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

Users Online : 76

AbstractMaterial and MethodsResultsDiscussionConclusionKey MessageReferences
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 Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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 Dematolgy,
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
Lucknow
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,
Muzaffarnagar.
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,
Bengaluru.
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 one’s 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
Consultant
(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 journals–No manuscripts–No 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)
E-mail: drrajendrak1@rediffmail.com
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.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : October | Volume : 4 | Issue : 6 | Page : 3150 - 3157

Does The Pharmacological Management Of Unstable Angina Vary With Age And Gender – A Descriptive Study

BANERJEE S*, KUMAR V*, RAMACHANDRAN P#, KAMATH A*

*Dept. of Pharmacology, #Dept. of Cardiology, Kasturba Medical College, Manipal University, India.

Correspondence Address :
Dr. Ashwin Kamath
Assistant Professor, Department of Pharmacology
Kasturba Medical College, Light house hill road
Mangalore – 575001, Karnataka
INDIA
Telephone number: +919844262808
Email address: mailmaka@gmail.com

Abstract

Purpose
Observational registries have shown the underutilization of evidence based therapies in women and elderly patients. While the burden of unstable angina is high in India, there is minimal data on the drug utilization patterns. Also, gender and age differences in the treatment have not been assessed. This study intends to present the data on drug utilization in the management of unstable angina in a tertiary care hospital and to detect the presence of significant gender or age related differences in the treatment.

Method
The case record files of all patients who were admitted with unstable angina during January 2006 to December 2008 were studied. The demographical details, comorbidities, the duration of the hospital stay, outcomes and the drugsadministered within 24 hours of admission and at discharge for each case was obtained.

Results
Of the 318 patients, 63.2% were males and 55.7% were less than 65 years of age. The mean (± SD) age of the males was 60.64 (± 11.71) years as compared to the mean age of 64.21 (± 9.98) years in females (p=0.006). The overall mortality was 1.89 %. There was an underutilization of aspirin and betablockers in the elderly, while antiplatelet agents and anigotensin converting enzyme inhibitors were used to a lesser extent in females. The prescription rate of statins was high.

Conclusion
There was an underutilization of drugs in the elderly and in female patients. The results are similar to the data reported from previous studies. The diagnosis and management of unstable angina poses a difficult challenge because these subgroups quite often present with atypical symptoms and have less extensive coronary artery disease.

Keywords

Drug utilization, unstable angina, gender, age

INtroduction
In recent years, considerable new information has come to light concerning the diagnosis and the subsequent management of patients with unstable angina (UA). The course and the prognosis of unstable angina is variable, but there is a high risk of myocardial infarction and death during the initial 2-3 months (1). While the short term mortality is low as compared to patients with ST-elevation myocardial infarction (STEMI), the long term outcomes for mortality and recurrent ischaemic events are higher (2).
Observational registries have shown the underutilization of evidence based therapies in women and elderly patients. Differences in cardiac care according to gender have been described over the past two decades. Two key areas which are responsible include the lower utilization of effective diagnostic strategies and the perception that women are at a lower risk than their male counterparts (3). Some studies suggest an equal delivery of cardiac care to both the male and female genders, once the diagnosis is established (4). However, a recent study which looked into the data of 35,875 patients with non ST-elevation acute coronary syndrome, who participated in the CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early initiative of the American College of Cardiology/American Heart Association guidelines) national quality improvement initiative, reported a less aggressive treatment of women than men, despite having a higher in-hospital risk of morbidity or mortality (5). Elderly patients with unstable angina tend to have atypical presentations of disease, substantial comorbidity, ECG stress tests that are more difficult to interpret and different responses to pharmacological agents as compared to the younger patients (6).

While the burden of unstable angina is high in India, there is minimal data on the utilization of various evidence based medicines in the management of the disease. The largest study to date in India is based on the data from the CREATE registry, a prospective multicentre study which was done to determine the treatment and outcomes of acute coronary syndrome (ACS). However, gender and age differences in the treatment were not assessed in this study (7). Also, the treatment received on hospital admission and discharge needs to be considered separately, since the early initiation of certain drugs can significantly decrease mortality or subsequent morbidity. This study intends to present the data on drug utilization in the management of unstable angina in a tertiary care hospital and to detect the presence of significant gender or age related differences in the treatment.

Material and Methods

The study was done at a tertiary care hospital with a dedicated coronary care unit in Southern India. The inpatient registry was searched to identify the patients who were admitted with unstable angina during the period from January 2006 to December 2008. The initial case selection was based on the International Classification of Disease Code (ICD-10, I20), which was later confirmed by going through the patient history and investigations which were recorded in the case file. The patients who were referred from other hospitals were not included in the study. Mandatory approval from the Institutional Ethics Committee was obtained prior to the initiation of the study. The demographical details, comorbidities, the duration of the hospital stay, outcomes and thedrugs administered within 24 hours of admission and at discharge for each case was obtained. The use of the following drugs was recorded – nitrates, antiplatelet agents, beta blockers, calcium channel blockers (CCB), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), diuretics, hypolipidaemics, nicorandil, Pfox inhibitors and anticoagulants.

Elderly patients were defined as those with ≥ 65 years of age. Drug utilization was defined as the percentage of patients receiving a particular drug.

The continuous variables have been presented as mean±SD and were compared by using the unpaired t test. The categorical variables have been compared by the Pearson’s Chi square test. The odds ratio and the adjusted odds ratio have been presented. The binary logistic regression model was used for this adjustment. The baseline variables which were adjusted for in the model were age, gender, hypertension, diabetes, hypercholesterolaemia, prior myocardial infarction, ischaemic heart disease and chronic kidney disease. P valueof <0.05 was considered to be statistically significant. The SPSS version11.5 software package was used for statistical analysis.

Results

The case record files of 318 patients who were admitted with unstable angina during the years from 2006-2008 were retrieved from the medical records section and were studied. 63.2% were males. 55.7% were less than 65 years of age. The mean (± SD) age of the males was 60.64 (± 11.71) years as compared to the mean age of 64.21 (± 9.98) years in females. The females were significantly older than the males [p = 0.006]. The median (25th percentile, 75th percentile) duration of hospital stay was 6 (4, 8) days. The overall mortality was 1.89 %. The mortality rate in males, females, patients aged < 65 years and the elderly were 2.55, 0.86, 2.31 and 1.44 percent, respectively. The difference among the groups was not significant.
The distribution of comorbidities according to gender and age is shown in (Table/Fig 1). A significantly larger percentage of elderly patients were hypertensive and had ischaemic heart disease and chronic kidney disease. With regards to gender, there were more hypertensives and hyperlipidaemics among the females than the males.

(Table/Fig 1) Distribution of comorbidities in patients with unstable angina according to age and gender

*Data obtained for 262 patients.


The utilization rates of various groups of drugs within 24 hours of admission and at discharge are shown in (Table/Fig 2). The commonly prescribed drugs were as follows – isosorbide mononitrate among the nitrates, clopidogrel among the antiplatelet agents, metoprolol among the beta blockers, amlodipine among the CCBs, ramipril among the ACE inhibitors, atorvastatin among the hypolipidaemics and unfractionated heparin (UFH) among the anticoagulants.

(Table/Fig 2) Drug utilization in patients with unstable angina within 24 hours of hospital admission and on discharge


The drug utilization pattern according to age is shown in (Table/Fig 3) and (Table/Fig 4) and according to gender is shown in (Table/Fig 5) and (Table/Fig 6). The use of percutaneous coronary intervention or coronary artery bypass grafting in males, females, younger and the elderly patients was 12.44, 6.84, 15.25 and 4.26 percent, respectively. Although the use of interventional procedures was less in the elderly as compared to the younger patients, the difference was not statistically significant after adjustment.

(Table/Fig 3) Drug utilization pattern according to age in years within 24 hours of admission


(Table/Fig 4) Drug utilization pattern according to age in years at discharge

(Table/Fig 5) Drug utilization pattern according to gender within 24 hours of admission

(Table/Fig 6) Drug utilization pattern according to gender at discharge

Discussion

The gender distribution of the patients in our study was similar to that found in other studies, which showed the predominance of the male gender. The age at presentation was considerably lower as compared to those of the patients in the CRUSADE registry (Median age of 65 years in males and 73 years in females) (5). Various studies have shown that the presentation of coronary disease occurs a decade
earlier in Indians and other Asians (8). The CREATE registry investigators reported a mean age of 59.31±11.83 years in patients with NSTEMI (7). With the improvement in the standard of living and access to health care, there is a steady increase in the population which survives beyond 65 years of age. In our study, elderly patients constituted 44% of the total cases. The elderly patients significantly more often had hypertension (78.0% vs 59.9%), ischaemic heart disease (53.2% vs 40.7%) and chronic kidney disease (14.9% vs 5.1%) as compared to the younger patients. Similarly, a gender difference in the presence of comorbidities was seen, with more hypertension and hyperlipidaemia in women. The CRUSADE investigators also showed that women with unstable angina were more hypertensive (5). Similarly, the TIMI III Registry Study Group reported an increased likelihood of women to have a history of hypertension and diabetes mellitus (9). Although in our study, more women had diabetes than men, which corroborated with previous studies, the difference was not significant.

More than 95% of the patients received antiplatelet agents and more than 90% received hypolipidaemics within 24 hours of hospital admission as well as on discharge. Among the antiplatelet agents, clopidogrel was utilized to a greater extent than aspirin. The CRUSADE investigators reported a greater use of aspirin (91.6% versus 41% for clopidogrel on admission, 90.4% versus 53.2% for clopidgrel on discharge) (5). The reasons for the higher utilization of clopidogrel in our study include its better gastrointestinal safety profile and the numerous clinical trials over the past few years, supporting the use of dual antiplatelet therapy. The combination of clopidogrel plus aspirin has been shown to confer a 20% reduction in cardiovascular death, MI, or stroke as compared to aspirin alone, in both low and high-risk patients with UA/NSTEMI (10). For secondary prevention, clopidogrel alone is at least as effective as or modestly more effective than aspirin (11). In our study, 70.4% of the patients within 24 hours of admission and 66.3% of the patients at the time of discharge were prescribed a dual antiplatelet therapy of aspirin and clopidogrel. Numerous trials have shown that early initiation and long-term treatment with statins reduce the risk of recurrent ischaemic events post-ACS, despite only modest angiographic reductions in the severity of coronary stenoses (12),(13). While the guidelines recommend the initiation of hypolipidaemic drugs prior to hospital discharge, there is evidence that initiation of a statin within 24 hours of admission lowers the incidence of death, stroke, reinfarction, heart failure and pulmonary oedema as compared to delayed administration of the drug (14). Atorvastatin was by far the most commonly used hypolipidaemic agent in our study, being prescribed in 88.7% and 91.7% of the patients within 24 hours of admission and at discharge respectively. These prescription rates are much higher than those reported by the CRUSADE (59.65% for statins on discharge) or CREATE investigators (53.9% for hypolipidaemics during hospitalization) (5),(7).

The use of ACEI/ARBs was similar in extent, while the use of beta blockers and heparin was less as compared to that reported by theCRUSADE registry. ACE inhibitors improve endothelial dysfunction, reduce the progression of atherosclerosis and prevent plaque rupture and thrombosis, apart from their well known benefits in patients with LV dysfunction and in post-MI patients (15),(16). ACEIs are useful if hypertension, diabetes, LV systolic dysfunction or heart failure complicates ACS. If tolerated, an ACEI may be used in all post-ACS patients (17). Among the beta blockers, metoprolol was commonly prescribed. Beta blockers are effective when used singly in UA and in combination with nitrates to reduce subsequent MI or recurrent ischaemia (18). The CREATE investigators reported the use of beta blockers in 61.9% of the NSTEMI patients. Various studies have reported the use of beta blockers ranging from 44.7% to 81.6% (5),(7),(9). In our study, unfractionated heparin was used in 36.8% of the patients and enoxaparin was used in 25.2% of the patients. Enoxaparin has several advantages over UFH, namely, the more effective inhibition of thrombin generation and less thrombocytopaenia (19). The American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines recommend enoxaparin over UFH. However, due to the higher cost of enoxaparin, its utilization was less in our study. In the study conducted by Malhotra S et al., the use of enoxaparin was more than that of UFH (57% vs 33%). But, enoxaparin accounted for about 60% of the total expenditure on a prescription (20).

With respect to age, a significantly less utilization of aspirin and beta blockers was seen in elderly patients. The difference was seen after the adjustment for baseline demographics and co-morbid conditions, as well. Similar findings have been reported by other studies (9),(21). Although older age and the presence of comorbidities would tend to increase the benefit of treatment, these characteristics are often associated with under-treatment, probably due to the fear of complications or the lack of adequate clinical trial evidences in the elderly. Studies have reported the increased use of nitrates, diuretics and CCBs in elderly patients. Similar findings were seen in our study. The increased use of nitrates on discharge was probably due to an increased risk of recurrent angina in the elderly. CCBs tend to be overused in the elderly patients despite their detrimental effects on the survival (15). One of the likely causes is the presence of comorbid hypertension. In our study, CCBs were more commonly used in the elderly, but the difference was not significant after adjusting for the baseline factors.

Previous studies have reported that women are less likely to receive antiplatelet agents, ACEI/ARBs, statins and heparin as compared to men. Our study revealed a significant underutilization of aspirin on admission along with clopidogrel and ACEI on discharge. In one of the largest studies to date, the National Registry of Myocardial Infarction-1 investigators found that similar treatment disparities existed among the STEMI patients (16). The pattern of relative underuse was similar, considering older, more established therapies such as aspirin, or newer ones such as clopidogrel, despite greater cardiac disability in women. However, the ACC/AHA guidelines are clearly gender neutral.

The under-treatment of women with UA was possibly due to multiple reasons. Women are more likely to have atypical symptoms such as dyspnoea and to have chest pain which is unrelated to coronary artery disease (22),(23). Elevated biomarkers are less often seen in women (5). Coronary artery disease tends to be non-obstructive and less extensive, as revealed by angiography studies (24). This profile makes it challenging to confirm the diagnosis of UA/NSTEMI and is a likely cause of underutilization. As women present at an older age, many have high-risk baseline features. This often leads to underutilization of drugs due to the fear of complications. One possible reason for aspirin underutilization is an increased incidence of bleeding in older women.

Limitations of the study
The major limitation of this study was that it was conducted in a tertiary care hospital and therefore, it was not representative of all hospitals in India. It would be beneficial to conduct further studies in other regions of India in order to compare the prescribing practices and take corrective measures, if any.

We have not looked into the long term outcome of patients who were treated for unstable angina. Therefore, although there was data to suggest the underutilization or the overutilization of drugs in certain groups, whether this difference in the drug prescribing patterns altered the outcome of the disease or not, cannot be said. However, since there is no difference in the in-hospital mortality, it can be said that the observed treatment differences did not adversely affect the immediate survival. Also, the statement about the underutilization of drugs is a relative one. The comparison between the genders and the age groups with adjustment for the baseline variables provides a reliable estimate. However, the determination of absolute underutilization would require the recording of other variables like cardiac markers, the TIMI (thrombolysis in myocardial infarction) score, the presence of contraindications for drugs, etc., which has not been done in our study. Similarly, general statements about underutilization wherever mentioned is in comparison to other similar studies.

Conclusion

This study identified the underutilization of drugs in females and in elderly patients, particularly antiplatelet drugs, despite a high overall use. Determining the specific causes for underutilization requires a more elaborate study. Our results are similar to the data reported from previous studies done in Europe and America. The prescription rate of statins was considerably high, as compared to that in other studies. There was no difference in the in-hospital mortality among any groups. The diagnosis and the management of unstable angina in women and the elderly poses a difficult challenge, because these subgroups of patients quite often present with atypical symptoms and have less extensive coronary artery disease. The clinicians need to keep in mind these differences when prescribing drugs for unstable angina.

Key Message

Observational registries have shown the underutilization of evidence based therapies in women and elderly patients with acute coronary syndrome.
Our study in patients with unstable angina in India revealed similar findings.
The presence of atypical symptoms, less extensive coronary disease and increased comorbidities in these groups might pose diagnostic and therapeutic challenges.

References

1.
Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). Circulation 2007; 116: 803– 877.
2.
Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999; 281: 707-713.
3.
Vaccarino V. Angina and Cardiac Care: Are There Gender Differences, and If So, Why? Circulation 2006; 113; 467-469.
4.
Roger VL, Farkouh ME, Weston SA, Reeder GS, Jacobsen SJ, Zinsmeister AR, et al. Sex differences in evaluation and outcome of unstable angina. JAMA 2000; 283(5): 646-52.
5.
Blomkalns AL, Chen AY, Hochman JS, et al. Gender disparities in the diagnosis and treatment of non–ST-segment elevation acute coronary syndromes: large-scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative. J Am Coll Cardiol 2005; 45: 832–837.
6.
Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, 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.
7.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet 2008; 371: 1435-42.
8.
Sharma M, Ganguly NK. Premature coronary artery disease in Indians and its associated risk factors. Vasc Health Risk Manag 2005; 1: 217-25.
9.
Stone PH, Thompson B, Anderson HV, et al. Influence of race, sex, and age on management of unstable angina and non–Q-wave myocardial infarction: the TIMI III registry. JAMA 1996; 275: 1104–1112.
10.
Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators: Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345 (7): 494-502.
11.
CAPRIE Steering Committee. A randomised, blinded, trial of Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events (CAPRIE). Lancet 1996; 348: 1329 –1339.
12.
Hulten E, Jackson JL, Douglas K, et al. The effect of early intensive statin therapy on acute coronary syndrome: A meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166: 1814-1821.
13.
Tonkin AM, Colquhoun D, Emberson J, et al. Effects of pravastatin in 3260 patients with unstable angina: Results from the LIPID study. Lancet 2000; 356: 1871-1875.
14.
Saab FA, Eagle KA, Klein-Rogers E, Fang J, Otten R, Mukherjee D. Comparison of Outcomes in Acute Coronary Syndrome in Patients Receiving Statins Within 24 Hours of Onset Versus at Later Times. Am J Cardiol 2004; 94: 1166-1168.
15.
The Danish Study Group on Verapamil in Myocardial Infarction. Effect of verapamil on mortality and major events after acute infarction (The Danish Verapamil Infarction Trial II-DAVIT II). Am J Cardiol 1990; 66: 779-785.
16.
Chandra NC, Ziegelstein RC, Rogers WJ, et al. Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I. Arch Intern Med 1998; 158: 981–988.
17.
Association of Physicians of India. API expert consensus document on management of ischemic heart disease. J Assoc Physicians India 2006; 54: 469-80.
18.
Gottlieb SO, Weisfeldt ML, Ouyang P, et al. Effect of the addition of propranolol to therapy with nifedipine for unstable angina: A randomized, double-blind, placebo-controlled trial. Circulation 1986; 73: 331-337.
19.
Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-heparin or unfractionated heparin. N Engl J Med 1995; 332 (20): 1330-1335.
20.
Malhotra S, Grover A, Verma NK, Bhargava VK. A study of drug utilization and cost of treatment in patients hospitalized with unstable angina. Eur J Clin Pharmacol 2000; 56: 755-761.
21.
Avezum A, Makdisse M, Spencer F, et al. 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.
22.
Patel H, Rosengren A, Ekman I. Symptoms in acute coronary syndromes: does sex make a difference? Am Heart J 2004; 148: 27–33.
23.
DeVon HA, Zerwic JJ. Symptoms of acute coronary syndromes: are there gender differences? A review of the literature. Heart Lung 2002; 31: 235-245Yusuf S, Mehta SR, Zhao F, et al. Early and late effects of clopidogrel in patients with acute coronary syndromes. Circulation 2003; 107: 966-972.
24.
Clayton TC, Pocock SJ, Henderson RA, et al. Do men benefit more than women from an interventional strategy in patients with unstable angina or non–ST-elevation myocardial infarction? The impact of gender in the RITA 3 trial. Eur Heart J 2004; 25: 1641–1650.

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)
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com