Acute Coronary Syndrome: A Retrospective Study of the Epidemiological and Evolutionary Profile of Patients Hospitalized at the Agadir Regional Hospital in Southern Morocco

2.1. Methodology and Setting of the Research

This study is a monocentric and retrospective epidemiological investigation with an analytical focus. Its objective was to identify and analyze the epidemiological, clinical, and evolutionary characteristics of acute coronary syndrome cases at the cardiovascular disease department of the Hassan II Regional Hospital Centre in the Souss-Massa region. This study specifically examined patients who were hospitalized in the cardiology department throughout the period from January 2019 to May 2022. This timeframe aligned with the COVID-19 pandemic, a period marked by several changes.

2.2. Population of Interest / Method of Sampling

Patients diagnosed with Acute Coronary Syndrome (ACS) and documented in the cardiovascular diseases department were the focus of this study. We performed exhaustive sampling, including all patients admitted during the study period, totaling 318 patients. The study incorporated all comprehensive patient records containing the essential information required for the investigation. Files with incomplete data or where the diagnosis of acute coronary syndrome was unclear or absent were excluded from the study.

2.3. Methodology of Data Collection

To complete this study, we reviewed the hospitalization records and medical files of patients who were hospitalized in the cardiology department at Hassan II Regional Hospital Center in the Souss-Massa region. A specialized survey form was created for this study to efficiently accomplish its objective. It consists of five key sections: the first section collects sociodemographic data (age, sex, origin, etc.) and risk factors (medical, surgical, toxic, etc.); the second section includes clinical tables (pain, clinical picture); the third section specifies the diagnosis (invasive, non-invasive: electrocardiogram, cardiac MRI, scintigraphy, transthoracic echography, chest X-ray, transthoracic echocardiogram); the fourth section discusses the therapeutic modalities used based on the type of ACS (cardiac rehabilitation, statins, antihypertensive, anticoagulant, antiplatelet treatment); and the last section is reserved for monitoring the patients’ condition and tracking its evolution (heart failure, mechanical complication, hemorrhagic shock, cardiogenic shock, thromboembolic complication, vascular dysfunction, arrhythmia, death).

2.4. Data Analysis

Qualitative variables were expressed using frequencies and percentages, while normally distributed quantitative variables were expressed using the mean plus or minus the standard deviation. For non-Gaussian distributed variables, the median (interquartile range, IQR) was used. To identify differences in the proportions of categorical variables, the chi-square test (Khi 2) or Fisher’s exact test was conducted based on their respective application circumstances. Additionally, univariate and multivariate logistic regression analyses were performed to identify characteristics associated with acute coronary syndrome (STEMI, NSTEMI) in the study population. All independent variables with a p-value less than 0.250 in the univariate analysis were included in the multivariate logistic regression analysis. Statistical significance was defined as p-values below 0.05. Data management and statistical analysis were performed using the Jamovi program for Windows, version 2.3.

2.5. Ethical Considerations

The present work is a monocentric retrospective analysis conducted on hospital medical records. This research was carried out in compliance with established principles and regulations governing scientific research, including the Declaration of Helsinki of 1975, as revised in 2013 (http://ethics.iit.edu/ecodes/node/3931). The study obtained legal authorization from the health authorities of the delegation of the Ministry of Health and Social Protection of Agadir under number (782/22).

3.1. The Sociodemographic and Clinical Characteristics of the Study Participants

A total of 318 patient records were identified in this study. The mean age of patients was 62.3 ± 13.3 years. The age group between 55 and 75 years old was the most represented, accounting for 56%. Adult males comprised 64.5% (n = 205), and females made up 35.5% (n = 113). The majority of patients were from urban areas, accounting for 69.2%. A significant proportion of patients were unemployed (65.9%), married (79.2%), and had uncertain medical coverage status (69.2%). Among economically disadvantaged individuals, the coverage rate was 13.8% (Table 1). Of the total 318 patients, 204 experienced ST-segment Elevation Myocardial Infarction (STEMI), while 114 had non-ST elevation Acute Coronary Syndrome (NSTEMI). Table 2 summarizes the clinical and medical features of the patients.

3.2. The Comparison of STEMI and NSTEMI Patients According to Sociodemographic Characteristics, Risk Factors, and Admission Modalities

The bivariate analysis revealed a statistically significant association between acute coronary syndrome and gender (p < 0.001), smoking (p = 0.026), chest X-ray findings, troponin levels, and atherosclerotic lesions. Most STEMI patients were male (n = 151, 47.5%), smokers (n = 73, 23.3%), had abnormal troponin levels (n = 145, 58.2%), and showed a higher prevalence of atherosclerotic pathologies (n = 204, 64.2%) (Tables 3 and 4).

3.3. The Comparison of STEMI and NSTEMI Patients According to Therapeutic Modalities and their Evolution

Acute coronary syndrome was found to be significantly associated with the following factors in the bivariate analysis: statin use (p = 0.032), cardiovascular rehabilitation (p = 0.008), favorable outcome (p = 0.001), heart failure (p = 0.009), cardiogenic shock (p = 0.016), and mortality (p = 0.033). Indeed, patients with ST-elevation Myocardial Infarction (STEMI) had a higher proportion receiving statins (n = 149, 46.5%), lower participation in cardiac rehabilitation (n = 2, 0.6%), a greater incidence of heart failure (n = 11, 3.5%), increased occurrence of cardiogenic shock (n = 10, 3.1%), and a higher mortality rate (n = 15, 4.7%) (Table 5).

3.4. Factors Associated with Acute Coronary Syndrome in the Study Population

The findings from the simple logistic regression indicate that sex (OR= 3.16; 95% CI [1.95-5.13]), smoking status (OR= 1.80; 95% CI [1.07-3.01]), chest X-rays (OR= 0.21; 95% CI [0.04-0.93]), troponin level (OR= 10.40; 95% CI [4.56-23.71]), statin therapy (OR= 0.58; 95% CI [0.36-0.95]), cardiac rehabilitation (OR= 0.15; 95% CI [0.03-0.74]), and disease progression (OR= 0.39; 95% CI [0.22-0.69]) were significantly associated with acute coronary syndrome in the studied population. However, the outcomes of multiple logistic regression indicated that the variables associated with acute coronary syndrome in our study sample were as follows: sex (AOR= 3.12; 95% CI [1.71-5.70]), chest X-rays (AOR= 0.15; 95% CI [0.02-0.84]), statin therapy (AOR= 2.15; 95% CI [1.20-3.85]), cardiac rehabilitation (AOR= 0.07; 95% CI [0.01-0.54]), and disease progression (AOR= 0.32; 95% CI [0.13-0.77]). (Table 6)

4.1. Epidemiological Profiles and Risk Factors

Among the patients included in our study, 16.4% were below the age of 50. This same proportion (16.2%) was also documented in the study conducted by Chen et al., which analyzed 1982 instances of acute coronary syndrome and found that this age group accounted for just 16.2% [17]. The number of STEMI and NSTEMI patients was 204 (64.2%) and 114 (35.8%) respectively; however, in another study conducted in Sudan, the STEMI and NSTEMI cases were 51 (42.5%) and 41 (34.2%), respectively [18]. Regarding risk factors, the study revealed a significant association between ACS and gender (AOR=3.12; CI95% [1.71-5.70]; p ≤ 0.001), which aligns with the study by Khraishah et al., which found that the prevalence and impact of ACS risk factors differ between men and women. The Global Registry of Acute Coronary Events includes more than 7,000 women and over 19,000 men from 14 countries who underwent coronary angiography between 1999 and 2006. This can be elucidated by the fact that women with ACS were older (median age: 69 years compared to 62 years) and had higher rates of hypertension (70% compared to 55%) and diabetes (29% compared to 22%) [19]. However, in Morocco, socio-cultural factors may also contribute, as men are more likely to engage in high-risk behaviors, such as smoking, and may have better access to healthcare compared to women, who often present at later stages of the disease. The second risk factor detected in our investigation was tobacco use (OR=1.80; CI 95% [1.07-3.01]; p=0.027). Furthermore, the research undertaken by Hubacek et al. carried out in Czechia, Lithuania, and Kazakhstan revealed that smoking was the primary risk factor for ACS (odds ratio [OR] 3.85 in the Czech study and 5.76 in the Lithuanian publication) [20]. In Agadir, tobacco use is widespread, particularly among younger populations, due to its social acceptance and limited public health interventions. The increased risk of ACS among smokers is well-documented, as smoking accelerates atherosclerosis and increases thrombotic risk, which explains the high proportion of STEMI patients who are smokers (23.0%).

4.2. Clinical Presentation and Diagnostic Investigations

Concerning the symptomatology, most patients exhibited a common clinical presentation, such as chest discomfort; hence, unusual symptoms were minimal. In the study conducted by Bhatt et al., it was found that resting chest discomfort was the predominant symptom of Acute Coronary Syndrome (ACS), impacting around 79% of males and 74% of females with ACS. Approximately 40% of males and 48% of females displayed non-specific symptoms, such as shortness of breath, either alone or, more commonly, in conjunction with chest discomfort [21]. An Identical outcome was found in a separate investigation [22], underscoring the need for increased vigilance to avoid diagnostic errors, particularly in diabetic and elderly patients. An Electrocardiogram (ECG) was performed on all patients, and scientific literature highlights the ECG as a crucial tool for evaluating the presence, extent, and severity of myocardial ischemia in acute coronary syndrome [23, 24]. Due to its importance in diagnosis and prognosis, most patients in this study underwent troponin testing, following the approach used by Antman et al. [25]. The implementation of high-sensitivity troponin tests to precisely quantify extremely low troponin concentrations and baseline levels at the onset of acute coronary syndrome, which are linked to the likelihood of experiencing recurrent cardiac events and adverse long-term outcomes, has already sparked debates [26, 27].

The analysis of patients with Acute Coronary Syndrome (ACS) in our sample indicated that atherosclerotic lesions are predominantly obstructive in composition (64.2% in patients with ST-elevation myocardial infarction). The study conducted by Dziedzic et al. included 966 patients and found a correlation between the diagnosis and the Systemic Inflammatory Response Index (SIRI). The highest values were recorded in patients diagnosed with acute coronary syndrome (ACS), specifically ST-elevation myocardial infarction (STEMI) [28]. A study by Karthikeyan et al. reported similar findings, indicating that atherosclerosis of the coronary arteries is the primary cause of the spectrum of coronary artery diseases, including acute coronary syndrome [29]. This may be attributed to delays in seeking medical care, limited access to primary prevention, and suboptimal management of cardiovascular risk factors in the region.

4.3. Therapeutic Management and Outcomes

The therapy employed in our investigation included the administration of antiplatelet medications, anticoagulants, antihypertensives, and statins. Another study has shown that individuals with ST-segment elevation myocardial infarction (STEMI) can be treated with fibrinolysis; however, this treatment is not recommended for patients experiencing acute coronary syndrome without ST-segment elevation (NSTEMI) [30]. Additionally, a separate study noted that antiplatelet medications were prescribed in 91.3% of cases, with statins prescribed in 85.7%. Furthermore, it noted that women had a significantly higher frequency of medication use, except for nitrates [31].

The higher proportion of statin use among STEMI patients (46.5%) aligns with international guidelines recommending statins for secondary prevention in Acute Coronary Syndrome (ACS). However, this percentage remains suboptimal, likely due to variations in prescription practices, patient adherence issues, or limited availability of medications in certain cases. Additionally, some patients may not have received statins due to delays in diagnosis or financial constraints. In regards to cardiovascular rehabilitation, the very low participation rate (0.6%) reflects the limited availability of structured rehabilitation programs in Agadir. In Morocco, cardiac rehabilitation is not widely integrated into routine post-ACS care due to a lack of specialized centers, financial barriers, and low awareness among patients and healthcare providers. This gap may contribute to poorer long-term outcomes, as rehabilitation plays a crucial role in secondary prevention and functional recovery. The evolution was accompanied by a favorable progression in 72.3% of our cohort, while an unfavorable progression was observed in 27.7% of the instances. The research conducted by Mboup et al. unveiled a significantly higher optimal hospital evolution rate of approximately 47.4% [32]. The predominant complications documented include mechanical consequences (12.9%), arrhythmia (6.9%), thromboembolic complications (4.4%), and cardiac failure (3.8%). A separate study found that arrhythmias and conduction abnormalities are prevalent consequences of Sudden Cardiac Arrest (SCA) and are most often seen in patients with unstable hemodynamics [33].

Nevertheless, the study conducted by Bougrini et al. did not report any instances of mechanical problems [34]. In Hassan II Hospital, as in many regional centers, the absence of 24/7 primary Percutaneous Coronary Intervention (PCI) services means that some patients may not receive timely reperfusion, increasing their risk of left ventricular dysfunction and hemodynamic instability. Concerning mortality, the study found that the mortality rate linked to acute coronary syndrome among Moroccan patients was 5.3%. Among these patients, 4.7% were diagnosed with STEMI and 0.6% were diagnosed with NSTEMI. In contrast, the figure reported by Gheini et al. indicated a death rate of 7.1% [35]. Another study undertaken in Chad over a span of 5 years revealed an even greater mortality rate of 15.63% [36]. A noteworthy association was observed in our study between the specific form of acute coronary syndrome (STEMI and NSTEMI) and mortality. The findings of our study align with the research conducted by MC Manus et al., which also found a significant association between ACS and mortality. However, while the NSTEMI group had a far higher incidence of deaths in their study, our sample only registered 0.6% [37]. This elevated mortality may be attributed to several factors, including delays in patient transport, limited access to optimal revascularization strategies (such as Percutaneous Coronary Intervention (PCI)), and the high burden of comorbidities.

Additionally, STEMI patients often experience more extensive myocardial damage, which increases their risk of fatal complications. Hassan II Hospital serves a large and diverse population, including patients from rural areas where healthcare accessibility is a major challenge. Many ACS patients arrive late to the hospital, limiting the effectiveness of acute interventions. Moreover, the hospital’s infrastructure constraints, including the limited availability of intensive cardiac care units and advanced interventional cardiology, may influence patient outcomes. To reduce morbidity and mortality in ACS patients, several strategies should be considered:

♦ Expanding access to cardiac rehabilitation programs to improve post-ACS recovery.

♦ Strengthening early detection and referral pathways to reduce delays in treatment.

♦ Enhancing primary and secondary prevention programs, particularly for high-risk groups.

♦ Improving access to reperfusion therapies, either through better coordination with tertiary centers or by increasing local PCI capabilities.

4.4. Study Limitations

This study has several limitations to consider. First, its single-center design limits the generalizability of the findings to the entire Moroccan population. A multicenter study would provide a more representative picture of the epidemiological and clinical profiles of ACS in the country. Second, missing data were considered, primarily due to hospital archive management, which could introduce selection or classification bias. Third, our study relied on retrospective data, which may limit the accuracy of certain information, particularly regarding treatment delays and acute phase interventions.