will help in improving the physical performance and health of our personnel., Sudden unaccustomed physical exertion can cause plaque erosion and precipitate an episode of ACS in young. Physical exertion may also be associated with an increased incidence of plaque rupture, which may produce sudden cardiac death or ACS. The relative risk of developing ACS or STEMI within 1 h after severe physical exertion is 5.9, and this risk worsens with the level of physical exertion and acclimatization to the environment. Dietary modification with more consumption of a healthy diet including fruits, vegetables, and plant-based diet may prevent ACS, and there is an increasing risk of more irregular and high-intensity physical exertion in young as it maintains acceptable levels of lipids in them. Maintaining an acceptable lipid profile may be helpful in preventing ACS., Healthy dietary practices are the most important determinant in preventing ACS in young adults, followed by lipid levels and smoking. Diet rich in cold-pressed oils such as mustard oil, cereals, vegetables, and fruits is closely associated with decreased incidence of CAD in Indians. Educating the masses with basic concepts of healthy diet and healthy stress-free lifestyle will go a long way in promoting physical and mental health, which, in turn, will enhance their operational capabilities.
Workplace stress also plays a very important role in triggering the cascade leading to ACS/myocardial infarction. Deployed personnel have to work in isolated, remote areas, difficult terrains, and in the combat zone; the level of stress is quite high due to high levels of uncertainty of outcomes of the tasks. Early recognition of ACS and prompt management is of utmost importance. If not recognized in time, UA may progress to sustained myocardial infarction with increased morbidity and mortality. Digital transmission of ECG plays a very important role in the early recognition and management planning of these individuals. In our study, almost all the ECGs were digitally transmitted either to a physician or to a cardiologist, and immediate treatment was started within available resources at the first point of medical contact.
The limitations of our study were that procoagulant workup could not be done in our cases below 40 years without any risk factors due to the limited availability of the facilities in our field tertiary setup. Moreover, the assay could have been confounded by the acute illness and concurrent anticoagulant therapy. Another limitation was that data on duration of service in the field area and sudden exertion on induction or re-induction after leave without proper acclimatization were also not available as the study was retrospective.
| Conclusion|| |
This study shows that ACS is common in serving personnel in a combat zone, and prompt recognition and initiation of treatment is of utmost importance in preventing mortality and long-term morbidity. Digital transmission of ECG and facility of prehospital thrombolysis will help in preventing sudden cardiac death. Immediate preceding exertion and smoking were the most common precipitators of ACS. Proper counseling about a healthy diet with increased intake of two or more servings of fruits and vegetables along with supervised graded exercise on induction and avoidance of unaccustomed exertion may also help in reducing the incidence of ACS in deployed serving personnel in a combat zone. Larger prospective studies are needed to study healthy dietary interventions among individuals deployed in combat zones.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhardwaj R, Kandoria A, Sharma R. Myocardial infarction in young adults-risk factors and pattern of coronary artery involvement. Niger Med J 2014;55:44-7.
] [Full text]
Sharma S. Occupational stress in the armed forces: An Indian army perspective. IIMB Manage Rev 2015;27:185-95.
Vanezis AP, Suvarna SK, Vanezis P. Sudden cardiac deaths in young British Army personnel. J R Army Med Corps 2011;157:184-7.
Ting HH, Krumholz HM, Bradley EH, Cone DC, Curtis JP, Drew BJ, et al.
Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: A scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology. Circulation 2008;118:1066-79.
Alanazi AF, Alrashidi QS, Aljerian NA. Paramedics beliefs and attitudes towards pre-hospital thrombolysis. Int J Appl Basic Med Res 2014;4:11-5.
Bawaskar HS, Bawaskar PH, Bawaskar PH. Preintensive care: Thrombolytic (streptokinase or tenecteplase) in ST elevated acute myocardial infarction at peripheral hospital. J Family Med Prim Care 2019;8:62-71.
] [Full text]
McGraw LK, Turner BS, Stotts NA, Dracup KA. Acute coronary syndromes in deployed military personnel. J Am Acad Nurse Pract 2011;23:427-33.
Parsons I, White S, Gill R, Gray HH, Rees P. Coronary artery disease in the military patient. J R Army Med Corps 2015;161:211-22.
Boos CJ, De Villiers N, Dyball D, McConnell A, Bennett AN. The relationship between military combat and cardiovascular risk: A systematic review and meta-analysis. Int J Vasc Med 2019;2019:9849465.
Yogesh Kumar YS, Sud S, Bhardwaj S, Pareek TK. Acute coronary syndrome in young males after a prolonged stay at high altitude. Med J Armed Forces India 2021;77:490-3.
Dash U, Karmarkar A, Dangi M. A study of high-altitude-associated conditions in soldiers less than 50 years of age admitted in the ICU of a tertiary care military hospital operating in a counter insurgency operation area. J Mar Med Soc 2017;19:138-41. [Full text]
Chukwura CL, Santo TJ, Waters CN, Andrews A. 'Nutrition is out of our control': Soldiers' perceptions of their local food environment. Public Health Nutr 2019;22:2766-76.
Bingham CM, Lahti-Koski M, Puukka P, Kinnunen M, Jallinoja P, Absetz P. Effects of a healthy food supply intervention in a military setting: Positive changes in cereal, fat and sugar containing foods. Int J Behav Nutr Phys Act 2012;9:91.
Ghodsi R, Rostami H, Parastouei K, Taghdir M, Esfahani AA, Nobakht M. Adherence to healthy dietary patterns and its association with physical fitness in military personnel. BMJ Mil Health 2020: bmjmilitary-2020-001553. doi: 10.1136/bmjmilitary-2020-001553.
Kato A, Minami Y, Katsura A, Muramatsu Y, Sato T, Kakizaki R, et al.
Physical exertion as a trigger of acute coronary syndrome caused by plaque erosion. J Thromb Thrombolysis 2020;49:377-85.
van Rosendael AR, de Graaf MA, Scholte AJ. Cardiac arrest during vigorous exercise: Coronary plaque rupture or myocardial ischaemia? Neth Heart J 2015;23:130-2.
Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med 1993;329:1677-83.
Kalanuria AA, Nyquist P, Ling G. The prevention and regression of atherosclerotic plaques: Emerging treatments. Vasc Health Risk Manag 2012;8:549-61.
Esselstyn CB. A plant-based diet and coronary artery disease: A mandate for effective therapy. J Geriatr Cardiol 2017;14:317-20.
Panagiotakos DB, Rallidis LS, Katsiotis E, Pitsavos C, Stefanadis C, Kremastinos DT. Background dietary habits are strongly associated with the development of myocardial infarction at young ages: A case-control study. e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 2008;3:e328-e334. doi: https://doi.org/10.1016/j.eclnm.2008.06.013
Rastogi T, Reddy KS, Vaz M, Spiegelman D, Prabhakaran D, Willett WC, et al.
Diet and risk of ischemic heart disease in India. Am J Clin Nutr 2004;79:582-92.
Hill N, Fallowfield J, Price S, Wilson D. Military nutrition: Maintaining health and rebuilding injured tissue. Philos Trans R Soc Lond B Biol Sci 2011;366:231-40.
Möller J, Theorell T, de Faire U, Ahlbom A, Hallqvist J. Work related stressful life events and the risk of myocardial infarction. Case-control and case-crossover analyses within the Stockholm heart epidemiology programme (SHEEP). J Epidemiol Community Health 2005;59:23-30.
Ryali V, Bhat PS, Srivastava K. Stress in the Indian Armed Forces: How true and what to do? Med J Armed Forces India 2011;67:209-11.
Newby DE, Fox KA. Unstable angina: The first 48 hours and later in-hospital management. Br Med Bull 2001;59:69-87.
Manten A, de Winter RJ, Minnema MC, ten Cate H, Lijmer JG, Adams R, et al.
Procoagulant and proinflammatory activity in acute coronary syndromes. Cardiovasc Res 1998;40:389-95.
[Table 1], [Table 2]