Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 197197

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferences
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
Knowledge is treasure of a wise man. The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help ones reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsNo manuscriptsNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2009 | Month : February | Volume : 3 | Issue : 1 | Page : 1289 - 1296 Full Version

Acute Coronary Syndrome In Elderly – The Difference Compared With Young In Intensive Care Unit Of A Tertiary Hospital In Western Nepal

Published: February 1, 2009 | DOI:
Paudel R*, Panta O B**, Paudel B***,Paudel K****, Pathak O K*****, Alurkar V M ******.

*MD,Lecturer,Dept of Medicine, Manipal Teaching Hospital/ ManipalCollege of Medical Sciences Pokhara,(Nepal).**Intern,Manipal Teaching Hospital Pokhara,(Nepal).***MD,Asst Professor,Dept of Medicine Manipal teaching Hospital/ Manipal College of Medical Sciences Pokhara,(Nepal) *****Intern, Manipal Teaching Hospital, Pokhara,(Nepal)******MD DM(Cardiologist),Prof,Dept of Medicine,Manipal Teaching Hosp/Manipal College of medical sciences.Pokhra,(Nepal).

Correspondence Address :
Dr.Raju Paudel,MD,Lecturer,Dept of Medicine.Manipal Teaching Hospital/Manipal College of Medical Sciences Pokhara,(Nepal) Phone: +977-61 526416 Extn:117/221


Introduction: Acute coronary syndrome (ACS), one of the commonest causes of intensive care unit (ICU) admission, casts a large burden of cost on the health care system, along with a huge mortality in the elderly population.
Objectives: This study determined the difference in presentation, complication, management and outcome in elderly patients with acute coronary syndrome, as compared to the young patients.
Material And Methods: Records of all patients who were diagnosed to have acute coronary syndrome, admitted to the ICU in the Manipal Teaching Hospital in the month of March 2006 to June 2007, was entered in a designated Proforma. Demographic details, clinical findings, treatment and complications were recorded. A total of 153 patients were analyzed and elderly patients (≥ 65 yrs) were compared with young patients (< 65yrs) using SPSS-10.0 software.
Results: Elderly patients constituted 51% (78) of the study population, among which 46.2% (36) were females. 7.7% (6) elderly patients presented with atypical symptoms, among which syncope was the commonest. Young patients were more likely to be hypertensive as compared to the elderly patients (70.7% vs. 39.7%; p<0.001). The median time of presentation to the hospital after chest pain was comparable in the two groups: 16 hours overall, but in cases of STEMI, elderly patients were brought to the hospital comparatively late, with a median time of 15 hours (IQ 5.5 – 72 as compared to young individuals in which median time was 7.25 hours (IQ 2.87 – 39 hours), which was statistically significant (p=0.000). Non ST elevated myocardial infarction (NSTEMI) and ST elevated myocardial infarction (STEMI) were similar in distribution among the elderly and young patients. Complication was seen predominantly among the elderly, with 62.8 %( 49) Vs38.7% (29); p =0.03. Overall, heart failure was the commonest complication (28.2%), followed closely by arrhythmias (26.9%). Cardiogenic shock complicating STEMI resulted in high patient mortality in both the age groups. Thrombolysed patients were similar in distribution in both groups. But the success rate of thrombolysis was lower in elderly patients (50%) as compared to young patients (76.9%). Beta blockers were less commonly used in the elderly- 47.4% (34) than in young patients- 61.3% (46). A combination of aspirin and clopidogrel was also less commonly used in the elderly patients {60.3% (47) Vs 76% (57); p=0.03}. Mortality was higher in the elderly patients (24.4% Vs 10.7%; p =0.03)
Conclusion: Elderly patients are more prone to complications, have less success rate for thrombolysis and have a higher mortality rate as compared to young patients of ACS.


Acute coronary syndrome, Elderly, Nepal, Young

Acute coronary syndrome (ACS), encompassing a range of disorders from unstable angina through non ST elevation to ST elevation myocardial infarction, is a leading cause of death in the world in both developed and developing countries. The South Asian countries of India, Pakistan, Bangladesh, Sri Lanka, and Nepal account for about a quarter of the world's population and contribute the highest proportion of the burden of cardiovascular diseases as compared with any other region globally(1),(2),(3). Death claims mostly the elderly population; in US, 83 % of IHD deaths were in patients of more than 65 years of age(4). The elderly are also at a higher risk for complication then the younger population. The elderly are a subgroup known to be at high risk, but community practice patterns continue to demonstrate that less use of cardiac medications and invasive care even among elderly individuals are likely to benefit them(4).Despite the large and expanding elderly population presenting for ACS care, existing evidence is limited and insufficient to guide management in this subgroup, to the same degree of certainty as in younger populations(5). Deaths related to cardiovascular disease also occur 5 to 10 years earlier in South Asian countries than they do in Western countries(6),(7). Data from Nepal in this regard is lacking. Hence, the present study was undertaken with the following objectives:
1. To study the demographic details of the patients presenting with acute coronary syndrome
2. To compare the differences in the elderly and young patients with regards to presentation risk factors, management and the outcome among the acute coronary syndrome patients

Material and Methods

The study population consisted of 153 patients of acute coronary syndrome, admitted and managed in the intensive care unit of Manipal Teaching Hospital during March 2006 to June 2007. The study population was prospectively observed during the hospital stay and the demographic details, presentation, clinical findings, management and outcome were recorded in a preformed proforma. The standard case definition of the American Heart Association (AHA) was used for classifying patients into categories of unstable angina, Non ST Elevation Myocardial Infarction (NSTEMI) and ST Elevation Myocardial Infarction (STEMI). Successful thrombolysis was defined clinically when the patients had relief from chest pain and electrocardiographically, by the decrease in the ST segment elevation by 50 % of the presenting ECG.

The study population was divided in two groups viz. >= 65 yrs of age and <65 yrs of age. The two groups were compared for patient characteristics, presentation, clinical findings, course of treatment at the hospital and the evolution of complication during the admission.

The SPSS package version10.0 was used to carryout the statistical analysis. The categorical data was analysed using χ2 test.. Continuous data are presented in the form of mean and median.


A total of 153 cases fulfilled the criteria of ACS, of which 78 (50.98%) were elderly and 75(49.02%) were young. Almost 50% of the patients in both the groups were females: 36 (46.2%) in the elderly and 35 (46.7%) in the young groups, respectively. The demographic details of the patients and risk factors are listed in (Table/Fig 1).

Type of ACS
STEMI and unstable angina were the predominant types of ACS seen in both the groups in proportionate amounts [n=38 (48.7%)] in the elderly and [n=33 (44%)] in the young patients and [32 (41%)] in the elderly and [34 (45.3%)] in the young patients, respectively. NSTEMI was seen in only 10% of cases in both groups. There was no statistical significance in the type of ACS seen when compared between the two groups.

Onset of symptoms to presentation
The median time of presentation to the hospital after the symptoms, was 16 hours (IQ -5.25 – 72) in the elderly and 15 hours ( (IQ -5.25 – 72) in the young and there was no statistical difference between the groups. However, among patients with STEMI, the median time of presentation to the hospital in young patients was 7.25 hours (IQ 2.87 – 39 hours) as compared to 15 hours (IQ 5.5 – 72 hours) in elderly patients, which was statistically significant (p=0.000).

Presenting Symptoms
Most of the individuals with ACS presented with chest pain, but those who presented with symptoms other than chest pain, like epigastric pain, sweating , breathlessness and syncope were classified as atypical presentation Atypical presentation was more common in the elderly as compared to the young (7.7 % vs 4.2%), but this was also not statistically significant.

Risk factors
Young patients were more likely to be hypertensive as compared to the elderly patients (70.7% vs 39.7%; p <0.001). However, there was no difference between the two age groups with regards to the habit of smoking (p=0.163), presence of diabetes (p=0.206), alcohol consumption (p=0.5) and a prior history of CAD (p=0.656).

Wall involvement in STEMI
Among a total of 71 STEMI patients, involvement of inferior wall and extensive anterior wall was seen in 36.6% (n=26) and 35.2% (n=25) patients respectively, followed by anterior wall 22.5% (n= 16) and lateral wall 8.5% involvement (n=6). There was no statistical significance with regards to the wall involvement among the elderly and young populations.

Overall, more complications were observed in the elderly population as compared to the younger group 62.8% vs 38.7%; p=0.03.Common complications seen in both of these groups were heart failure, seen in 24.4% of the elderly and 17.35% of young patients, arrhythmia in 23.1% of the elderly patients vs 16% of young patients, cardiogenic shock in 14.1% of the elderly patients vs 10.7% of young patients and hypotension in 7.7% of the elderly patients vs 5.3% of young patients .There was no statistical significance in the type of individual complications . Presentation with sudden cardiac death was observed in 3.8 % of elderly patients, whereas there was none in the young age group. The details are listed are listed in (Table/Fig 2).

The elderly patients were less likely to be treated with B –blockers as compared to the young individuals (47.4% vs 61.3%). A combination of aspirin and clopidogrel was also less commonly used in the elderly 60.3% (47) than the young 76% (57), which was statistically significant( p= 0.03).Use of ACE inhibitors and statin was uniform in the both the groups.

Mortality was higher in elderly 19 (24.4%) patients as compared to young patients 8(10.7%) (p value 0.026) (OR of 2.69 with 95% CI). Among those with ACS, mortality was mainly seen in 13 cases of STEMI among elderly patients and in 8 patients among young individuals .There was a high mortality rate when patients presented with cardiogenic shock and congestive heart failure. The mortality was mainly seen in patients with extensive anterior wall MI (11 out of 16), followed by inferior wall STEMI (7 out of 26).

Only 19 (33.9%) patients were thrombolysed, out of which 8 were elderly (30.8%) and 11 were young (36.7%). Four cases (50%) of thrombolysis in elderly patients were successful whereas only 9 (81.8%) cases were successful among the young.

Reasons For Not Giving Thrombolysis
When we analyzed the reasons for not giving thrombolysis in STEMI, the main reason was late presentation of the patient, observed in 24 (38) of elderly patients and 16(33) of young individuals .The other reasons being history of stroke in 4 patients, 2 in each group, followed by the previous use of streptokinase in 3 individuals (2 in the elderly group and 1 in young age group) and non availability of streptokinase in the hospital, in 3 patients.


In our study, we found that sex distribution in both the elderly and young patients were almost equal, with a male:female ratio of 1.14:1. The various studies done previously showed that elderly patients were more likely to be females, due to the loss of the protective action of oestrogen in these individuals (8)is trend was not seen in our study, as compared to previous studies done in south East Asia and USA. (9),(10).

Smoking (74% vs 62 %), Alcohol intake (29% vs 17%) , Diabetes mellitus(19 % vs 12 %) ,and Prior CAD were ( 24 % vs 21 %) seen more commonly in the elderly than in young patients, however, the younger patients were found to have hypertension (70% vs 40 %), which was statistically significant. Control of hypertension is of utmost importance, as this is one of the major risk factors, irrespective of the age group.

The main risk factors which showed consistently significant associations across all South Asian countries in both sexes, were current and former smoking, high ApoB100 /Apo-I ratio, history of hypertension and history of diabetes. Alcohol consumption did not appear to be protective in native South Asians and this may be related to a lower prevalence or differences in patterns of drinking (binge drinking in South Asians vs regular drinking in other countries). In South Asian households, prolonged cooking of vegetables is a common practice, which may destroy 90% of the folate content, leading to an increased risk for CAD (11). A similar inverse association between the intake of vegetables and AMI has been reported in a case-control study from India (12). These data collectively provide the basis for public health education, aimed at substantially increasing the consumption of fruits and vegetables.

It is likely that the recent increase in CHD in South Asians is due to lifestyle changes associated with urbanization, perhaps interacting with a genetic predisposition that leads to abdominal obesity, dysglycaemia, and dyslipidaemia (13). So, the knowledge of underlying risk factors in population subgroups will be useful for targeting the secondary preventive strategies. In this study, we did not consider the risk factors like apolipoprotein and homocysteine levels which are the important risk factors of CAD, specially in Asian countries, besides the conventional risk factors.

In our study, the atypical presentation was seen more commonly in elderly individuals as compared to the younger group, as shown by previous studies. In GRACE (Global Registry of Acute Coronary Events), the average age of patients presenting with atypical symptoms was 72.9years, whereas the average age of patients presenting with typical symptoms was 65.8 years. In NRMI, only 40% of those aged 85 years of age, had chest pain on presentation as compared with 77% of those aged 65 years. .Although chest pain remains a common symptom of ACS, elderly patients were more likely to present with dyspnoea (49%), diaphoresis (26%), nausea and vomiting (24%), and syncope (19%) as a primary complaint; hence, MI may go unrecognized(14).

Atypical presentations have been shown to result in portend, a worser prognosis (a 3-fold higher risk of in-hospital), in part, because of delays in diagnosis and treatment and less use of evidence-based medications. Because of the high prevalence of atypical features and associated worse outcomes in the elderly, a high index of suspicion for ACS is advisable(14),(15).A typical presentation was recorded in very less individuals in our study, seen in only 3.8 % of the elderly population and most of them presented with syncopal attack. Mortality was observed in 50% of the elderly, presenting with atypical symptoms. Future prospective studies should focus on various atypical presentations.

The median time of presentation after the symptoms started in our study, was 16 hours, and this was more in elderly individuals as compared to the younger group, which was supported by similar studies done in India and developing countries. When the data of STEMI was looked into, the median time of hospital presentation was 7.25 hours in younger individuals as compared to 15 hours in elderly individuals. It might be because the elderly mainly had atypical presentations. The time from onset of symptoms to presentation at the hospital is typically longer among patients in India, than in the West.16-20The time from onset of symptoms to arrival at the emergency department, for patients with acute ST elevation myocardial infarction (STEMI) ranges between 110 and 140 minutes in North America,(16),(17)while in India, it is 180–330 minutes(18), (19).In the recently concluded CREATE registry, the median symptom-to-door time was 300 minutes for patients with STEMI (unpublished data). This delay in presentation is due to several factors, including lack of symptom awareness, longer distances travelled to reach hospital and problems of transportation (18), (19).Only 5.4% of patients are brought to hospital in an ambulance, with the large majority using public transport (buses) and hired vehicles (taxis, auto rickshaws, etc)(18). Of interest is the fact that consultation with the family doctor, local practitioner or local primary health centre has been found to be an important cause of delay in presenting at the hospital (18),(19),(20).In addition, older people and women have been observed to present disproportionately late, irrespective of whether their symptoms were typical or atypical. Since the transit time to reach hospital plays an important role in outcomes, there is a need for increasing public awareness about the symptoms, facility of ambulance services, etc.

Thrombolytic therapy was instituted in individuals who presented within 12 hours of STEMI, if there was no contraindication. Among 31 patients with STEMI who presented within 12 hours, 10 patients from the younger group (58.8%) were thrombolysed and 8 (57.1%) among the elderly individuals were thrombolysed .The reasons for not thrombolysing individuals presenting within 12 hours, were mainly stroke (n =4 ), prior use of streptokinase (n=3) and surgery in the recent past(n=1) . Failure to reach the hospital within 12 hours is the primary reason for not instituting the thrombolytic therapy in STEMI, which was seen in 24 (38) of elderly patients and 16(33) of the younger group. Several other studies have also shown that fewer elderlies were thrombolysed, mainly due to the delay in seeking medical care.(21),(22).

Individuals in whom there was prior use of streptokinase could not be thrombolysed due to unavailability of t-PA. Though t-PA is expensive and affordability can be a problem in developing countries, availability in hospitals if ensured, can be used in needy cases.

Elderly individuals had more complications as compared to young patients, which was statistically significant (62.8% vs 38.7%) (p=0.03) .The common complications observed were heart failure, cardiogenic shock, arrythmias and sudden cardiac death.Among the arrythmias observed, heart block was predominant, followed by atrial fibrillation, ventricular tachycardia, junctional rhythm and supraventricular tachycardia.

The mortality in the elderlies was significantly higher as compared to young individuals (19 (24.4%) vs 8(10.7%) (p=0.026). Among the elderlies, 13 of 19 STEMI patients died during the hospital stay as compared to all the 8 young STEMI patients who remained alive. Likewise, more patients presenting with cardigenic shock (100% vs 87.5% in young) and congestive heart failure died in the hospital. Sudden cardiac death was also more common among the elderly.

Age is a powerful predictor of adverse events after ACS.23-25 After accounting for other factors, the odds for in-hospital death increase by 70% for each 10-year increase in age(23).

The use of beta blockers was less in the elderly population as compared to the young population, though it was not statistically significant p=0.569, despite various studies recommending the optimal use of b –blockers in elderly individuals .Though in our study, the use of b-blockers was optimized, till there was a clear cut contraindication, like in patients with severe heart failure (KILLIP III and IV class), AV blocks were seen in ECG and patients of COPD with significant bronchospasms . Numerous large multicenter randomized trials have confirmed the beneficial role of oral ß-blocker therapy in lowering mortality rate and recurrent coronary ischaemic events with similar or greater efficacy in older patients as compared to younger patients after acute MI (26),(27)[28,(29),(30),(31) Use of combination antiplatelets, Aspirin and Clopidogrel, was less in elderly individuals as compared to the young patients (60.3% vs 76%) (p=0.03). However, the use of ACE inhibitors and statins were uniform in both the groups.

Our study had a small sample size with observation of in-hospital mortality cases only. Follow up studies were not done subsequently after the discharge. Angiographic studies were not done in our patients, thus making our data primitive.


Our study was able to identify the differences in various aspects between the elderly and young patients of ACS .The complication rate and the mortality rate were found to be higher in elderly individuals with ACS. Upgrading the existing facilities in the hospital with the use of evidence based management will be helpful to manage these patients properly and to decrease the complications and mortality in patients with ACS. The preventive strategies for modifying the conventional and unconventional risk factors through public education and awareness will go a long way in curtailing the cases of ACS, especially in developing countries. Long term prospective follow up study with angiography will be required in the future to overcome the limitations of our study.


The authors would like to acknowledge Dr.Abishek Maskey and Dr. Gaurav Shrestha,Post graduate students in Internal Medicine, for helping us in data collection.


. Reddy KS, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circulation 1998; 97: 596-601.
. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of diseases, part 1: general considerations, the epidemiologic transition, risk factors and impact of urbanization. Circulation 2001;104: 2746-53.
. Reddy KS. Cardiovascular diseases in non-Western countries. N Engl J Med 2004; 350: 2438- 40.
. Avezum A, Makdisse M, Spencer F, et al. GRACE Investigators. Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J. 2005; 149:67–73.
. Alexander KP, Newby LK, Cannon CP et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115 (19): 2549-69
. Murray CJL, Lopez AD. Global Health Statistics, Global Burden of Disease and Injury Series. Boston, Mass: Harvard School of Public Health; 1996.
. Murray CJL, Lopez AD. Global Comparative Assessments in the Health Sector. Geneva, Switzerland: World Health Organization; 1994.
. Chew S, Ng SC. Hormone replacement therapy (HRT) and ischaemic heart disease: Getting to the heart of the matter. Singapore Med J 2002; 43 (1):41-4.
. Kam R, Cutter J, Chew SK, Tan A, Emmanuel S, Mak KH, Chan CNS, Koh TH, Lim YL. Gender differences in outcome after an acute myocardial infarction in Singapore. Singapore Med J 2002; 43(5): 243-8.
. Tresch DD. Management of the older patient with acute myocardial infarction: difference in clinical presentations between older and younger patients. J Am Geriatr Soc 1998; 46(9):1157-62.
. MatthewsJH,WoodJK.Megaloblastic anemia in vegetarian Asians. Clin Lab Haematol.1984; 6:1-7.
. Rastogi T, Reddy KS, Vaz M, etal. Diet and risk of ischemic heart disease in India .Am J Clin Nutr. 2004; 79: 582-92.
. Joshi P, Islam S, Pais P. et al. Risk Factors for Early Myocardial Infarction in South Asians Compared With Individuals in Other Countries. JAMA 2007; 297 (3):286-94
. Brieger D, Eagle KA, Goodman SG , et al. GRACE Investigators. Acute coronary syndromes without chest pain, an under diagnosed and under treated high-risk group:Insights from the Global Registry of Acute Coronary Events. Chest.2004; 126:461–69.
. Kanne WB , Abbott RD . Incidence and prognosis of unrecognized myocardial infarction: an update on the Framingham study. N Engl J Med 1984;311: 1144–47.
. Luepker RV, Raczynski JM, Osganian S, et al. Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial. JAMA 2000; 284: 60–7.
. Anand SS, Pais P, Pogue J, et al. A comparison of practice patterns for acute myocardial infarction between hospitals in Canada and India. Indian Heart J 1997; 49: 35–41.
. George E, Savitha D, Pais P. Pre-hospital issues in acute myocardial infarction. J Assoc Physicians India 2001; 49: 320–3.
. Rajagopalan RE, Chandrasekaran S, Pai M, et al. Pre-hospital delay in acute myocardial infarction in an urban Indian hospital: a prospective study. Natl Med J India 2001; 14: 8–12.
. Malhotra S, Gupta M, Chandra KK, et al. Prehospital delay in patients hospitalized with acute myocardial infarction in the emergency unit of a north Indian tertiary care hospital. Indian Heart J 2003; 55: 349–53.
. Boucher JM, Racine N, Thanh TH, Rahme E, Brophy J, Theroux P. Age-related differences in in-hospital mortality and the use of thrombolytic therapy for acute myocardial infarction. Canadian Medical Association Journal 2001; 164(9):1285-90.
. Straznicky IT, French JK, White HD, Califf RM. Fibrinolysis for acute myocardial infarction in the elderly patient: Is it effective or too dangerous? Am J Geriatr Cardiol 1998; 7(1): 22-7.
. GrangerCB, GoldbergRJ, DabbousO, et al. Global Registry of Acute Coronary Events Investigators. Predictors of Hospital mortality in the Global Registry of Acute Coronary Events. Arch Intern Med.2003; 163: 2345–53.
. EagleKA, LimMJ, DabbousOH, et al. GRACE Investigators. A validated prediction model for all forms of acute coronary syndrome:estimating the risk of6-month post discharge death in an international registry. JAMA 2004; 291: 2727–33.
. BoersmaE, PieperKS, SteyerbergEW, et al. Predictors of outcome In patients with acute coronary syndromes without persistent ST-segment elevation: results from an international trial of 9461 patients. Circulation 2000; 101:2557–67.
. Hjalmarson A, Elmfeldt D, Herlitz J, et al. Effect on mortality of metoprolol in acute myocardial infarction: a double-blind randomised trial. Lancet. 1981; 11: 823–27.
. A randomized trial of propranolol in patients with acute myocardial infarction, I: mortality results. JAMA. 1982; 247: 1707–14.
. A randomized trial of propranolol in patients with acute myocardial infarction, II: morbidity results. JAMA. 1983; 250: 2814–19.
. Gundersen T, Abrahmsen AM, Kjekshus J, Ronnevik PK. Timolol-related reduction in mortality and reinfarction in patients ages 65–75 years surviving acute myocardial infarction: prepared for the Norwegian Multicentre Study Group. Circulation. 1982; 66: 1179–84.
. Pedersen TR. Six-year follow-up of the Norwegian Multicenter Study on timolol after myocardial infarction. N Engl J Med. 1985; 313: 1055–58.
. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA.1997; 277: 115–21.

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)