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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.
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Dr. Mamta Gupta
Consultant
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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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
Anuradha

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
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

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

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


Published: October 1, 2010 | DOI: https://doi.org/10.7860/JCDR/2010/.997
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.

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