Document Type : Original Article

Authors

1 Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical, Yazd, Iran

2 Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

3 Department of Clinical Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

4 Department of Clinical Biochemistry, Faculty of Medical Sciences, Tarbiat Modares University, Tehran

5 Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

Abstract

BACKGROUND: Although several studies have attempted to identify coronary artery disease (CAD) risk factors, few have explored the association between lifestyle-related factors and the severity of coronary artery stenosis. The present study was designed to assess the association between a combination of lifestyle, dietary, cardiometabolic, psychological, and mental factors, and CAD severity in adults undergoing angiography.
METHODS: This cross-sectional study aimed to recruit a total of 700 patients (aged 35 to 75 years) who met the inclusion criteria and were referred for angiography between July 2020 and November 2021 to Afshar Hospital, a central heart disease hospital in Yazd city, Iran. To assess the presence and intensity of CAD, we used the Gensini and SYNTAX scores. Biochemical factors were measured using standard kits from serum samples, and extra serum and whole blood samples were retained for further analyses. Data on general information, dietary food and supplement intake, eating habits, medicinal herbs consumption, psychological and mental state, sleep quality, and other variables were gathered by trained interviewers using specific questionnaires.
RESULTS: In total, 720 participants (444 males and 276 females) aged 56.57±9.78 years were included in the current study. Moderate to severe coronary artery stenosis was prevalent in 47.0% and 17.9% of participants based on Gensini and SYNTAX scores, respectively.
CONCLUSION: The results of this study will enhance our understanding of the association between different risk factors and the severity of coronary artery stenosis.

Keywords

1.    Yalcin G, Ozsoy E, Karabag T. The relationship of body composition indices with the significance, extension and severity of coronary artery disease. Nutr Metab Cardiovasc Dis. 2020;30(12):2279-85. https://doi.org/10.1016/j.numecd.2020.07.014
2.    Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med. 2016;4(13):256. https://doi.org/10.21037/atm.2016.06.33
3.    Khan MA, Hashim MJ, Mustafa H, Baniyas MY, Al Suwaidi S, AlKatheeri R, et al. Global Epidemiology of Ischemic Heart Disease: Results from the Global Burden of Disease Study. Cureus. 2020;12(7):e9349. https://doi.org/10.7759/cureus.9349
4.    Gholami SS, Azar FEF, Rezapour A, Tajdini M. Cost-effectiveness of coronary artery bypass graft and percutaneous coronary intervention compared to medical therapy in patients with coronary artery disease: a systematic review. Heart Fail Rev. 2019;24(6):967-75. https://doi.org/10.1007/s10741 -019-09811-3
5.    Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart disease and stroke statistics-2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e29.  
6.    Bechthold A, Boeing H, Schwedhelm C, Hoffmann G, Knüppel S, Iqbal K, et al. Food groups and risk of coronary heart disease, stroke and heart failure: A systematic review and dose-response meta-analysis of prospective studies. Crit Rev Food Sci Nutr. 2019;59(7):1071-90. https://doi.org/10.1080/10408398.2017.1392288
7.    Malakar AK, Choudhury D, Halder B, Paul P, Uddin A, Chakraborty S, Chakraborty S. A review on coronary artery disease, its risk factors, and therapeutics. J Cell Physiol. 2019;234(10):16812-23.
https://doi.org/10.1002/jcp.28350
8.    Phrommintikul A, Krittayaphong R, Wongcharoen W, Boonyaratavej S, Wongvipaporn C, Tiyanon W, et al. Management and risk factor control of coronary artery disease in elderly versus nonelderly: a multicenter registry. J Geriatr Cardiol. 2016;13(12):954-9. 
9.    Weber T, Lang I, Zweiker R, Horn S, Wenzel RR, Watschinger B, et al. Hypertension and coronary artery disease: epidemiology, physiology, effects of treatment, and recommendations: A joint scientific statement from the Austrian Society of Cardiology and the Austrian Society of Hypertension. Wien Klin Wochenschr. 2016;128(13-14):467-79. https://doi.org/10.1007/s00508-016-0998-5
10.    Park SJ, Yang HM, Seo KW, Choi SY, Choi BJ, Yoon MH, et al. The relationship between coronary atherosclerosis and body fat distribution measured using dual energy X-ray absorptiometry. Atherosclerosis. 2016;248:190-5. https://doi.org/10.1016/j.atherosclerosis.2016.03.014
11.    Akhabue E, Thiboutot J, Cheng JW, Vittorio TJ, Christodoulidis G, Grady KM, et al. New and emerging risk factors for coronary heart disease. Am J Med Sci. 2014;347(2):151-8. https://doi.org/10.1097/MAJ.0b013e31828aab45
12.    Sinning C, Lillpopp L, Appelbaum S, Ojeda F, Zeller T, Schnabel R, et al. Angiographic score assessment improves cardiovascular risk prediction: the clinical value of SYNTAX and Gensini application. Clin Res Cardiol. 2013;102(7):495-503. https://doi.org/10.1007/s00392-013-0555-4
13.    Yadav M, Palmerini T, Caixeta A, Madhavan MV, Sanidas E, Kirtane AJ, et al. Prediction of coronary risk by SYNTAX and derived scores: synergy between percutaneous coronary intervention with taxus and cardiac surgery. J Am Coll Cardiol. 2013;62(14):1219-30. https://doi.org/10.1016/j.jacc.2013.06.047
14.    Alber HF, Wanitschek MM, de Waha S, Ladurner A, Suessenbacher A, Dörler J, et al. High-density lipoprotein cholesterol, C-reactive protein, and prevalence and severity of coronary artery disease in 5641 consecutive patients undergoing coronary angiography. Eur J Clin Invest. 2008;38(6):372-80. https://doi.org/10.1111/j.1365-2362.2008.01954.x
15.    Zhang Y, Wu NQ, Li S, Zhu CG, Guo YL, Qing P, et al. Non-HDL-C is a Better Predictor for the Severity of Coronary Atherosclerosis Compared with LDL-C. Heart Lung Circ. 2016;25(10):975-81. https://doi.org/10.1016/j.hlc.2016.04.025
16.    Zhao X, Sun D, Xu RX, Guo YL, Zhu CG, Wu NQ, et al. Low-density lipoprotein-associated variables and the severity of coronary artery disease: an untreated Chinese cohort study. Biomarkers. 2018;23(7):647-53. 
https://doi.org/10.1080/1354750X.2018.1474256
17.    Qin Y, Yan G, Qiao Y, Ma C, Liu J, Tang C. Relationship between Random Blood Glucose, Fasting Blood Glucose, and Gensini Score in Patients with Acute Myocardial Infarction. Biomed Res Int. 2019 Oct 15;2019:9707513. https://doi.org/10.1155/2019/9707513
18.    Muhammed A, Zaki MT, Elserafy AS, Amin SA. Correlation between prediabetes and coronary artery disease severity in patients undergoing elective coronary angiography. Egypt Heart J. 2019;71(1):1-7. https://doi.org/10.1186/s43044-019-0034-y
19.    Parsa AFZ, Jahanshahi B. Is the relationship of body mass index to severity of coronary artery disease different from that of waist-to-hip ratio and severity of coronary artery disease? Paradoxical findings: cardiovascular topic. Cardiovasc J Afr. 2015;26(1):13-6. https://doi.org/10.5830/CVJA-2014-054
20.    Rubinshtein R, Halon DA, Jaffe R, Shahla J, Lewis BS. Relation between obesity and severity of coronary artery disease in patients undergoing coronary angiography. Am J Cardiol. 2006;97(9):1277-80. https://doi.org/10.1016/j.amjcard.2005.11.061
21.    Nabati M, Moosazadeh M, Soroosh E, Shiraj H, Gholami M, Ghaemian A. Correlation between overweightness and the extent of coronary atherosclerosis among the South Caspian population. BMC Cardiovasc Disord. 2020;20(1):1-11. https://doi.org/10.1186/s12872-020-01534-w
22.    Ekici B, Ercan EA, Cehreli S, Töre HF. The effect of emotional status and health-related quality of life on the severity of coronary artery disease. Kardiol Pol. 2014;72(7):617-23. https://doi.org/10.5603/KP.a2014.0023
23.    Kahraman S, Cam Kahraman F, Zencirkiran Agus H, Kalkan AK, Uzun F, Karakayalı M, et al. Perceived stress level is associated with coronary artery disease severity in patients with ST-segment elevation myocardial infarction. Turk Kardiyol Dern Ars. 2020;48(5):494-503. https://doi.org/10.5543/tkda.2020.30020
24.    Assari S, Zandi H, Ahmadi K, Kazemi Saleh D. Extent of Coronary Stenosis and Anxiety Symptoms among Patients Undergoing Coronary Angiography. J Tehran Heart Cent. 2017 Oct;12(4):155-159. 
25.    Salari A, Ashouri A, Moghtader AJ, Ahmadnia Z, Alizadeh I. The relationship between depression symptoms and severity of coronary artery disease in patients undergoing angiography. Iran J Psychiatry. 2020;15(4):370. https://doi.org/10.18502/ijps.v15i4.4305
26.    Hou L, Li F, Wang Y, Ou Z, Xu D, Tan W, et al. Association between dietary patterns and coronary heart disease: a meta-analysis of prospective cohort studies. Int J Clin Exp Med. 2015 Jan 15;8(1):781-90.
27.    Kahleova H, Levin S, Barnard ND. Vegetarian Dietary Patterns and Cardiovascular Disease. Prog Cardiovasc Dis. 2018 May-Jun;61(1):54-61. https://doi.org/10.1016/j.pcad.2018.05.002
28.    Waldeyer C, Brunner FJ, Braetz J, Ruebsamen N, Zyriax BC, Blaum C, et al. Adherence to Mediterranean diet, high-sensitive C-reactive protein, and severity of coronary artery disease: Contemporary data from the INTERCATH cohort. Atherosclerosis. 2018 Aug;275:256-61. https://doi.org/10.1016/j.atherosclerosis.2018.06.877
29.    Oikonomou E, Psaltopoulou T, Georgiopoulos G, Siasos G, Kokkou E, Antonopoulos A, et al.  Western Dietary Pattern Is Associated With Severe Coronary Artery Disease. Angiology. 2018 Apr;69(4):339-46. https://doi.org/10.1177/0003319717721603
30.    van Dam RM. New approaches to the study of dietary patterns. Br J Nutr. 2005 May;93(5):573-4. https://doi.org/10.1079/BJN20051453
31.    Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol. 2002 Feb;13(1):3-9. https://doi.org/10.1097/00041433-200202000-00002
32.    Kahleova H, Salas-Salvadó J, Rahelić D, Kendall CW, Rembert E, Sievenpiper JL. Dietary Patterns and Cardiometabolic Outcomes in Diabetes: A Summary of Systematic Reviews and Meta-Analyses. Nutrients. 2019 Sep 13;11(9):2209. https://doi.org/10.3390/nu11092209
33.    Chiavaroli L, Viguiliouk E, Nishi SK, Blanco Mejia S, Rahelic D, Kahleova H, et al. DASH Dietary Pattern and Cardiometabolic Outcomes: An Umbrella Review of Systematic Reviews and Meta-Analyses. Nutrients. 2019 Feb 5;11(2):338. https://doi.org/10.3390/nu11020338
34.    Fabiani R, Naldini G, Chiavarini M. Dietary Patterns in Relation to Low Bone Mineral Density and Fracture Risk: A Systematic Review and Meta-Analysis. Adv Nutr. 2019 Mar 1;10(2):219-236. https://doi.org/10.1093/advances/nmy073
35.    Poulter N. Coronary heart disease is a multifactorial disease. Am J Hypertens. 1999 Oct;12(10 Pt 2):92S-95S. https://doi.org/10.1016/S0895-7061(99 )00163-6
36.    Kannel W. Importance of hypertension as a major risk factor in cardiovascular disease. Hypertension: McGraw-Hill, New York; 1977. p. 888-910.
37.    Jiang Y, Li Y, Shi K, Wang J, Qian WL, Yan WF, et al. The additive effect of essential hypertension on coronary artery plaques in type 2 diabetes mellitus patients: a coronary computed tomography angiography study. Cardiovasc Diabetol. 2022 Jan 4;21(1):1. https://doi.org/10.1186/s12933-021-014 38-9
38.    Kim CH, Noh IK, Ryu JM, Bae EJ, Cho HJ, Kim MS. Canonical Correlation between Behavioral-Psychological Variables and Predictors of Coronary Artery Disease Prognosis. Int J Environ Res Public Health. 2020 Mar 2;17(5):1608. https://doi.org/10.3390/ijerph17051608
39.    Gensini GG. A more meaningful scoring system for determining the severity of coronary heart disease. Am J Cardiol. 1983 Feb;51(3):606. https://doi.org/10.1016/S0002-9149(83)80105-2
40.    Mazzotta C, Basu S, Gower AC, Karki S, Farb MG, Sroczynski E, et al. Perivascular Adipose Tissue Inflammation in Ischemic Heart Disease. Arterioscler Thromb Vasc Biol. 2021 Mar;41(3):1239-50. https://doi.org/10.1161/ATVBAHA.120.315865
41.    Rampidis GP, Benetos G, Benz DC, Giannopoulos AA, Buechel RR. A guide for Gensini Score calculation. Atherosclerosis. 2019 Aug;287:181-3. https://doi.org/10.1016/j.atherosclerosis.2019.05.012
42.    Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, et al. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention. 2005 Aug;1(2):219-27.
43.    Vasheghani-Farahani A, Tahmasbi M, Asheri H, Ashraf H, Nedjat S, Kordi R. The Persian, last 7-day, long form of the International Physical Activity Questionnaire: translation and validation study. Asian J Sports Med. 2011 Jun;2(2):106-16. https://doi.org/10.5812/asjsm.34781
44.    Hagströmer M, Oja P, Sjöström M. The International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity. Public Health Nutr. 2006 Sep;9(6):755-62. https://doi.org/10.1079/PHN2005898
45.    Zimorovat A, Moghtaderi F, Amiri M, Raeisi-Dehkordi H, Mohyadini M, Mohammadi M, et al.  Validity and Reproducibility of a Semiquantitative Multiple-Choice Food Frequency Questionnaire in Iranian Adults. Food Nutr Bull. 2022 Jun;43(2):171-188. https://doi.org/10.1177/03795721221078353
46.    Ahmadi SM, Masjediarani A, Bakhtiari M, Davazdahemamy MH, Mohamadian R. Psychometric properties of Persian version of Beck depression inventory in coronary patients. Universa Med. 2019;38(1):33-40. https://doi.org/10.18051/UnivMed.2019.v38.33-40
47.    Ahmadi SM, Arani AM, Bakhtiari M, Emamy M. Psychometric properties of the persian versions of patient health questionnaire-9 and patient health questionnaire-2 in patients with coronary heart disease. Int Cardiovasc Res J. 2019;13(2):45-9.
48.    Kaviani H, Mousavi A. Psychometric properties of the Persian version of Beck Anxiety Inventory (BAI). Tehran Univ Med J. 2008.
49.    Nazifi M, Mokarami H, Akbaritabar A, Kalte HO, Rahi A. Psychometric properties of the Persian translation of Pittsburgh sleep quality index. Health Scope. 2014;3(2):e15547. https://doi.org/10.17795/jhealthscope-15547
50.    Ansari NN, Naghdi S, Hasson S, Valizadeh L, Jalaie S. Validation of a Mini-Mental State Examination (MMSE) for the Persian population: a pilot study. Appl Neuropsychol. 2010 Jul;17(3):190-5.
51.    Rosner B. Fundamentals of biostatistics: Cengage learning; 2015.
52.    Tarver T. Heart Disease and Stroke Statistics-2014 Update: A Report From The American Heart Association. J Consum Health Internet. 2014;18(2):209. https://doi.org/10.1080/15398285.2014.902284
53.    A Razik N, Deep A, Abokrisha M, Mosad E, Hasan-Ali H. The relationship between lipid parameters after fat loading and coronary artery disease severity. ARYA Atherosclerosis. 2022;18(5):1-9. https://doi.org/10.48305/arya.2022.16286.2416
54.    Kilic A, Baydar O. Relationship Between Fasting Glucose, HbA1c Levels, and the SYNTAX Score 2 in Patients With Non-ST-Elevation Myocardial Infarction. Angiology. 2022 Feb;73(2):177-81. https://doi.org/10.1177/00033197211014678
55.    Yassir S, Adhikari P, Rao NL, RM P. Association of anthropometric measurements with angiographic findings among diabetic patients with coronary artery disease. J Cardiovasc Dis Res. 2021;12(1):39-43. https://doi.org/10.31838/jcdr.2021.12.01.10
56.    Tsukihashi Y, Shiga Y, Suematsu Y, Idemoto Y, Tashiro K, Yano Y, et al. Presence and severity of coronary artery disease in patients who achieved intensive blood pressure reduction at the time of coronary computed tomography angiography. Hypertens Res. 2021 Feb;44(2):206-14. https://doi.org/10.1038/s41440-020-00545-6
57.    Ramesh S, Besharat MA, Nough H. Spiritual well-being and coronary artery diseases severity: Mediating effects of anger rumination and worry. Health Educ J. 2021;80(5):501-12. https://doi.org/10.1177/0017896920976697
58.    Ferrannini E, Cushman WC. Ferrannini E, Cushman WC. Diabetes and hypertension: the bad companions. Lancet. 2012 Aug 11;380(9841):601-10. https://doi.org/10.1016/S0140-6736(12)60987-8
59.    Muntner P, Whelton PK, Woodward M, Carey RM. A Comparison of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline and the 2017 American Diabetes Association Diabetes and Hypertension Position Statement for U.S. Adults With Diabetes. Diabetes care. 2018;41(11):2322-9. https://doi.org/10.2337/dc18-1307
60.    Jun JE, Kang M, Jin SM, Kim K, Hwang YC, Jeong IK, et al. Additive effect of low skeletal muscle mass and abdominal obesity on coronary artery calcification. Eur J Endocrinol. 2021 May 6;184(6):867-77. https://doi.org/10.1530/EJE-20-0885