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

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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

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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.
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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 : 2011 | Month : April | Volume : 5 | Issue : 2 | Page : 264 - 268

A Study On The Association Of Coronary Artery Disease And Smoking By A Questionnaire Method

YATHISH .T.R, MANJULA .C.G , SRINIVAS.R.DESHPANDE, GAYATHREE.L

DEPARTMENT OF PHYSIOLOGY,SRI DEVRAJ URS MEDICAL COLLEGE, kOLAR

Correspondence Address :
Dr.YATHISH .T.R, Assistant Professor
Department of physiology, Hassan Institute of Medical Sciences
Hassan-573201, Karnataka, India, (Mobile)- +91-9448410163
E-mail: yathi_aradhya@yahoo.co.in

Abstract

Background: Coronary artery disease is an important cause of morbidity and mortality in developed and developing countries. Cigarette smoking is thought to be major risk factor.
Aim: To study coronary artery disease among smokers by the Rose questionnaire method.
Methods: A cross-sectional study was done from March 2005 to March 2006. The presence of coronary artery disease was detected by the Rose Angina Questionnaire. The questionnaire method which was adopted was noninvasive and inexpensive.
Results: This study showed that the occurrence of coronary artery disease was higher in the smokers (61%), with a relative risk of 1.71(95% confidence interval 1.4, 2.0) as compared to the nonsmokers (36%), which was significant. Increased levels of nicotine may be a contributory factor to atherosclerosis which is observed in smokers.
Conclusion: Cigarette smoking not only accelerates the early onset of coronary artery disease but also increases the risk of the development of coronary artery disease by more than 80%.

Keywords

Coronary artery disease, Cigarette smoking, Rose angina questionnaire, and Rose smoking questionnaire.

How to cite this article :

YATHISH .T.R, MANJULA .C.G , SRINIVAS.R.DESHPANDE, GAYATHREE.L. A STUDY ON THE ASSOCIATION OF CORONARY ARTERY DISEASE AND SMOKING BY A QUESTIONNAIRE METHOD. Journal of Clinical and Diagnostic Research [serial online] 2011 April [cited: 2018 Nov 15 ]; 5:264-268. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=April&volume=5&issue=2&page=264-268&id=1281

INTRODUCTION
Coronary artery disease (CAD) 1 is the end result of the accumulation of atheromatous plaques within the walls of the coronary arteries .Atherosclerosis is a disease in which fatty substances such as cholesterol, cellular waste, calcium and other substances are deposited along the lining of the artery walls. These sticky, yellowish deposits, known as plaques, may progress to the narrowing of the arteries and is the most common cause of chronic arterial occlusive disease. 1Epicardial coronary arteries are the major sites of atherosclerotic disease. A spectrum of symptoms result, the severity ofwhich depends on the extent of the involvement and the available collateral circulation. Thus, the symptoms may range from pain at rest to exertion. The pain is due to insufficient blood flow in the myocardium, which is caused by blocked arteries. 1The major risk factors for atherosclerosis are gender, age , heredity, cigarette smoking, diabetes, high blood pressure, high triglyceride levels, low density lipoprotein levels, chronic kidney disease, abdominal aortic aneurysm, alcohol abuse, overweight, not getting enough exercise, excessive amounts of stress and excess C-reactive protein and homocysteine,etc. 1 Cigarette smoking constitutes the single most important, independent and effective risk factor of atherosclerosis as per many previous studies. 1 It is well known that the risk of smokers developing coronary heart disease is at least 2–4 times of that seen in nonsmokers. Although all types of tobacco smoking are known to increase the risk of developing CAD, smoking cigarettes particularly increases this risk more than pipe smoking or cigar smoking. Environmental tobacco smoke which is also called passive smoke is known to cause chronic respiratory conditions, cancer, and heart disease. Active and passive tobacco smoke is associated with the dysfunction of the endothelial physiology and vascular impairment. The American Heart Association estimates that nearly 40000 people die yearly from heart and blood vessel disease which is caused by passive smoking. Further, yearly, more than 400,000 people die from smoking related illnesses in the United States alone. Cigarette smoking is said to be responsible for between 17% and 30% of all deaths from cardiovascular illness. The effects of cigarette smoking are dose-related and life style modification measures involving quitting smoking are probably the single most important steps to decrease the chance of coronary artery disease and a heart attack.1 A preliminary Google search showed scanty results regarding the questionnaire based studies which were done with respect to the male smokers in south Karnataka, with respect to the Coronary artery afflictions in 2005, when we embarked on this questionnaire based study. A similar search using the key words ‘smokers’, ‘coronary artery disease’, ‘south Karnataka at Health University’ and ‘Medline data bases’ also returned few results. Hence, we decided to go ahead with this inexpensive exploratory study to estimate the incidence of coronary artery disease among the smokers in south Karnataka.

Material and Methods

Our observational, exploratory, descriptive, cross- sectional, institutional study was aimed to assess the incidence of coronary artery disease among the smokers vis a vis the nonsmokers in suburban South Karnataka. This preliminary, one year study was conducted in the teaching referral hospital which was attached to the Sri Devraj Urs Medical College, Kolar, in South Karnataka, India, during March 2005 to March 2006. A total of 200 adult men above the age of 30 years, who visited the hospital with pain in the chest, were randomly selected and they constituted the materials for the present study. The subjects were categorized into smokers (the study group) and non-smokers (controls).They were examined in detail after taking the individual, well informed consent after obtaining the mandatory clearance from the ethical committee of the institution. The exclusion criteria included tobacco chewers and tobacco use in any other form than smoking cigarettes and beedies.Also excluded were those subjects with a family history of diabetes mellitus, hypertension, coronary artery disease, chronic lung disease, and drug intake affecting the cardiovascular system. For each subject, personal history like drug history and the history of smoking were recorded in detail. Previous or current cigarette smoking was considered as a positive smoking history. The number of cigarettes and their frequency were also noted. All subjects were asked to answer the well explained standardized Rose questionnaire either orally or in writing. The Rose Questionnaire, also called as the London School of Hygiene Cardiovascular Questionnaire, has been frequently used in epidemiological research as a standard, unbiased and validated measure of the prevalence of angina in general populations since its introduction in 1962.2 The questionnaire method which was adopted, was noninvasive and inexpensive and can be easily carried out in the community. The diagnosis of the coronary artery disease was confirmed by other methods. The data were collected and analyzed statistically.

Results

200 male subjects were selected as per the criteria which were laid down in the methods and materials section for the present study. The Rose questionnaire was used as a tool to detect coronary artery disease. The data which was thus collected was statistically analyzed and discussed. The results were compared between the two groups viz the smokers and the non smokers. Of the 200 participants, 150(75%) were smokers, 50 (25%) were nonsmokers. The data which were obtained were arranged in a tabular form and was interpreted. The analysis was performed by using the SPSS 8.0 statistical package for Windows. The continuous variables were expressed as the mean + standard deviation and the qualitative data were expressed as percentages. The Chi-square test was carried out to evaluate the significance of coronary artery disease in the two groups. The mean difference was significant at a P<0.05 level. A conclusion was drawn, based on the outcome of this statistical treatment. (Table/Fig 1) shows the distribution of the subjects according to their ages. The youngest subject in the study group was found to be aged 31 years and the oldest was aged 70 years. The youngest subject in the control group was aged 31 years and the oldest was aged 70 years. The mean age of the study group was 48.56 years and that of the control group was 48.96 years. (Table/Fig 2) shows the mean values in each age group .The parameters like the age at which smoking was started, the number of cigarettes, the duration of smoking and the end inspiratory breath holding (EIBH) in seconds, were taken into consideration. (Table/Fig 3) shows that the incidence of coronary artery disease was maximum in the age group of 51-60 years and that it was least in the 31-40 years age group. (Table/Fig 4) shows that the coronary artery disease in non smokers was more in the older age group i.e. the age group of 61-70 years (24%), it was 12% in the age group of 51-60 years, and that it was absent between the age group of 31-50 years. Coronary artery disease was not seen in age group of 31-50 years and the incidence seemed to increase as the age advanced, as was seen in the age group of 61-70 years (20%), as a part of the normal senile thickening of the coronary vasculature. The comparison of (Table/Fig 3) and (Table/Fig 4) show the occurrence of coronary artery disease among the smokers and the non smokers respectively. Among the nonsmokers, the aged people were at a higher risk of developing coronary artery disease .There was a high correlation between smoking and coronary artery disease (Pearson’s correlation coefficient P<0.01).(Table/Fig 5)shows that among the 200 subjects, 110 cases (55%) had chest pain on exertion and rest and that 90(45%) had no exertional chest pain. Among the 150 smokers, 92 (Incidence rate-61.3%) had a classic symptom of coronary artery disease which started in the third decade of life. Out of 50 non-smokers, only 18 (Incidence rate -36%) had coronary artery disease which started after the fifth decade of life. The exposure rate of the occurrence of coronary artery disease in the smokers was 83%. The exposure rate of the occurrence of coronary artery disease in the non smokers was just 64%. The statistical association between the exposure and the occurrence of CAD was calculated by p-values, which in this case was p< 0.001. The odds ratio was 2.81, which meant that the smokers showed a risk of having CAD 2.81 times more than non smokers. The relative risk (RR) among the smokers was 1.71(95% confidence interval 1.4, 2.0). We rejected the null hypothesis in our study, since the calculated Chi- square value (9.72) was greater than the table value of the chi square value (3.84) at a 5% level of significance. This means that the two attributes, coronary artery disease and smoking are not independent. Smoking increases the risk of development of CAD. The standard error of significance between CAD and smoking was 7.713, which was greater than 1.96 at a 5% level of significance. This means that there was statistical significance between CAD and smoking.

Discussion

Ischaemic heart disease (IHD) causes more deaths and disability and incurs greater economic costs than any other illness in the developed world. IHD is the most common, serious, chronic and life threatening illness in the United States, where >12 million persons have IHD, > 6 million people have angina pectoris, and > 7 million people have sustained myocardial infarction. Similar data has emerged from the burgeoning middle and upper classes in India. Large increases in IHD throughout the world are projected, and IHD is likely to become the most common cause of death worldwide by 2020.(1) This fact remains true, despite a 30% reduction in the mortality which was caused by CAD over the past 3 decades. Many factors have led to a decrease in the mortality and morbidity caused by CAD, including the introduction of coronary care units, bypass surgery (e.g., coronary artery bypass graft), thrombolytic therapy, angioplasty (e.g., percutaneous transluminal coronary angioplasty PTCA), and a tremendous emphasis on lifestyle modification. Over the decades, in India too, advanced coronary care set ups offering world class care have emerged in major cities and towns and health awareness regarding the disease is increasing in the communities.(1) Various diagnostic tests like Electrocardiogram (ECG), Exercise stress test Echocardiogram, Nuclear scan, Electron-beam computed tomography (EBCT), Computed Tomography angiography, Magnetic resonance angiography and Coronary angiography are available for the early diagnosis of CAD. (1) It is well appreciated that the symptoms of CAD can range widely, 1from no symptoms at all, to mild intermittent chest pain, to pronounced and steady pain. A person who experiences angina may feel heaviness, tightness, pain, burning, pressure, or squeezing, usually behind the breastbone, but sometimes the pain also spreads to the left side of the neck, arms, jaws, and shoulders. Angina is often accompanied by lightheadedness, shortness of breath, nausea, sweating and fainting. These symptoms are usually brought on by exertion and are relieved by rest. Nevertheless, some people (especially diabetics) have heart attacks without ever experiencing any of these symptoms. (1) Cigarette smoke contains chemicals like Nicotine, Carbon monoxide, Ammonia, formaldehyde, tars, etc. (2)The chief pharmacological active ingredient in tobacco is nicotine (acute effects) and tars (chronic effects). The effects of nicotine on the cardiovascular system are known to be similar to sympathetic stimulation. It causes tachycardia, ventricular extra systoles, increase in plasma noradrenalin, blood pressure, and cardiac output and the oxygen consumption also increases. It increases atherosclerotic narrowing and platelet adhesiveness and it also lowers the high-density lipoprotein levels. Cholesterol-carrying lipoproteins also enter the walls of the arteries more easily, where they can develop into a hard plaque and atherosclerosis. This reduces the amount of oxygen that can be carried by the red blood cells into the bloodstream. (3), (4) We studied smokers and non smokers with coronary artery disease from the ages of 30 to 70 years. The peak incidence of coronary artery disease was in the age group of after 40 years. The average age of the start of smoking was nearly 24.8±4.2 in all the age groups. The number of cigarettes in each group on an average was 15.8±3.8 per day. The duration of smoking on an average was 25.7±3.6 years. The end inspiratory breath holding on an average was 25 seconds. The earlier the age of the start of smoking, the more was the number of cigarettes smoked, the longer was the duration of smoking and the longer was the end inspiratory breath holding and all these factors were found to increase the risk of development of coronary artery disease. The findings of the present study were in conformity with earlier studies which were done by many others, which are discussed below. Winniford et al (3) concluded that in patients with atherosclerotic coronary artery disease, cigarette smoking increases the myocardial oxygen demand but may cause an inappropriate decrease in the coronary blood flow and the myocardial oxygen supply. Their study explored the mechanism of smoking- induced coronary vasoconstriction and specifically researched on it to determine whether smoking causes an alpha-adrenergically mediated increase in the coronary artery tone.(3)Cigarette smoking and hypercholesterolaemia influence the renin-angiotensin system (RAS) functions, including increased RASmediated vasoconstriction, mitogenic signaling, and angiotensin II type 1 receptor (AT1R) expression as per the studies by Zak and Wita (4); who concluded that the 1166C allele increases the risk of CAD which was associated with the presence of cigarette smoking and hypercholesterolaemia.(4) In another study on 808 persons (5)who were active smokers at the time of the incident infarction, 449 had quit smoking during hospitalization or after discharge. Among the quitters, the relative risk decreased as the duration of the cessation increased. In persons who quit smoking after infarction, the risk declined to equal that of the nonsmokers by 3 years after the cessation.(5) After five years, the mortality was 22% among those who continued smoking and it was 15% among the quitters6 as per another study. The relative risk for mortality in smoking continuers vs. quitters was 1.55 (95% confidence interval, 1.29 to 1.85). This study supported the recommendation that patients with coronary artery disease should stop smoking.(6)Herbert (7) reported that, when patients undergoing selective coronary arteriography were studied to determine whether the extent of their coronary artery disease (CAD) was related to cigarette consumption, those without demonstrable lesions averaged 29.0 pack years, while patients with a single vessel disease averaged 38.3 pack years, those with double vessel disease averaged 44.9 pack years and those with triple vessel disease averaged 67.5 pack years. Nonsmokers with significant CAD were ten years older than their smoking counterparts (p<0.01). This study demonstrated a correlation between the number of cigarettes consumed and the severity of CAD, as well as the accelerating effect of cigarette consumption on the development of CAD. (7)Futher, endothelium dependent vasodilatation is mediated by the release of nitric oxide which is formed by constitutively expressed endothelial nitric oxide synthase (ecNOS4a). This genotype was also associated with a history of myocardial infarction. This smoking dependent excess coronary risk in the ecNOS4a homozygote is consistent with a predisposition to endothelial dysfunction.(8) In yet another study, the association between the extent and duration of the smoking habit and the severity of coronary atheroma was examined in 387 patients who underwent routine coronary arteriography before valve replacement surgery. The total number of cigarettes which were smoked in life correlated significantly with the severity of the coronary artery disease (p < 0.001) and the number of coronary arteries correlated with stenoses of 50% or more (p< 0.001).(9) Moniek et al(10) showed that inflammation and smoking were associated with a risk of cardiovascular disease, but that not much was known yet about their relationship. They studied the relationships with the inflammatory markers like C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α).IL-6 and TNF-α were significantly higher in patients than in controls. They concluded that inflammation is affected by both smoking and cardiovascular disease.10 Another study (11) showed the effects of cigarette smoking and the cessation of smoking in a cohort of 1893 men and women from the Coronary Artery Surgery Study (CASS) registry, who were 55 years of age or older and had angiographically documented coronary artery disease. The six-year mortality rate was greater among the continuing smokers (n = 1086) than among those who had quit smoking (n = 807); the relative risk was 1.7 (95 percent confidence limits, 1.4, 2.0). Many other studies concluded that smoking cessation lessens the risk both in older as well as younger persons with coronary artery disease. (12), (13), (14) Rose GA, Blackburn H and Gillum RF used the WHO/Rose Questionnaire on ischaemic heart pain and intermittent claudication patients by doing epidemiological field surveys. They concluded that in this particular situation, the questionnaire diagnosis showed reasonable (about 83 %) sensitivity and high specificity as compared to the diagnosis which was made by the physicians. Rose et al noted that the interviews of the physicians took 15 minutes each, as compared to about 1 minute duration for the questionnaire. (15) S. Ugurlu, E. Seyahi and H. Yazici assessed the prevalence of angina, myocardial infarction and intermittent claudication by using the Rose questionnaire among patients with Behcet’s syndrome. Male patients with vascular involvement had more claudication (15/67) than those without vascular involvement (4/69) (P < 0.006).16 Many others studied the sensitivity, specificity, and the predictive value of noninvasive testing methods like the questionnaire method and compared them with traditional clinical evaluation methods and invasive techniques of vascular disease in a defined population. It has been felt that the former can be usefully incorporated in cardiovascular risk assessment and screening programs.(17), (18)

Conclusion

Smoking increases the risk for the development of CAD by more than 80%. The coronary artery disease risk profile and the Rose questionnaire allows physicians to identify high-risk individuals during a routine office visit and these can also be used to educate patients about the modifiable risk factors, particularly smoking and blood pressure. Improved compliance with risk factor modification strategies may result in a beneficial impact on survival.

Acknowledgement

Our sincere thanks to the Principal of Sri Devaraj Urs Medical University for permitting this work .Thanks are also due to all the faculty members of the Department of Physiology for their kind cooperation and encouragement.

References

1.
. Dennis L. Kasper, Eugene Braunwald, Anthony S. fauci, et al eds. Harrison’s principles of internal medicine 16th ed 2005;.226:1434- 1436.
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. Rose GA, Blackburn H, Gillum RF, Princes RJ. Cardiovascular Survey Methods, 2nd Edition, Monograph Series No. 56, Geneva, World Health Organization 1982; 173-175.
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. Winniford MD, Wheelan KR, Kremers MS, et al. Smoking-induced coronary vasoconstriction in patients with atherosclerotic coronary artery disease: evidence for adrenergically mediated alterations in coronary artery tone Circulation 1986; 73:662-667.
4.
. Iwona Zak and Krystian Wita. The risk of coronary artery disease associated with cigarette smoking and hypercholesterolemia is additionally increased by the presence of the AT 1 R Gene 1166C Allele .Biochemical Genetics 2008;469(11-12);799-809.
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. Thomas D. Rea, Heckbert, Kaplan Smith, Lemaitre, and Psaty. Smoking status and risk for recurrent coronary events after myocardial infarction. Ann Intern Med 2002; 137(6): 494-500.
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.Ronald E. Vlietstra, Richard A. Kronmal, Albert Oberman, Robert L. Frye, Thomas Killip III .Effect of cigarette smoking on survival of patients with angiographically documented coronary artery disease. JAMA. 1986; 255(8):1023-1027.
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. Walter H. Herbert.Cigarette smoking and arteriographically demonstrable coronary artery disease. Chest 1975; 67:49-52.
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. Xing L. Wang, Ah Siew Sim, Renee F. Badenhop et al. A smoking dependent risk of coronary artery disease associated with a polymorphism of the endothelial nitric oxide synthase gene. Nature Medicine 1996; 2: 41 – 45.
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. Ramsdale DR, E B Faragher, C L Bray, D H Bennett, C Ward, and D C Beton. Smoking and coronary artery disease assessed by routine coronary arteriography.Br Med J (Clin Res Ed) 1985; 290(6463): 197-200.
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. Moniek P. M. de Maat, Cornelis Kluft. The association between inflammation markers, coronary artery disease and smoking. Vascular Pharmacology 2002: 39(3): 137-139.
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. Hermanson B, GS Omenn, RA Kronmal, and BJ Gersh. Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease. Results from the CASS registry. NEJM 1988; 319(21):1365-1369.
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. Patricia M. Smith and Ellen Burgess. Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial. CMAJ 2009; 180 (13):8-15.
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. Van Berkel T.F.M., H. Boersma, J.W. Roos-Hesselink, R.A.M. Erdman and M.L. Simoons .Impact of smoking cessation and smoking interventions in patients with coronary heart disease. European Heart Journal 1999; 20(24):1773-1782.
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. McKenna, Kryss; Higgins, Helen. Factors influencing smoking cessation in patients with coronary artery disease. Patient education and counseling 1997; 32(3):197-205.
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. Rose GA. The diagnosis of ischemic heart pain and intermittent claudication in field surveys. Bull World Health Organ 1962; 27:645-658.
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. Ugurlu S, E. Seyahi and Yazici H. Prevalence of angina, myocardial infarction and intermittent claudication assessed by Rose Questionnaire among patients with Behcet’s syndrome. Rheumatology 2008; 47(4):472-475.
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. Smith GD, Shipley MJ and Rose G. Intermittent claudication, heart disease risk factors, and mortality. The Whitehall Study. Circulation 2000; 82: 1925-1931.
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. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996;776-990

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