Atherosclerosis is a leading cause of vascular disease worldwide. Its major clinical manifestations include ischemic heart disease, ischemic stroke, and peripheral arterial disease ^[1]. The existence of atherosclerosis has been recognized for 500 years; as a pathological condition, it has been recognized for 150 years. Understanding of atherosclerotic vascular disease has evolved most dramatically over the past 25 years with the growth of the field of vascular biology ^[2]. Atherosclerosis is an inflammatory disease, because of high plasma concentrations of cholesterol, in particular those of low-density lipoprotein cholesterol. The process of atherogenesis has been considered by many to consist largely of the accumulation of lipids within the artery wall; however, it is much more than that ^[1].

Over 300 risk factors have been associated with atherosclerosis and its major complications, coronary heart disease and stroke. However, between 70% and 90% of the risk of atherosclerotic disease can be explained by different associations between conventional risk factors, such as smoking, abnormal lipids, hypertension, diabetes, obesity, psychosocial factors, unhealthy diet, and lack of physical activity ^[3]. Keeping in view the diversity of race, geographical and cultural diversification present in India, studying the prevalence and other aspects of this disease in a specific population is of great importance specially for the targeted population. Not many studies have been carried out in Haryana region. Hence, this study is being undertaken to collect and analyze information about prevalence and other aspects of coronary arteries’ atherosclerosis.

Data regarding age, sex, locality, weight of heart, gross heart examination, Modified American Heart Association (MAHA) grading on coronary artery atherosclerosis, lumen obstruction, major artery involvement, number of vessel involvement and age- and gender-wise coronary artery involvement were recorded and analyzed by descriptive method.

In the present study, 80 patients were studied who came for postmortem at tertiary care hospital in north India from year 2021 to 2022. All the cases of known age were included, coming for postmortem examination. Transgender, mutilated bodies, unknown bodies and decomposed bodies were excluded from this study. The specimen of heart fixed in 10% buffered formalin solution was further processed for histopathology. Specimen was weighted and thoroughly examined grossly. Grossing was done by inflow–outflow method along the direction of blood flow. The sections were processed, stained and examined as per standard protocol. For coronary arteries, malleable probe 2–3 mm in diameter was inserted through coronary ostia to check their position and serial sections across coronary arteries were taken. Gross examination of left anterior descending artery (LAD), right coronary artery (RCA) and left coronary artery (LCA)was done for the presence of any atherosclerotic plaques, thrombus and calcification with associated lumen reduction. Multiple sections were taken as per need. Hematoxylin and Eosin (H & E)-stained slides were visualized under light microscopy. Sections were studied and classified as per MAHA Classification of Atherosclerosis.

A cross-sectional study was conducted in the Department of Forensic Medicine at tertiary care hospital, Sonepat, Haryana, for the duration of 1year. The autopsy study gives an understanding the basic process which sets the stage for clinically significant atherosclerotic coronary artery disease. There is no method to validate the coronary atherosclerosis in a living patient. The autopsy study provides a better representation and layout of the prevalence of coronary atherosclerosis in living population. Maximum cases seen in the age group of 30–39 years, i.e., 21 (26.2%) cases followed by 20 cases (25%) in the age group of 40–49 years then 19 cases (23.7%) in 20–29 years of age group. Two cases were observed each in 60–69 and 70–79 years age groups. Youngest case found in this study was 11 years old and eldest case seen was in 77 years old (Table 1). Out of 80 cases, 63 cases were male (78.8%), whereas only 17 cases were females (21.2%) with male : female ratio of 3.7:1 (Table 2), which were similar with other studies ^[5-8]. On the basis of weight of heart, we found that average weight of heart is more in males as compared with females (Table 3). These results are comparable to the similar findings of previous studies ^[8-9] but does not tally with the ratio given in KV Krishna Das ^[10]. In our study, LCA and RCA were equally involved but more than RCA (Figure 1), with LCA and LAD being involved in 61 cases out of 80 cases that had some lesions according to MAHA grading system, whereas RCA was involved in 58 cases out of 80 cases that had some lesions according to MAHA grading system (Table 4). In our study, the prevalence of coronary atherosclerosis in 3^rd and 4^th decade of life, gives 95.23% and 100%, respectively (Table 6) which were similar with other studies ^[7,11-12]. We also observed that both severity and age group-wise ratio of atherosclerosis increases as the age increases (Table 6). These findings are in agreement with other studies ^{[4,8,9,11,13,14]}. This is because in this modern globalized era, where human life style has become more and more complex and challenging. Various life stressors (anxiety, depression, etc.) along with a sedentary lifestyle and lack of exercise coupled up with smoking and excessive alcohol intake and poor dietary habits like intake of junk food and increased use of refined and processed food items in place of whole grains and fresh fruits and vegetables can be important factors for earlier initiation of development and progressive increase in atherosclerotic lesions in this young Indian population. This clearly indicates that atherosclerosis in coronary arteries is significantly higher in younger age group and demands the need for early screening to detect or treat the patient so as to avoid deadly consequences of coronary atherosclerosis.

In our study, all three major coronary arteries (80 cases x 3 = 240 arteries) were examined microscopically and categorized into eight grades (Figure 2). In our study, 60 arteries out of 240 (25%) were found to be unremarkable with maximum cases in RCA. Grade II lesions were the overall most common finding observed in 59 arteries (24.58%) with maximum cases observed in LAD, i.e., 22 cases followed by 21 cases in LCA and 16 cases in RCA (Table 7). Grade III lesions were the overall second most common finding observed in 44 arteries (18.33%) with maximum cases observed in LCA, i.e., 17 cases followed by 14 cases in LAD and 13 cases in RCA. Advanced atherosclerotic lesions, i.e., grade V, VI, VII, VIII were observed in 25 arteries (10.33%). Maximum cases of advanced lesions were observed in RCA, i.e., 10 cases followed by LAD, i.e., 9 cases followed by LCA in which 6 cases were reported (Table 7). This was in concordance with the data given by other researchers ^[8,14,15]. In the present study, we found a male (84.37%) preponderance of coronary atherosclerosis as compared with 58.82% in females (Table 8), which is similar with the past researcher studies ^[4-7] in which males were affected most compared with the females.

Coronary artery disease has been expanding at alarming pace and causing significant morbidity and mortality globally. Coronary atherosclerosis and myocardial infarction are one of the most common fatal cardiac diseases discovered in autopsies. The study of human atherosclerotic lesion is an extremely difficult task in a living subject and, hence, an autopsy study is the best possible and cost-effective procedure. This study was conducted using MAHA classification, which describes eight grade lesions, helping in estimating the exact disease burden in the population. The fact is that progression of these lesions are preventable through health-care programs, necessitates collecting baseline information on the prevalence of such lesions. Thus, our study will help in providing valuable data to the literature regarding the morphology of atherosclerotic lesions and its relation to the significant cardiac morbidity.

Conflict of interest: No.

Source of funding: Nil.

Ethical approval: Taken via letter no BPSGMCW/RC641/IEC/2021, dated 26.02.2021.

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