European Journal of Cardiovascular Medicine

Cardiovascular disease is the leading cause of death worldwide. 1 artery disease (CAD) is the most common and is characterized by the accumulation of lipids and immune cells in the subendothelial space of the coronary arteries or atherosclerosis. This process involves the inflammatory response of the vascular endothelium 2,3,4. Endothelial cells (EC) form a semipermeable monolayer that separates the wall of the arteries from the components of intravascular flow3,4,5. This barrier regulates vascular tone, prevents platelet aggregation, and maintains fluid homeostasis. The endothelium produces vasodilator and vasoconstrictor molecules such as nitric oxide (NO) and endothelin, respectively; the imbalance in production of these vasoactive substances results in the loss of its function, which is defined as endothelial dysfunction3,4,6,7. Endothelial dysfunction plays an essential role in the development of atherosclerosis and can be triggered and exacerbated by different cardiovascular and cardiometabolic risk factors8,9. Currently, there is a wealth of data on endothelial dysfunction and the risk of developing atherosclerosis and CAD.10 Endothelial dysfunction, including hypertension and atherosclerosis, is the main risk factor for stroke, myocardial infarction, and heart failure. The main pathological phenomenon behind this disease is atherosclerosis.  

Atherosclerosis is not a single entity. The lesion of atherosclerosis takes different forms depending upon their anatomic site, age, genes, and physiological status of the effected individual and presumably upon, so called risk factors to which each individual may have been exposed. One of such risk factors is oxidative stress. Oxidative stress plays a crucial role in the pathophysiology of acute myocardial infarction (MI) and monitoring various biochemical parameters can provide valuable insights into the condition of patients post-MI. The serum level of Malondialdehyde (MDA), a marker of lipid peroxidation, is often elevated in acute MI patients. Elevated MDA levels indicate increased oxidative stress and potential damage to cell membranes, highlighting the importance of managing oxidative stress in post-MI care. Ascorbic acid, also known as Vitamin C, is a powerful antioxidant that helps combat oxidative stress by neutralizing free radicals. Monitoring serum levels of ascorbic acid in acute MI patients can provide valuable information about their antioxidant status and overall health post-MI. Serum calcium levels are also significant biomarkers to consider in acute MI patients. Calcium plays a crucial role in cardiac muscle contraction and relaxation, and abnormal serum calcium levels can impact cardiac function. Monitoring serum calcium levels can help healthcare providers assess the cardiac health and risk stratification of MI patients. 

 
There are many causal factors for oxidative stress and the generation of free radical. Thus generated free radical causing lipid peroxidation of  membrane  lipids and also the phospholipid layer of LDL Cholesterol.  This oxidized LDL-cholesterol accumulates subintimally in the coronary vessels and behaves differently from the native cholesterol and initiates and propagates many cellular reaction along with some more intracellular and extra cellular mechanism  resulting in the formation of atherosclerosis.The atheromatous plaque is rich in Oxidized LDL. proliferated smooth muscle cells, fibrous tissues, calcium, macrophages, collagen tissue and many other cellular reactants. The progression of the atheromatous phenomenon due to oxidative stress can be slowed down by many antioxidants. Ascorbic acid (Vit-C) is one of such antioxidants. By evaluating these biochemical parameters we can gain valuable insights into the oxidative stress status and overall health of acute MI patients. This information helps tailor treatment plans to manage oxidative stress effectively and improve patient outcomes post-MI. The present study evaluates the patients with coronary artery disease proven by E.C.G, Coronary angiogram, and serum enzyme CK-MB. 
AIM:  
To evaluate the patients of coronary artery disease proven by E.C.G, Coronary angiogram and serum enzyme CK-MB. 
Objectives: 
1.To estimate the serum level of Malondialdehyde (MDA) in patients and as well as the age and sex matched healthy 
controls.

Study design: Case-Control study 
Study setting: Patients of AMI admitted in Acute coronary care unit, Department of Cardiology, King George Hospital, 
Visakhapatnam, and CARE Hospital Visakhapatnam. 
Study duration: 1 year May -2021-June 2022 
Study participants: 50 patients with AMI admitted in Acute coronary care unit and 30 matched controls 
Inclusion criteria: 
• Patient presenting with a history consistent with Acute Myocardial Infarction (AMI). 
• Age < 65 years 
• Ischaemic myocardial pain > 30min. duration but <24 hrs duration unrelieved by isosorbide dinitrate. 
• ECG changes consistent with Transmural infarction. 
• More than 70% block in angiographic imaging. 
• Who gave consent and willing to participate in the study 
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE                
Volume:14    Issue:3 
697 
Article Title: Oxidative stress among patients with coronary artery disease: A case control study. 
Exclusion criteria: 
• Contraindication to thrombolytic therapy. 
• Patient ECG showing Left ventricular hypertrophy, Bundle Branch Block,                                                                                      
fascicular block. 
• All the Patients received IV Streptokinase 1.5 IU and conventional treatment of AMI. 
• Standard 12 lead ECG was recorded. 
• Not willing to participate in the study 
Study procedure:  
The following investigations were carried out among study subjects 
o Estimation Serum Lipid Peroxidation Product—MDA(Keisatoh,1978) 
o Blood Sugar (Glucose Oxidase - Peroxidase Method) 
o Serum Cholesterol (Chod/Pod Method) 
o Serum Triglycerides (Gpo /Pod Espas, 1973) 
o Serum HDL Cholesterol (Phosphotungstate-Chod-Pod) 
o Serum LDL And VLDL - By Calculation (Friedwald W.T.,1972) 
o Estimation of Serum Calcium (Ortho Crsesolpthalein Complex one Method) 
o Serum Ascorbic Acid Estimation (Mc Cormick And Green,1994) 
Outcomes measured:  
A comparison between the two groups was made in terms of Blood Malondialdehyde levels, Serum Ascorbic acid levels, 
Serum Calcium level, total cholesterol level,  LDL-Cholesterol level and fasting blood sugar levels.  
Ethical considerations:  Permission from the Institutional ethical committee (IEC) attached to AMC, Visakhapatnam was 
taken before conducting the study.   Every patient was explained the whole process and advantages of availing their data 
for the study. Confidentiality of the patient was maintained. After she/he accepts, an informed consent form was given in 
the local language or understandable language and the person was asked to sign it or put a thumb impression. 
Statistical analysis:  
Continuous variables were presented as mean ± SD (min–max) and categorical variables were presented in number (%). 
Significance was assessed at 5% level of significance assuming normal distribution of dependent variables. We used two 
tailed, independent student t test to find the significance of study parameters on continuous scale between two groups. 
Statistical analysis was performed using IBM SPSS statistics software version 24, Microsoft Word and Excel was used for 
data entry. A p value<0.05 was considered statistically significant.

The present study comprises 50 cases of coronary artery diseases and 50 healthy controls. In study group males constitute 
70% and females constitute 30% and in Controls males constitute 66.66% and females constitute 33.33%. Among the cases 
68% were smokers and 32% were non-smokers. Whereas in controls 20% were smokers and 80% were non-smokers. 
Serum Calcium level is increased in the study group with a mean value of 11.37 + 0.58 mg/dl. in comparison with the 
control group with a mean value of 10 + 0.82mg/dl and ‘p’ value <0.001 which was statistically significant. The fasting 
blood sugar levels in diabetic individuals in the study group was significantly increased in comparison with the normal 
healthy control group. 
Table – I   MDA LEVELS IN CASES AND CONTROLS 
Range 
(nmol/ml) 
Mean 
S.D 
(nmol/ml) 
Cases n = 50 
5.0 - 7.5 
6.06 + 0.63 
P value 
Controls n = 50 
2.1 - 4.0 
3.0 + 0.53 
< 0.001

In the present study. Mean values of Malondialdehyde among cases is 6.06 nmol/ml + 0.63 (Mean + S.D) with the range 
of 5.0 to 7.5 nmol/ml and that of control is 3.0 nmol/ml + 0.53 ( Mean + S.D) with the range of 2.1 to 4.0 .The increase in 
the serum Malondialdehyde among cases is significant with a ‘p’ value of <0.001. 
Table:II    MALONDIALDEHYDE (MDA) LEVELS IN CORONARY ARTERY DISEASE PATIENTS (CAD) 
Range 
nmol/ml 
No of 
Males 
35 No Of 
Females 
15 Total 50 
5 – 5.9 20 58% 7 47% 27 54% 
6 -  6.9 10 28% 8 53% 18 36% 
> 7 5 14% 0 0 5 10% 
 
The above table shows that total patients with Malondialdehyde level > 6 nmol/ml are 23(46%). 
Table:III:  MDA LEVELS AND LIPID PROFILE IN CASES AND CONTROLS 
 Mean Values Mean Values   
 Cases Controls ‘t’ Value ‘P’ Value 
MDA Levels (nmol/ml) 6.068 3.0 25.5 <0.001 
LDL (mg/dl) 175.93 104 16.03 <0.001 
TCholesterol (mg/dl) 248.26 170 18.8 <0.001 
HDL(mg/dl) 33.2 38 4.8 <0.001 
The table shows a comparison of various biochemical parameters in cases and controls with MDA Levels, LDL, Total 
Cholesterol and HDL shows statistical significance. The total cholesterol level is also increased in study group with a mean 
value of 248.20+ 20.17 mg /dl in comparison to the control group with a mean value of  170 + 16.14 mg/dl. The LDL
Cholesterol level is also increased in the study group with a mean value of    175.96 + 22.06 mg/dl in comparison with the 
control group with a mean value of 104 + 17.77 mg/d with ‘t’ value 16.03 and ‘p’ value of,0.00l which is statistically 
significant. The fasting blood sugar levels in diabetic individuals in the study group was significantly increased in 
comparison with the normal healthy control group. 
Table: IV:   MDA LEVELS AND ASCORBIC ACID LEVELS IN MALES AND FEMALE IN THE CASES AND 
CONTROLS 
 
MDA LEVELS MALES FEMALES TOTAL 
CASES 6.1 + 0.06 6.0 + 1 6.06 + 0.63 
CONTROLS 2.74+ 0.47 2.90 + 0.66 
3.0 + 0.53 
ASCORBIC ACID 
LEVELS 
   
CASES 25.74+ 2.90 24.67 + 2.91 25.42+ 2.89 
CONTROLS 
 
41+ 6.38 
 
42+ 4.42 
 
41 +5.6

About 50 coronary artery disease (CAD) patients presented with Acute Myocardial Infarction (AMI) were studied for the 
Malondialdehyde level as a marker of Lipid Peroxidation and as a risk factor in association with other risk factors. The 
antioxidant status also been study by estimating the serum Ascorbic acid level. Around 30 age matched controls were 
taken for comparison.  The present study included 35 male and 15 female patients The age group varied from 38 – 64 
years, majority falling between 46-55 years.  
On observation the following risk factors were noted in descending order increased LDL-Cholesterol level (96%), 
Increased calorie intake (Obese)92%), Hypercholesterolemia (70%) Diabetes Mellitus (70%), Smoking (68%), BMI 
(66%). 
Mean Blood Malondialdehyde levels are (6.06+ 0.63 nmol/ml) elevated in the cases compared to controls (3 + 0.53 
nmol/m) Coronary event in CAD patients is found to occur mostly in patients between 46- 65 years. The incidence is more 
in the later age in females than males. 
The diagnosis is made based on the 2 out of 3 criteria as chest pain lasting more than 30 minutes but less than 24 
hours and unrelieved by Disodium isosorbide dinitrate and ECG changes consistent with myocardial infarction i.e. ST 
segment elevation of 1 mm from base line in chest leads or T wave inversion with or without Q waves in 12 lead ECG or  
Angiographic evidence of Coronary vessel block. 
In the present study there was a significant increase in the MDA level in comparison with the control group consistent with 
the suggestion (David et al) That the lipid peroxidation has occurred in the re-perfused patients. In the study there is 
increased levels of LDL Cholesterol in association with increased levels of MDA in AMI patients consistent with the 
literature. There is decreased levels of antioxidant vitamin in comparison with the controls consistent with the study of Joel 
A Simon et al study of10.000 Americans in NHANES II survey.11 
There were increased levels of serum calcium in the study group is consistent with increased levels of coronary artery 
calcium with the decreased levels of serum Ascorbic acid levels consistent with the study of Joel A Simon et al in CARDIA 
study.11 
There is a substantial body of evidence to suggest that oxygen derived free radicals are largely the cause for ischemic 
injury. Free radicals measured directly by electron spin resonance (electron paramagnetic resonance) are generated in large 
amounts shortly after reperfusion.12 
Lipid peroxidation in smokers was higher in controls compared to non-smokers. Lipid peroxide showed a definite increase 
in smokers (p < 0.001) in cases of AMI. Smoking is also known to effect Free radical activity. Smokers also showed an 
increase in lipid profile compared to non-smokers. According to studies by Pryor & Church et al13, 14and Cross et al,15 - 
17 a strong association between cigarette smoking and generation of free radicals by cigarette smoke is to be considered. 
STUDY 
COMPARATIVE STUDY 
YEAR 
1993 
MDA (nmol/ml) 
Young et al 18 6.86 + 2.9 
1999 
M.K. Daga et al 19 8.2+ 2.9 
2007 
Present study 6.06+ 0.63 
The Values of present study are in consistent with the above studies. The values of Young et al represented the 
basal values estimated before thrombolytic therapy. Other values indicated higher lipid peroxidation levels after successful 
thrombolysis and reperfusion. 
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE                
Volume:14    Issue:3

1. Lipid peroxidation showed a linear relationship with increase age in case and control groups and it was 
significantly increased in obese individuals and in individual with increased levels of LDL- Cholesterol and 
decreased level of Serum ascorbic acid level 
2. MDA is an important biomarker to assess successful thrombolysis and subsequent free radical-mediated 
myocardial damage. 
Conflicts of interest: Nil 
Funding sources: Nil

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