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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 44  |  Issue : 3  |  Page : 102-106

Relation of metabolic syndrome to the presence and severity of coronary artery ectasia


Cardiovascular Medicine Department, Tanta Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission05-Apr-2016
Date of Acceptance04-May-2016
Date of Web Publication19-Jan-2017

Correspondence Address:
Mohamed Naseem
Cardiovascular Medicine Department, Tanta Faculty of Medicine, Tanta University, Tanta, 3111
Egypt
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DOI: 10.4103/1110-1415.198658

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  Abstract 

Background Coronary artery ectasia (CAE) refers to abnormal dilatation of the coronary vasculature. CAE has been suggested to be associated with inflammation. Previous studies have confirmed a positive association between metabolic syndrome (MS) and inflammatory markers. Therefore, the present study aimed to examine the association between CAE and MS and to evaluate the relationship between CAE severity and MS score.
Patients and methods A total number of 100 patients with the diagnosis of coronary angiographic isolated CAE constituted the first group and 100 patients with obstructive coronary artery disease constituted the second group. Isolated CAE was defined as CAE without significant obstructive coronary artery stenosis. The severity of isolated CAE was determined according to the Markis classification. Obstructive coronary artery disease was defined as stenosis 50% or more of the lumen of one or major epicardial coronary artery. MS was defined according to the National Cholesterol Education Program criteria. The MS score was defined as the number of MS components present.
Results Male sex predominance, a higher prevalence of MS, a higher level of triglycerides, and a lower of level of high-density lipoprotein were found in patients with isolated CAE (P=0.016, <0.001, <0.001, and <0.001, respectively). In multivariable logistic regression analysis, MS was independently associated with isolated CAE (odds ratio: 1.315; 95% confidence interval: 1.206–1.434; P<0.001). There was a significant correlation between CAE severity evaluated by means of the Markis classification and MS score. The severity of CAE was found to increase with increased MS score (r=−0.601 and P<0.001).
Conclusion Isolated CAE is associated with MS and the severity of CAE increases with higher MS score.

Keywords: Coronary, ectasia, metabolic syndrome


How to cite this article:
Naseem M, Samir S. Relation of metabolic syndrome to the presence and severity of coronary artery ectasia. Tanta Med J 2016;44:102-6

How to cite this URL:
Naseem M, Samir S. Relation of metabolic syndrome to the presence and severity of coronary artery ectasia. Tanta Med J [serial online] 2016 [cited 2020 Dec 1];44:102-6. Available from: http://www.tdj.eg.net/text.asp?2016/44/3/102/198658


  Introduction Top


The term coronary artery ectasia (CAE) refers to an abnormal dilatation of coronary artery segment to a diameter at least 1.5 times of the adjacent normal reference coronary segment [1],[2]. CAE is encountered during diagnostic coronary angiography in 3–8% of patients [3],[4].

Most of the patients with CAE are asymptomatic. However, they can also still present with angina pectoris or even acute coronary syndrome in the absence of obstructive coronary artery disease (OCAD) [5]. However, the mechanism by which CAE is formed is not well understood. On the basis of the data from previous studies, more extensive and aggressive inflammation in the coronary tree may be responsible for CAE [6].

Metabolic syndrome (MS) is characterized by clustering of well-known independent risk factors for coronary artery disease (CAD), including high blood pressure, insulin resistance or elevated fasting blood glucose, high triglycerides (TG), low high-density lipoprotein (HDL), and abdominal obesity [7]. It has become evident that the inflammatory condition plays an important part in the etiology of the MS and largely contributes to the related pathological outcomes [8]. More than half of the symptomatic patients who underwent diagnostic coronary angiography fulfilled the MS criteria, as shown in a study by Solymoss et al. [9]. Data from the previous studies showed that MS score is more beneficial in predicting CAD severity compared with the binary method of defining MS [10].

The aim of this study was, first, to examine the association between MS and CAE and to determine the potential relationship between CAE severity and MS score.


  Patients and methods Top


This prospective study included consecutive patients who underwent diagnostic coronary angiography at the Cardiac Catheterization Laboratory in the Cardiology Department, Tanta University, between June 2014 and December 2015.

One hundred patients with isolated CAE constituted the first group and 100 patients with OCAD constituted the second group. Coronary angiography was performed using conventional methods through the femoral approach. CAE was defined as dilatation of a segment of the coronary with a diameter 1.5 or more times than that of the adjacent normal coronary segment [11]. Isolated CAE was defined as CAE without significant obstructive coronary artery stenosis [12]. The severity of isolated CAE was determined according to the classification system introduced by Markis et al. [4]. CAE was classified in the decreasing order of severity as follows: diffuse ectasia of two or three vessels as type I, diffuse ectasia in one vessel and localized ectasia in another vessel as type II, diffuse disease in one vessel only as type III, and localized segmental ectasia as type IV. OCAD was defined as stenosis 50% or more of the lumen of one or major epicardial coronary artery [12].

Exclusion criteria were as follows: (i) presence of CAE and concomitant OCAD; (ii) marked atherosclerotic disease that normal reference diameter of the coronary vessel could not be detected; (iii) ectatic coronary segment at the site of prior percutaneous coronary intervention; (iv) having a history of coronary bypass grafting; and (v) documented connective tissue disorders and vasculitis.

The diagnostic criteria for MS were based on the updated 2005 Third Adult Treatment Panel of the National Cholesterol Education Program clinical definition [7]. This requires the presence of any three of five of the following: (i) abdominal obesity (waist circumference>102 cm in men and >88 cm in women); (ii) elevated TG level (>150 mg/dl) or being on drug treatment for elevated TG; (iii) reduced HDL-cholesterol level (<40 mg/dl in men and <50 mg/dl in women); (iv) high blood pressure (systolic>130 mmHg or diastolic>85 mmHg, or being on an antihypertensive medication); and (v) a high fasting plasma glucose concentration (>100 mg/dl) or being on drug treatment for elevated glucose.

The MS score was defined as the number of MS components present [13].

Echocardiography was performed using the commercially available GE Vivid 7 (USA) echocardiograph with 2.5 MHz transducer according to the recommendations of the American Society of Echocardiography and left ventricular ejection fraction was evaluated using the biplane Simpson’s method [14].

Informed consent was taken from all patients and the study was approved by the local ethical committee.

Statistical analysis

All statistical studies were carried out using statistical package for the social sciences software (SPSS 18.0 for Windows; SPSS Inc., Chicago, Illinois, USA).

The quantitative variables were expressed as mean±SD. The qualitative data were expressed as counts and percentage. To compare values, Student’s t-test and the χ2-test were used for quantitative and qualitative values, respectively. Values with P less than or equal to 0.05 were selected for multivariable logistic regression analysis. Multivariable logistic regression analysis was performed to identify independent associates of CAE. Spearman’s ρ test was used to assess the relationship between severity of CAE and MS score. A P-value of less than 0.05 was considered as statistically significant.


  Results Top


Baseline clinical characteristics of patients with CAE (n=100) and those with OCAD (n=100) are presented in [Table 1]. There were no statistically significant differences between the two groups as regards age, hypertension, diabetes mellitus, smoking status, family history of premature CAD, BMI, waist circumference, total cholesterol, low-density lipoprotein level, fasting glucose level, systolic blood pressure, diastolic blood pressure, serum creatinine, ejection fraction, and current medications prescribed. Male sex predominance, a higher prevalence of MS, a higher level of TG, and lower level HDL were found in patients with isolated CAE (P=0.016, <0.001, <0.001, and <0.001, respectively).
Table 1: Baseline clinical characteristics

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Multivariable logistic regression model was built to identify the independent associates of isolated CAE ([Table 2]). Male sex, MS, TG level, and HDL level were entered in the model as independent variables. MS was found to be independently associated with isolated CAE (odds ratio: 1.315; 95% confidence interval: 1.206–1.434; P<0.001).
Table 2: Multivariable logistic regression analysis to detect independent associates of isolated coronary artery ectasia

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According to the Markis classification, type I was found in 22 (22%) patients with isolated CAE, type II in 32 (32%) patients, type III in nine (9%) patients, and type IV in 37 (37%) patients.

Patients with CAE were divided into four subgroups according to MS score to detect a correlation between Markis’s class and MS score. Using Spearman’s ρ test, the severity of CAE was found to increase with increased MS score (r=−0.601 and P<0.001) ([Table 3]).
Table 3: Correlation between isolated coronary artery ectasia severity and metabolic syndrome score

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  Discussion Top


To the best of our knowledge, this is the first study to investigate the relation between the CAE and MS. The major findings of the present study were as follows: (i) compared with patients with OCAD, patients with isolated CAE had higher prevalence of male sex, higher prevalence of MS, higher level of TG, and lower HDL; (ii) multivariable logistic regression analysis identified MS as an independent predictor of isolated CAE; and (iii) the severity of CAE was found to increase with increased MS score.

CAE has been suggested as a variant of CAD. However, there is no clear relationship between atherosclerosis and CAE [15].

The histopathological examination revealed a marked difference between CAE patients and those with the classic atherosclerosis. CAE is characterized by extensive destruction of the media layer of the vascular wall and extensive inflammatory cell infiltration [16].

Turhan et al. [6] compared C-reactive protein (CRP) level in patients with isolated CAE, patients with OCAD, and those with normal coronary arteries. The authors showed that only patients with CAE had elevated CRP levels compared with the other two groups. In a later report, Turhan et al. [17] reported a positive correlation between the length of ectatic segment and the plasma level of soluble intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-elastin.

Akturk et al. [18] detected a statistically significantly higher level of insulin-like growth factor-1 in patients with CAE compared with those with normal coronary arteries.

Kalaycıoğlu et al. [19] reported a higher neutrophil-to-lymphocyte ratio in patients with CAE than in patients with OCAD and in controls. The findings of the previous studies suggest that severe chronic inflammation may plays a role in the development of CAE.

MS is characterized by accumulation of closely related cardiovascular risk factors, in which obesity and insulin resistance play a major role. It is well established that MS is associated with increased level of inflammation. hsCRP, interleukin 6, plasminogen activator inhibitor 1, and adhesion molecules were found to be significantly elevated in patients with MS [20], and this could explain the association between CAE and MS.

In the present study, the relationship between MS score and CAE severity was evaluated. In previous studies the questions have been raised whether the risk associated with MS is beyond the risk associated with its individual factors [21],[22]. Counting the number of MS components appears to be more important compared with diagnosing MS by the presence of three or more components [9],[10]. Kim et al. [13] found that MS score was an independent predictor of CAD in patients without DM. In another study, MS score was related to the severity of CAD and the presence of multivessel disease in nondiabetic individuals. However, this relation is not present in diabetic patients. The authors also reported a positive correlation between MS score and CRP level, suggesting that accumulation of individual markers of MS may lead to more severe vascular inflammation [23].


  Conclusion Top


The present study showed that MS is independently associated with isolated CAE. In addition, the severity of CAE increased with the increase in MS score.

Study limitation

Limitations of the study are as follows: a relatively small sample size and the lack of inclusion of inflammatory markers such as hsCRP, interleukin 6, and metalloproteinase (MMP) in the study. However, these markers are costly and not available in everyday practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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