Characteristic of Clinical Likelihood Chronic Coronary Syndrome patients with Significant Coronary Lesion in RSUP dr. Mohammad Hoesin

Chronic coronary syndrome (CCS) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries, whether obstructive or non-obstructive. Significant Coronary artery disease (CAD) is defined by invasive coronary angiography as >50% stenosis of the left main stem, >70% stenosis in a major coronary vessel, or 30% to 70% stenosis with fractional flow reserve ≤0.8. This study aimed to identify the characteristics of clinical likelihood CCS patients with site of significant coronary lesion based on pre-test probability (PTP) from demographic characteristics; risk factors; laboratory and echocardiography findings. This is a retrospective cohort study. We reviewed 60 medical records of clinical likelihood chronic coronary syndrome patients with positive inducible ischemia area from dobutamine stress echocardiography and significant CAD lesion from coronary angiography. The incidence of significant CAD in this population was 56.1%. There was a significant relationship between age > 65 years with the incidence of significant LAD lesion (23.3%, p = 0.019); significant LCx lesion (20%, p = 0.043). There was a significant relationship between PTP score ≥ 16% with significant LAD lesion (55.0%, p = 0.001); significant LCx lesion (45.0%, p = 0.031); and significant RCA lesion (40.0%, p = 0.050). Patients with age > 65 years have a higher incidence of significant LAD and LCx lesions. Patients with pre-test probability score ≥ 16% have a higher incidence of significant lesions across coronary branches, predominantly in the LAD.


INTRODUCTION
Coronary artery disease (CAD) is a pathological process characterized by atherosclerotic plaque accumulation in the epicardial arteries, whether obstructive or non-obstructive.The dynamic nature of the CAD process results in various clinical presentations, which can be conveniently categorized as either acute coronary syndromes (ACS) or chronic coronary syndromes (CCS) (Boden et al., 2023;Buse et al., 2021;Panuccio et al., 2023;Vink et al., 2023).Significant Coronary artery disease (CAD) is defined by invasive coronary angiography as >50% stenosis of the left main stem, >70% stenosis in a major coronary vessel, or 30% to 70% stenosis with fractional flow reserve ≤0.8 .
The 2019 ESC guidelines updated the method for estimating the pre-test probability (PTP) of obstructive coronary artery disease (CAD).The concept of pretest probability (PTP) based on variables such as sex, age and angina characteristics.This pre-test probability can be further modified by applying other known clinical risk markers such as smoking, hypertension diabetes, dyslipidemia, family history of CVD, resting ECG changes (Q wave or ST-segment/T wave changes), LV dysfunction suggestive of CAD, abnormal excersice ECG and coronary Calcium by CT.This can be correspondingly diminished or augmented to give a clinical likelihood ratio for obstructive CAD (Boivin-Proulx et al., 2023;Dai et al., 2024;Rinaldi et al., 2024;Sands & Edwards, 2023).
Stress echocardiography has reached its established rank in the diagnosis and prognosis of coronary artery disease (Kadoglou et al., 2022;Pargaonkar et al., 2020;Pezel et al., 2021).Dobutamine stress echocardiography is the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment.This study aimed to identify the characteristics of significant coronary lesion patients with low clinical likelihood CCS patients with site of significant coronary lesion based on pre-test probability (PTP); demographic characteristics; risk factors; laboratory and echocardiography findings.

RESEARCH METHODS
We designed this study as a retrospective cohort study.Therefore, we reviewed medical records of 60 patients with CCS who had been evaluated has a positive coronary lesion based on dobutamine stress echocardiography (DSE) and significant coronary lesion based on coronary angiography at Mohammad Hoesin Hospital Palembang between January 2022 and March 2023.Data then analyzed using SPSS Statistics 23.Data were analyzed using bivariate analysis.Variables with p value <0.25 were taken and a second bivariate analysis was carried out to compare the variables with the site of lesion on significant CAD (LM, LAD, LCx, RCA).
Variables with p value <0.05 were analyzed using multivariate analysis.Variables with p value <0.05 considered to have a significant relationship.
The diagnosis of CCS was establish on the basis following criteria: (i) patients with suspected CAD and 'stable' anginal symptoms, and/or dyspnea, (ii) patients with new onset of heart failure (HF) or left ventricular (LV) dysfunction and suspected CAD, (iii) asymptomatic and symptomatic patients with stabilized symptoms <1 year after an ACS, or patients with recent revascularization, (iv) asymptomatic and symptomatic patients >1 year after initial diagnosis or revascularization, (v) patients with angina and suspected vasospastic or microvascular disease, and (vi) asymptomatic subjects in whom CAD is detected at screening (Pacheco et al., 2022).
Patients with CCS criteria and had positive DSE examination and significant coronary lesions were included in the study.Patients who have CCS criteria but negative DSE results are exclude in the exclusion criteria.From 100 patients, we exclude 40 patients who had negative DSE.In total 60 patients who had positive DSE and significant coronary lesion were enrolled in this study (figure 1).

Figure 1. Inclusion and Exclusion Criteria
This study were approved by local ethics committee based on research protocol.The requirement of informed consent was waived by the committee.

RESULTS AND DISCUSSION
Bivariate Analysis of Significant and Non-Significant CAD Bivariate analysis of low clinical likelihood significant and non-significant CAD.This research was conducted retrospectively significant coronary syndrome patients with positive DSE examinations and coronary angiography examination from January 2022 to March 2023.The proportion of significant CAD in this population was 56.1% and non significant CAD was 17.1%.From these data it is known that patients with aged > 65 years have a higher incidence of significant CAD than non-significant CAD (25.0%vs 1.7%, p = 0.055).Patients with male gender had a higher proportion of significant CAD than non-significant CAD (60.0%vs 10.0%, p = 0.016).There was a significant difference between gender in significant and nonsignificant CAD (60.0%vs 16.7%, p = 0.016).Patients with history of smoking and CAD significant and CAD non significant (60.0%vs 3.3%, p = 0.016).Proportion of patients with history of DM type II with significant CAD and non significant CAD (25.0%vs 81.8%, p = 0.161).
The proportion of significant CAD and non significant CAD in patients with history of hypertension (60.0%vs 20.0%, p=0.426).
Based on demographic characteristics, clinical symptoms of the patient, the results of echocardiography and laboratory examinations, we summarized the patient data and calculated the PTP value based on the 2019 ESC guideline.4We found that the proportion of significant CAD higher than non significant CAD events in patients with a PTP value > 16% (66.2% vs 5.0%, p = 0.000).

Multivariate Analysis
Variables that will be included in the multivariate analysis are variables that in the bivariate analysis have a p value smaller than 0.05.Based on the bivariate analysis that has been carried out previously, the variables that can be entered into the multivariate analysis are: patients aged > 65 years with significant LAD lesion (p = 0.017), significant LCx lesion (p = 0.040).Patients with PTP values > 16% had significant LAD lesion (p = 0.001), significant LCx lesion (p = 0.020), and significant RCA lesion (p = 0.023).
The multivariate analysis used is logistic regression with the backward selection method where variables that have a p value of more than 0.05 will be excluded and repeated multivariate analysis will be carried out until the final result is a final model with significant variables with a p value ≤ 0.05.Logistic regression was chosen because the dependent variable is a variable.categorical.The results of the multivariate analysis, it was found that there was a significant relationship between age > 65 years and significant LAD lesions (p = 0.019).Significant relationship between age > 65 years and significant LCx lesions (p = 0.043).Significant relationship between PTP > 16% and significant LAD lesions (p = 0.001).Significant relationship between PTP > 16% and significant LCx lesions (p = 0.031).Significant relationship between PTP > 16% and significant RCA lesions (40.0%, p = 0.050).
From the results of the first bivariate analysis, it was found that the highest characteristic with a p value <0.25 in patients with significant CAD was age > 65 years; male gender; history of smoking and history of diabetes mellitus; EDV > 235 and GLS < -15.6 which indicates the patient has LV dysfunction; blood pressure > 140/90; LDL > 100 mg/dL and TG > 150 mg/dL; GDS > 200 mg/dL and HbA1C > 5.6.
From demographic characteristics, clinical parameters using echocardiography and sphymomanometer as well as laboratory examination results, we grouped patients based on PTP values < 16% and > 16% using the 2019 ESC guidelines.From the results of bivariate analysis, PTP values > 16% and significant CAD incidence rates were obtained = 0.000.Then we correlated age > 65 years and PTP > 16% with the site of lesion on significant CAD to see whether there was a relationship between age 65 years and PTP > 16% and the incidence of LM disease or significant lesions found on the LAD, LCx or RCA.
The results from the data analysis, it was found that there is a significant relationship between age > 65 years and significant LAD lesions (p = 0.019).There is a significant relationship between age > 65 years and significant LCx lesions (p = 0.043).There is a significant relationship between PTP > 16% and significant LAD lesions (p = 0.001).There is a significant relationship between PTP > 16% and significant LCx lesions (p = 0.031).There is a significant relationship between PTP > 16% and significant RCA lesions (40.0%, p = 0.050).The limitation in this research is that the lack of research samples makes the data difficult to analyze using multivariate analysis and many biases in the research.

CONCLUSION
In conclusion, the bivariate analysis of significant and non-significant CAD revealed important associations between demographic characteristics, clinical parameters, and laboratory findings.Notably, patients aged over 65 years showed a higher incidence of significant CAD, especially in the left anterior descending (LAD) and left circumflex (LCx) arteries.Male gender, a history of smoking, and higher pre-test probability (PTP) values (>16%) were also significantly associated with significant CAD, with correlations observed in specific coronary arteries.Additionally, certain clinical parameters such as elevated blood pressure, abnormal echocardiography results, and specific laboratory findings were associated with significant CAD.The multivariate analysis further confirmed the significant relationships between age > 65 years, PTP > 16%, and the presence of significant lesions in the LAD, LCx, and right coronary artery (RCA).However, it is essential to acknowledge the limitations of this study, including a small sample size and potential biases, which may impact the generalizability of the findings. BIBLIOGRAPHY Characteristic of Clinical Likelihood Chronic Coronary Syndrome patients with Significant Coronary Lesion in RSUP dr.Mohammad Hoesin Palembang Page 496 Asian Journal of Engineering, Social and Health Volume 3, No. 3 March 2024

Table 2 . Bivariate Analysis Characteristics Patients Based on LM Disease
Page 491 Asian Journal of Engineering, Social and Health Volume 3, No. 3 March 2024