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\begin{document}

             \author[1]{Husham Abdallah Yahya  Yousif}

             \affil[1]{  Sudan medical specialization board}

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\date{\small \em Received: 8 June 2015 Accepted: 4 July 2015 Published: 15 July 2015}

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\begin{abstract}
        


 Objectives: The aim of this study was to reveal the mode of presentation of coronary  artery disease(CAD) and the outcome of coronary artery bypass graft surgery(CABG) Methods: This was a retro - prospective study conducted in El shaab and Ahmed Gasim Hospitals  from 201 2 to 2015. Fifty nine patients were included in the study of whom 49(83.1%) were males  and 10(16.9%) were females. The study variables included; patients demographics, etiological risk factors, form of  presentation, blood and imaging investigations, indica tions for coronary artery bypass graft  (CABG) surgery, modalities of CABG surgery, prognostic risk factors and outcome of CABG.   

\end{abstract}


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\let\tabcellsep& 	 	 		 \par
Outcome of Coronary Artery Bypass Graft Surgery in Elshaab and Ahmed Gasimhospitals  {\ref (2012)} {\ref (2013)} {\ref (2014)} {\ref (2015)} Cardiovascular disease is the leading cause of mortality and important cause of disability. Worldwide, cardiovascular disease (CVD) is responsible for 30\% of all deaths and 10\% of DALYs (disability-adjusted life Years). In Africa, the burden of cardiovascular disease is increasing rapidly and it is now apublic health concern. It has amajor socio-economic impact on individuals, families and societies in terms of health care cost, work absenteeism and national productivity. had good results in some selected cases with regard to postoperative morbidity and mortality. Methods: This was a retro-prospective study conducted in El shaab and Ahmed Gasim Hospitals from 2012 to 2015. Fifty nine patients were included in the study of whom 49(83.1\%) were males and 10(16.9\%) were females.\par
The study variables included; patients demographics, etiological risk factors, form of presentation, blood and imaging investigations, indications for coronary artery bypass graft (CABG) surgery, modalities of CABG surgery, prognostic risk factors and outcome of CABG.\par
Results: The ages of the patients ranged between(43 -77 Years) with mean age of 60.23, 46 patients(78\%) were from central part of Sudan, 15 patients(25.5\%)had more than one risk factor, 34 patients(57.6\%) had single risk factor and 10 patients(16.9\%) had no identified risk factor.DM was found in 26 patients(44.8\%) and so was HTN. 11 patients(18.7\%) presented with MI. All patients underwent ECG, Echo., Blood tests and coronary angiography,30 patients(50.8\%) had 3 vessel disease.,Thirty six patients(61,0\%) underwent on-pump CABG, 23 patients(39\%) underwent off-pump CABG. Six patients(10.2\%) had small Rt. Coronary artery, 2 patients(3.4\%) had severe pulmonary hypertension and 1 patient(1.7\%) had raised serum creatinine. Fifty one patients(86.4\%) were discharged within first seven postoperative days, 6 patients(10.2\%) were discharged within more than 7 days and 2 patients(3.4\%) died within first 7 postoperative days.All patients had sternal wounds healed within one Month postoperatively and those with coexisting leg wounds; 3 (5.1\%) had leg wounds infection within this period, 51patients(86.4\%) had relieved angina, 52 patients(88.1\%) had improved physical activity and the same number of patients achieved psychological improvement within the same period.  
\section[{Conclusion}]{Conclusion} 
\section[{Results}]{Results}\par
Fifty nine patients with CAD were enrolled in this study from 2012 -2015. Of the total number; 49 patients (83.1\%) were males and 10 patients (16.9\%) were females.\par
Their ages ranged between (43 -77 Years) with mean age of 60.29 and 8.305 Std. deviation.With regard to their geographical distribution; 46 patients(78\%) were from central part of Sudan, 6 patients(10.1\%) were from Northeren Sudan, 5 patients(8.5\%) were from Western Sudan, 2 patients(3.4\%) were from Eastern Sudan and no patient from Southren included in the study. 
\section[{a) Etiological risk factors}]{a) Etiological risk factors}\par
Diabetes mellitus represented risk factor in 26(44.8\%) patients and it was the most common risk factor alone followed by hypertension, and in coexistence with other risk factors hypertension was the most common; as 13 patients(22\%) were diabetic only, 12 patients(20\%) were both diabetic and hypertensive and 1 patient(1.7\%) was diabetic and smoker. 12 patients(20.3\%) were hypertensive only, 2 patients(3.4\%) were both hypertensive and smokers, 7 patients(11.9\%) were smokers only, 2 patients(3.4\%) had hyperlipidemia. There was no positive family history or hyperurecemia as CAD risk factor among the patients enrolled in thestudy and 10 patients(16.9\%) did not have identified risk factor b) Form of presentation   {\ref 6}) e) Prognostic risk factors Concerning prognostic risk factors; severe pulmonary hypertension was found in 2 patients(3.4\%), raised serum creatinine in 1 patient(1.7\%), small Rt. Coronary artery was found in 6 patient(10.2\%) and there was no identified prognostic risk factor in 50 patients(84.7\%). 
\section[{f) Early outcome}]{f) Early outcome}\par
Fifty one patients(86.4\%) were discharged within seven postoperative days from hospital, 6 patients(10.2\%) were discharged within more than 7 postoperative days because of chest infection and all of them were above the age 60 Years, 2 male patients(3.4\%) had died within first seven postoperative days( one (75 Years old ) died on day zero in ICU because of respiratory failture and he was known diabetic and presented with unstable angina and grade 3 dyspnea according to ATSS preoperatively. The other patient(63 Years old) died on day 1 in ICU because of heart failture he was also diabetic presented with stable angina with grade3 dyspnea preoperatively). 
\section[{g) Late outcome( one Month postoperative)}]{g) Late outcome( one Month postoperative)}\par
All had sternal wounds healed within one month postoperatively as well as stable sternumand those with coexisting leg wounds, 3 of them had leg wound infection within one month postoperatively.\par
Fifty patients(84.7\%) had decreased antianginal drugs within one month postoperatively, 9 patients(15.3\%) did not had decreased antianginal drugs. Fifty one patients(86.4\%) had relieved anginal pain, 8 patients(13.6\%) were still suffering from variable range of severity of symptoms, 4 patients(6.7\%) had recurrent angina and 3 of themunderwentcatheterization. 52 patients(88.1\%) had improved physical activity and the same number of patients achieved psychological improvement within one Month postoperatively and no death occurred during this period.     {\ref Dalen, 1993)}. Variability in the results of these studies could be explained by differencies in practice patterns by different centres and could also be influenced by regional, cultural and socio-economical factors affecting the health care dynamics of female patients  {\ref (Ghali et al.,2002)}. Since the interplay of the above factors is unique in each society, the results from any given study can not be universally applied. There is thus need to study local factors affecting any population before health care practices and policies may be modified. 
\section[{Outcome of Coronary Artery}]{Outcome of Coronary Artery}\par
With reference to data from Sudan heart institute, CAD is predominantly male disease in Sudanese as is the case of the rest of the worl the ratio was 28\% females and 72\% males in MI trial. And 32\% females and 68\% males in the CABG group. In our study 83.1\%(n =49 pt.) of the total number(59 pt.) were males and 16.9\%(n =10 pt.) were females. In MI group excluding those with previous history of IHD the mean age of patients was 57 Years, and the mean age of patients in CABG group was 61 Years same as age of South Asian patients and younger than European patients \hyperref[b0]{(1)}.In our study the mean age of the patients underwent CABG was 60.29 with standard deviation of 8.305 which is very close and also comparable to the mean age in CABG group.\par
With regard to the geographical distribution of CAD, 78\%(n =46)of patients who underwent CABG in our study were from central part of the Sudan; the fact that may support the incrimination of environmental risk factors like( sedentary life style, high fat diet, local tabaco abuse) as acause beyond increasing incidence of CAD in developing World \hyperref[b0]{(1)}.\par
Globally, diabetics are at 4 folds increased risk of developing CAD than are normal individuals(2). Patients with type2 diabetes without aprior MI (mean age of 58 Years) are at the same risk of MI (20 -19 percent) respectively and coronary mortality of (15 versus 16 percent) as patients without DM who had prior MI.(3)And hypertension accounts 47\% of all IHD events globally(14). Fourteen studies were reviewed for the association between smoking and risk of CAD. The definition of smoking applied varied between studies, which included former smokers and current smokers. Former smokers had arisk ratio of 0.68 fore CAD when compared to never smokers, while current smokers had arisk ratio of 1.81. When stratified by diabetic and non diabetic populations the adjusted risk ratios were not significant.\par
One study, in addition to reporting on the association of the risk factors of interest, also reported association between composite risk factors and risk of CAD. The composite risk factor was defined as having any 1, 2, or 3 of the conditions, which include hypertension, smoking, high TC, low HDL -C, diabetes and obesity. Among CAD patients, 83.7\% had at least 1 risk factor, 47.6\% had at least 2, and 18.5\% had at least 3 risk factors. Among patients with no CAD, only 64.7\%, 25.3\%, and 6.6\% had atleast 1, 2, or 3 risk factors respectively. And these were each statistically different from the results fore CAD patients. Of all patients with at least one risk factor, CAD patients had more additional risk factors than non CAD patients by afactor of more than 2, to 1. Additionally, each of the individual risk factors were significant contributors to the risk of CAD(4).\par
Twelve studies were selected for review on the association between lipid conditions and risk of CAD. Three studies reported the association between hyperlipidemia and risk of CAD, 2 between dyslipidemia and risk of CAD and 10 between values on total cholesterol (TC) and triglyceride (TG), LDL -C, HDL -C and risk of CAD. For the association between hyperlipidemia and the risk of CAD, significant crude and adjusted odds ratios were reported in only one case cas-control study conducted in Shenyang, where the crude OR was reported as 2.77 and adjusted OR as 2.63 (95\% confidence interval[CI]: 2.32 -2.99). The criteria for defining hyperlipidemia were not provided in this study (5) .\par
In Sudan like many other less-devoloped countries, particularly in sub-Saharan Africa, most of data on disease burden come from extrapolations, as in the Global Burden of Disease Study (GBDS), which relies on cause of -death-models and expert opinion \hyperref[b8]{(8)}.According to Sudan Heart Journal 2013; acomprehensive search in the internet for any topic related to the epidemiology of CAD in Sudan was done, using terms such as prevalence, incidence, mortality, morbidity, risk factors, ischemic heart disease, coronary artery disease, myocardial infarction, acute coronary syndrome and angina with no joy. Website of the Sudanese Ministry of Health was also logged into looking for any statistics related to CAD in Sudan. The epidemiology of CAD in Sudan is derived exclusively from the united nations projected global burden of CAD2().In this retrospective study which depended on patients files and notes, the prevalence of risk factors in CAD patients referred for CABG was as follows: diabetes 49\%, hypertension 47\%, tobacco abuse 41\%, and family history(6) 23\%.\par
In our study,26(44\%) were diabetics and the same ratio were hypertensive, 10 patients(16.9\%) were smokers, 2 patients(3.4\%) were hyperlipidemic all alone inaddition to those with coexisting risk factors. DM was the most common single risk factor 22\%(n = 13) followed by HTN 20.3\%(n = 12), hyperlipidemia was the less common risk factor followed by smoking and no patients identified with hyperurecemia or positive family history for CAD and 10 patients had no risk factor.(Tables \hyperref[tab_2]{1, 2 ,5}). Twenty one of diabetic patients(35.6\%) underwent CABG were males and 5 patients(8.5\%) were females, the ratios of gender distribution in hypertensive patients were the same as in diabetics. No females recorded with hyperlipidemia or history of smoking in our study. Thirty four patients(57.6\%) presented with single risk factor and 15 patients(25.5\%) presented with 2 risk factors.\par
According to patient data from National Registery of MI of USA, of the total number(1.14 million patients) in the study with acute MI, about 35\% of patients with acute MI may not have chest pain upon their arrival to emergency department \hyperref[b7]{(7)}.\par
In our study, of the total number(59 patient) 18.7\%(n = 11) of patients presented with MI, majority of them presented with composite risk factor(5 patients with both DM and HTN) and among single risk factors HTN was the most common(3 patients). Other eleven patients presented with unstable angina, 55.9\%(n =33) presented with stable angina and 6.7\%(n = 4) had no angina. Table \hyperref[b3]{(3)}.With regard to shortness of breathing according to ATSS; Four patients(6.7\%) presented with grade 4 dyspneawith 1 : 3 female to male ratio and 31patients(52.6\%) had no dyspnea table.\par
In aclinical study published in African Juornals on line via Sudan Juornal of Medical Sience 2012; It was revealed that the Lt. anterior descending artery(LAD) was the most involved and the Lt. main artery(LM) was the least involved \hyperref[b6]{(6)}.\par
In our study, 30 patients(50.8\%) presented with three vessel disease, 14 patients(23.7\%) presented with critical artery disease untreated by catheter, 11 patients presented with 2vessel disease with decreased ejection fraction, 3 patients(5.1\%) presented with LM artery disease and 1 patient presented with 2 vessel disease with normal ejection fraction (Table  {\ref 6}). Over all, LAD was the most common vessel to be involved and LM was the least commonly involved as was the case in the study mentioned above.\par
There is general agreement that CABG improves prognosis in the early postsurgical Years in those patients with symptomatic LM coronary artery stenosis or stenosis of three main coronary vessels although this advantage is not to be significant after 10 -12 Years(Cundiff 2002, Hlatkyetal; 2004). However, cardiac surgery has advanced to appoint where mortality rates have declined dramatically \hyperref[b8]{(8)}.\par
With reference to (PMC -US National library of medicine -National institute of health sience); up to 25\% of CABG operations are off pump, they are as safe as on pump and in experienced hands have less early postoperative complications. In our study, 36 patients(61.0\%) underwent on pump CABG, 5 of them(8.4\%) were females and 31(52.5\%) were males.Twenty three patients(39\%) underwent off pump CABG, an other 5 were female and 18(30.5\%) were males and no patient with CAD underwent minimally invasive CABG (Tables 6, 7 ,8). Most of patients underwent on pump CABG 40.7\%(n =24)were having 3 vessel disease and most of those underwent off pump CABG were those with critical artery disease untreated by catheterization 22.4\%(n = 13) Table \hyperref[b6]{(6)}. Nine patients(15.3\%) had ungraftable vessels, among them, 6 patients(10.2\%) had small Rt. Coronary artery and 3(5.1\%) had severly diseased circumflex artery.Left internal mammary artery graft was used in 53 pa patients(89\%), bilateral internal mammary artery graft was used in one patient(1.7\%) and this had severely calcified aorta and saphenous vein graft(SVG) was used in 18 patients(30,5\%) in 2 patients the SVG was harvested infrainguinal and for the rest of them it was below knee. With regard to associated cardiac comorbidities, One(1.7\%) female patient of 78 Years old presented with history of aortic valve replacement because of severe aortic stenosis and one male patient presented with Lt. ventricular thrombus, severe pulmonary hypertension and low ejection fraction.\par
With reference to Journal of Cardiothoracic Surgery published online in Dec.2014 areview of retrospective analysis in myocardial preservation techniques during coronary artery bypass graft surgery: are we protecting the heart?. Data was analized for 54 patient undergoing CABG surgery. Twenty eight patients received antegrade cold blood cardioplegia(group 1), 16 patients received cross clamp fibrillation(group 2) and 10 antegrade retrograde warm blood cardioplegia (group 3). No significant difference was found with respect to baseline patient baseline characteristics. Expectedly , cross-clamp time was significantly lower in group 2. However, all the remaining paramerters were similar among the 3 groups. In current practice the route of delivery is at the surgeons discretion and as such there is no consensus on using specific route to supply the cardioplegia into the myocardium. The most common technique used by the majority of cardiac surgeons is the antegrade route. Although significant clinical evidence favours the saftey of this method, severe coronary artery stenosis in patients undergoing CABG may prevent the uniform distribution of cardioplegicsolusion through the myocardium and, importantly, sub-optimal or inadequate distribution to parts of the myocardium increases the risk for PMI. Aproposed solution to overcome this limitation is the retrograde rout of delivery (9) . But finally, the population size in these studies was too small to come to ameaningful conclusion on the benefit of particular protection strategy. In our study, 54 patients (91.6\%) underwent antegradecardioplegia and 5(8.4\%) patients underwent retrograde cardioplegia because of severely stenosed coronary ostia (9) .\par
With regard to outcome of CABG, one study found that 50\% of patients were significantly depressed 8 days postsurgery, but this declined substantially with time to 24\% 8 weeks postsurgery and 22\% at 12 Months(64,65). Assessment of quality of life(QOL) 3 Months before and after heart surgery found that physical mobility was improved in 77\% of patients(Wilson-Barnett 1981). Upto 80 of CABG patiets were angina free upto 5 Years after surgery(Fihn et al 2001). Twenty three percent of CABG patients were rehospitalized in the first 6 Months following surgery, cardiac problems were responsible for 32\% of problems: cardiac complications 14\%, gastrointestinal difficulties 14\% and problems in other organ systems 45\%  {\ref (Jenkins et al, 1983)} Concerning the outcome of CABG in our study; fifty one patients(86.4\%) were discharged within the first seven postoperative days from hospital, 6 patients(10.2\%) were discharged after more than 7 postoperative days because of chest infection, all of them were males and above the age of 60 Years, 3 of them underwent on pump CABG and the other 3 off pump CABG, three patients had single risk factor and other 3 had 2 risk factors,( 2 of them were hypertensive an other 2 were both hypertensive and diabetic, 1 was only diabetic and an other one was both diabetic and smoker), HTN and DM were the most common risk factors both alone and in coexistence, and all patients without identified risk factor were discharged within first postoperative week. Two (3.4\%) male patients had died within first seven postoperative days: one(75 Years old) died on day zero in the ICU because of respiratory faillture due to severe pulmonary hypertension. The other patient(63 Years old) died on day one in the ICU with heart failture. Both patients were known diabetic, presented with grade 3 dyspnea according to ATSS and both of them underwent on pump CABG. The first patient presented with unstable angina and the second patient presented with stable angina. One Month postoperatively all patients had healed sternal wounds as well as stable sternums and those with coexisting leg wounds 3 patients(5.1\%) had leg wound infection within this period and both were known diabetic and above 70 Years. Fifty patients(84.7\%) had decreased their antianginal drugs,52 patients(88.1\%) had improved their physical activity and the same number of patients(86.4\%) had relieved anginal pain , 6 patients were still suffering from variable range of severity of angina 1(1.7\%) of them was females and 5(8.4\%) were males, 2 werehpertensive and diabetic, 1 diabetic only, 1 smoker and 1 had no risk factor , 2 presented with no dyspnea, 1 with grade 0, 1 with grade 1 and 2 with grade 4 dyspnea according to ATSS. Five of them underwent on pump CABG and 1off pump CABG.\par
IV. 
\section[{Coclusion}]{Coclusion}\par
? Coronary artery disease was predominantly male disease in Sudanese patients in El shaab and Ahmed Gasim Hospitals ? Great majority of CAD patients were from central part of Sudan ? Diabetes and hypertension were equal in frequency as etiological risk factors followed by smoking and no patients with positive family history or hyperurecemia were identified in the study ? Significant number of patients had no identified etiological risk factor ? Stable angina was the most common form of presentation followed by equally frequent unstable angina and myocardial infarction ? Majority of patients presented with MI were those with more than single risk factor ? On pump CABG was the most common modality of surgical treatment and three vessel disease was the most common indication for CABG ? Off pump CABG had good outcome in some selected cases with regard to postoperative morbidity and mortality\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
    \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.85\textwidth}}
Year 2015\end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.6904163393558522\textwidth}P{0.0687745483110762\textwidth}P{0.015357423409269442\textwidth}P{0.010683424980361352\textwidth}P{0.0647682639434407\textwidth}}
\tabcellsep Risk factors\tabcellsep Gender\tabcellsep \tabcellsep Total No.\&(\%)\\
\tabcellsep \tabcellsep Male\tabcellsep Female\\
\tabcellsep DM\tabcellsep 10\tabcellsep 3\tabcellsep 13(22.1\%)\\
\tabcellsep HTN\tabcellsep 19\tabcellsep 3\tabcellsep 12(20.3\%)\\
\tabcellsep smoking\tabcellsep 7\tabcellsep 0\tabcellsep 7(11.9\%)\\
\tabcellsep hyperlipidemia\tabcellsep 2\tabcellsep 0\tabcellsep 2(3.4\%)\\
\tabcellsep DM \& HTN\tabcellsep 10\tabcellsep 2\tabcellsep 12(20.3\%)\\
\tabcellsep DM \& smoking\tabcellsep 1\tabcellsep 0\tabcellsep 1(1.7\%)\\
\tabcellsep HTN \& smoking\tabcellsep 2\tabcellsep 0\tabcellsep 2(3.4\%)\\
\tabcellsep No risk factor\tabcellsep 8\tabcellsep 2\tabcellsep 10(16.9\%)\\
\tabcellsep Total\tabcellsep 49\tabcellsep 10\tabcellsep 49(100\%)\\
III.\tabcellsep Discussion\tabcellsep \tabcellsep \\
\multicolumn{3}{l}{Internationally, CAD affects women in}\tabcellsep \\
\multicolumn{3}{l}{postmenopausal age at the same frequency as men}\tabcellsep \\
\multicolumn{3}{l}{and in the Western W orld ; it has now surpassed}\tabcellsep \\
\multicolumn{3}{l}{cancers of all types as aleading cause of mortality in}\tabcellsep \\
\multicolumn{3}{l}{females(Crouse and Kramer, 1996). It is known that}\tabcellsep \\
\multicolumn{3}{l}{when female patients present chest pain, they are more}\tabcellsep \\
\multicolumn{3}{l}{likely to have other problems than CAD compred to}\tabcellsep \\
\multicolumn{3}{l}{males with chest pain (Crouse and Kramer, 1996; Miller}\tabcellsep \\
\multicolumn{3}{l}{et al., 2001). This notion may probably been the cause}\tabcellsep \\
\multicolumn{3}{l}{of gender disparities noted in the management of}\tabcellsep \\
\multicolumn{3}{l}{female CAD population not only at primary health care}\tabcellsep \\
\multicolumn{3}{l}{level(Crilly et al., 2008; Bosner et al., 2009) but also at}\tabcellsep \\
\multicolumn{3}{l}{the level of diagnostic work up and choice of}\tabcellsep \\
\multicolumn{3}{l}{revascularization procedure. Under referral of female}\tabcellsep \\
\multicolumn{3}{l}{patients fore exercise test and coronary angiography}\tabcellsep \\
\multicolumn{3}{l}{has not only been shown when they present with chest}\tabcellsep \\
\multicolumn{3}{l}{pain(Daly et al., 2006; D'Hoore et al., 1994; Petticrew et}\tabcellsep \\
\multicolumn{3}{l}{al,. 1993) but also when they have proven CAD}\tabcellsep \\
\multicolumn{3}{l}{presenting in the form of acute MI(Ayanian and Epstein,}\tabcellsep \\
\multicolumn{3}{l}{1991;Nguyen et al., 2008 Dellborg and Swedberg, 1993;}\tabcellsep \\
Alpert and\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
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\end{document}
