CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 31 244 subjects who were recommended CABG surgery after coronary angiographic evaluation in this study. The HADS questionnaire was filled in by subjects before the coronary angiography procedure. The study was prospectively conducted according to the Declaration of Helsinki ethical principles for medical research involving human subjects. Informed consent was obtained from all patients who participated in this study, which was approved by the local ethics committee (YDU/2018/61-629). Fasting venous blood samples were obtained from all patients following a fasting period of eight hours, to determine laboratory parameters. Patients with diabetes mellitus (DM) were identified on admission as those with documented DM using either oral hypoglycaemic agents or insulin treatment. Hypertension (HT) was defined as blood pressure above 140/90 mmHg or using antihypertensive therapy on admission. Hyperlipidaemia (HL) was defined as total cholesterol level at least 200 mg/dl (5.18 mmol/l) or using antihyperlipidaemic therapy on admission. Heart failure diagnosis was based on clinical features and echocardiography results. Patients with clinical features of heart failure or whose left ventricular ejection fraction was < 50% were excluded from the study. Chronic kidney disease was defined as a serum creatinine level > 1.5 mg/dl. Patients with chronic liver disease, chronic kidney disease, inflammatory diseases and acute coronary syndromes were excluded. If the patients were taking anti-depressant therapy they were excluded. Thirty-five patients were excluded and a total of 209 patients were included in our study. The data of patients were prospectively analysed for demographic features, echocardiographic parameters, biochemical parameters, HADS and SS. All patients underwent transthoracic echocardiography using a Vivid S5 (GE healthcare) echocardiography device and Mass S5 probe (2–4 MHz). Standard two-dimensional and colour-flow Doppler views were acquired according to the guidelines of the American Society of Echocardiography and European Society of Echocardiography.8 The ejection fraction was measured according to Simpson’s method. All patients underwent elective coronary angiography according to the Judkins technique. Angiograms were reviewed by at least two non-blinded reviewing cardiologists. All lesions causing ≥ 50% stenosis in a coronary artery with a diameter ≥ 1.5 mm were included in the SS calculation. Website software (http://www. SYNTAXcore.com) was used for the calculation. Scoring was performed for each patient in keeping with the following parameters: coronary dominance, number of lesions, segments included per lesion, the presence of total occlusion, bifurcation, trifurcation, aorto-osteal lesion, severe tortuosity, calcification, thrombus, diffuse/small-vessel disease and lesion length > 20 mm. The SS was evaluated separately by two interventional cardiologists blinded to the study protocol and patient characteristics. Patients were divided into two groups according to the SS: ≥ 23, high, < 23, low. The anxiety–depression status of our study population was evaluated using the HADS questionnaire. This questionnaire is a routine diagnostic tool for the evaluation of anxiety–depressive disorders in different countries.9 It has two subscales, including anxiety and depression, each of which comprised items rated on a four-point Likert scale. The total HADS score ranged between 0 and 42 with 0–14 being considered low, 15–28 moderate and 29–42 high. This questionnaire has previously been well validated to assess anxiety and depression in patients with CAD.10 Statistical analysis Statistical analysis was performed using the SPSS (version 20.0, SPSS Inc, Chicago, Illinois) software package. Continuous variables are expressed as the mean ± standard deviation (SD), and categorical variables are expressed as a percentage. The Kolmogorov–Smirnov test was used to evaluate the distribution of variables. The Student’s t-test was used to evaluate continuous variables showing normal distribution, and the Mann–Whitney U-test was used to evaluate variables that did not show a normal distribution. A p-value < 0.05 was considered statistically significant. To identify the predictors of higher SS, the following variables were initially assessed in a univariate model: DM, HL, smoking and HADS. Significant variables in univariate analysis were then entered into a multivariate logistic regression analysis using backward stepwise selection. Furthermore, receiver operating characteristic (ROC) curve analysis was applied to evaluate the diagnostic performance of HADS for differentiating between low and high SS patients. Results The high SYNTAX score (HSS) group had a higher prevalence of DM, HL and smoking (60.3 vs 31.7%, p < 0.001; 66.4 vs 29.1%, p < 0.001; 57.3 vs 34.7%, p < 0.001, respectively) (Table 1). There was no significant difference between the groups with regard to age, gender, marital status, body mass index, educational level and medication (Table 1). The HADS was significantly higher in the HSS group (24.8 ± 10.7 vs 11.3 ± 6.4, p < 0.001) (Table 1). There was no significant difference between the two groups with regard to laboratory parameters or left ventricular ejection fraction (64.3 ± 6.1 vs 64.7 ± 5.9%, p = 0.739) (Table 2). On multivariate analysis DM, HL and the HADS were independent predictors of HSS [odds ratio (OR): 3.164; 95% confidence interval (CI): 1.937–6.934, p < 0.001; OR: 3.429, 95% CI: 1.861–7.657, p < 0.001; OR: 2.736, 95% CI: 1.934–4.092, p < 0.001, respectively] (Table 3). In ROC analysis, a cut-off value was determined for the HADS with high SS. The cut-off value was 21.4 [area under the curve (AUC) = 0.668; 80.9% sensitivity, 69.9% specificity, 95% CI: 0.583–0.753] (Fig. 1). Discussion In our study, we found that DM, HL and HADS were independent predictors for a higher SS. Besides, DM and HL are major risk factors for the development of CAD. Changes in lipid and carbohydrate metabolism accompanying insulin resistance lead to the appearance of atherogenic lipoproteins, hyperglycaemia and increased concentration of free fatty acids. Several studies found that DM and HL were strongly associated with extensity and complexity of CAD.11 Tanaka et al.12 found that age, male gender and DM were significant and independent risk factors for a higher SS. Anxiety–depressive disorders are common in patients with CAD and are consistently associated with lower quality of life, higher medical cost, poorer somatic outcomes and mortality.
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