Cardiovascular diseases (CVDs) continue to pose a significant global health challenge, claiming 20.5 million lives in 2021.¹ Among CVDs, coronary artery disease (CAD), is the most prevalent, affecting around 126 million people worldwide, with projected increase from 1,655 to over 1,845 cases per 100,000 by 2030.^1,2 CVDs account for 31.8% of all deaths and 14.7% of total disability-adjusted life years (DALYs) in India, with a mortality rate of 272 per 100,000, above the global average.^3,4 Incidents of myocardial infarction (MI) and acute coronary syndrome (ACS) have increased by 138% since 1990. The World Economic Forum and Harvard estimate a $2.17 trillion economic loss for India (2012–2030) from rising CVD prevalence.⁵ These statistics emphasize the urgent need for targeted measures, particularly for ACS, in India.

CAD is primarily caused by atherosclerosis, which is influenced by non-modifiable risk factors such as age, gender, race, and family history, along with modifiable risk factors like unhealthy diets, obesity, smoking, physical inactivity, high alcohol consumption, and other conventional risk factors like hypertension, diabetes mellitus (DM), and dyslipidemia.^4,6–9 Lifestyle risks worsen vascular and metabolic function, while hypertension, DM, and dyslipidemia accelerate atherosclerosis and increase the likelihood of complex CAD, heart failure, and adverse cardiovascular events.^6,9,10

Multimorbidity is common in CAD patients, with overlapping conditions reducing quality of life, complicating management, and increasing healthcare burden.¹¹ Identifying CAD risk factors, including comorbidities and lifestyle factors, is essential for age-appropriate prevention and improved outcomes.¹² Polypharmacy is also common in cardiovascular care due to multiple comorbidities.¹³ These challenges call for integrated care that balances safety, adherence, and patient well-being.

Although CAD is well recognized as a leading cause of morbidity and mortality, evidence on the interplay of risk factors, comorbidities, and therapeutic practices in tertiary care populations remains limited. Addressing this gap, the primary objective of the present study is to evaluate risk factors, comorbid conditions, and drug therapy patterns among patients with CAD. The secondary objective is to assess the magnitude of polypharmacy and changing prescribing patterns in the treatment of CAD and comorbidities.

The findings of the present study unveil the evolving pattern of CAD in India in a tertiary care setting, reflecting the long-standing concerns raised by Goyal et al.¹⁴ Our study provides a comprehensive assessment of CAD patients through stratified age and gender-demographic analysis, along with trends in multi-morbidities, along with their combinations. Additionally, it describes current prescription practices among CAD patients and emphasizes the existence of lifestyle determinants as risk factors

Previous studies by Khan et al.² and Zeinali-Nezhad et al.⁷ focused mostly on risk factor prevalence or epidemiological trends. Similarly, studies by Tefera et al.¹³ and George et al.¹⁵ examined drug utilization patterns. Our multidimensional method, by contrast, addresses the cross-links among patient profiles, risk assessment, and prescription analysis. This allows for a systematic understanding of CAD and its therapeutic management.

The demographics of our study population revealed an increased prevalence of CAD among older adults of men and women. Out of 300 participants, 69.3% of the participants were male, predominantly between 56 and 75 years of age. These results are consistent with previous Indian and South Asian data,^2,5,16 as well as with the epidemiological evaluation reported by Prabhakaran et al.,¹⁷ who noted comparable demographic changes in CAD incidence. This demographic stratification facilitates a more granular understanding of risk distribution within the selected study population.

As per multinomial regression analysis of the study data, age was found to be statistically significant for the likelihood of stable angina. These results are consistent with the study of González- Juanatey et al.,¹⁸ who showed that angina is more common as individuals age. According to their large cohort analysis, people over 75 were substantially more likely than people under 65 to suffer angina. Although that study could not distinguish between stable and unstable angina, it emphasizes the significance of age as a primary predictor of clinical presentation in CAD.

In our study, gender showed a significant association with all CAD presentations. Males had a considerably higher risk of myocardial infarction, including NSTEMI and STEMI, while females were more likely to present stable angina and unstable angina. These findings are partially consistent with an Indian study by Galani et al.,¹⁹ who found a higher prevalence of STEMI in men (54.30%) than in women (38.18%). Contrary to our finding, the reported study indicated a higher prevalence in women (61.81%) than in men (45.69%) with NSTEMI. Similarly, the meta-analysis by Dutta et al.²⁰ demonstrated significantly lower odds of STEMI in women but higher odds of NSTEMI/unstable angina, demonstrating gender-specific ACS trends across different cohorts. Our findings are entirely supported by another Indian study by Pagidipati et al.,²¹ who found that women were considerably less likely than men to present with STEMI. When combined, these results confirm that women are more likely to exhibit stable ischemic symptoms, whereas men are more likely to present acute coronary events like STEMI and NSTEMI. Furthermore, there were no statistically significant correlations found in our investigation between CAD types with clinical and lifestyle-related risk factors. This could be due to the small sample size and reliance on medical records rather than one-to-one patient interviews, which could have resulted in an underreporting of these characteristics.

The main drivers in CAD progression, as observed in the present study, were hypertension (71%), DM (50%), and dyslipidemia (48.3 %). Specifically, the coexistence of hypertension and DM was observed in 22% of our cohort, while the triad of hypertension, DM, and dyslipidemia was present in 14.6% of the patients. These findings reiterate the clustering phenomenon noted by Zeinali-Nezhad et al.⁷ and further supported by a recent Indian multicenter study by Singh et al.,⁶ which highlights the convergence of these three risk factors and their additive impact on CAD severity. However, our work differs by quantifying these combinations in a treatment-oriented context, which is vital for clinical decision-making in multimorbid patients.

When risk factors due to lifestyle are being assessed, our inpatient cohort had relatively low rates of smoking (21%) and alcohol use (20.3%), compared to unhealthy eating habits (25.3%). These findings are in line with international studies, such as the Prospective Urban Rural Epidemiology (PURE) study.²² The observed low rates of smoking and alcohol may be influenced by the study's reliance on medical records, which may underreport such behaviors. The substantial influence of a sedentary lifestyle on global health was demonstrated in PURE, where lifestyle-related risk factors accounted for roughly 26.3% of the population-attributable fraction (PAF) for fatalities. The comparatively lower incidence of lifestyle-related risk factors in our cohort could be attributed to underreporting or enhanced patient awareness. However, the need for diet modifications, as pointed out earlier by Ng et al.,¹² Dehghan et al.,²³ and Mozaffarian et al.,²⁴ should be incorporated in this study.

One of the major novelties of this study is the prospective observation of CAD drug prescription patterns in contrast to the retrospective registry-based design, such as the Kerala ACS Registry.¹⁵ Our observations show the universal use of aspirin and statins in accordance with current guidelines of ‘2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the management of patients with ACS’ and ‘2023 ESC Guidelines for the management of ACS.^25–27 Comparable adherence to antiplatelet and statin guidelines has also been documented in recent Indian pharmacotherapy studies.^28,29 In our study, ticagrelor was prescribed to 66% of the patients, as compared to clopidogrel (36%). Such a shift implies higher compliance with recent international guidelines, like the 2017 ESC focused update on dual antiplatelet therapy, which supports ticagrelor use.³⁰ A recent Indian study analyzing post-ACS therapy has also demonstrated a trend toward increased use of ticagrelor.²⁸ Variations in clopidogrel response reported in earlier studies also justify the clinical preference for ticagrelor in high-risk CAD patients.³¹

Likewise, the higher prescription of dapagliflozin (35.5%) among diabetic patients with CAD in our cohort is likely due to the clinical influence of evidence from the Dapagliflozin Effect on Cardiovascular Events – Thrombolysis in Myocardial Infarction 58 (DECLARE-TIMI 58) trial, which demonstrated cardio-renal benefits of dapagliflozin in patients with Type 2 diabetes and increased cardiovascular risk.³² Recent research conducted in India, such as the BRIDGE-DS study by Bhamri et al.,³³ which showed notable improvements in glycemic control, blood pressure, and lipid parameters among T2DM patients with atherosclerotic CVD treated with dapagliflozin, corroborates these findings with those of the worldwide. Similarly, Ray et al.³⁴ and Kumar et al.³⁵ observed positive benefits in metabolic control, body weight reduction, and improved cardiovascular risk profiles among Indian patients receiving dapagliflozin therapy. When taken together, these findings suggest that the increasing use of dapagliflozin in our study is a logical and evidence-based change in prescribing practices, impacted by both positive Indian data and evidence from international clinical trials.

In the current study, beta-blockers (59.6%) were the most widely prescribed drugs among anti-hypertensives, followed by ARBs (42.2%), CCBs (34%), and ACEIs (8.9%). Varying patterns were also observed in other Indian studies. Dawalji et al.³⁶ reported comparable beta-blocker use (59.4%) with higher ACEI (27.06%), while Mukadam et al.³⁷ noted greater ACEI (69.7%) and CCB (62.5%) usage but lower beta-blocker use (22.9%). These variations reflect differences in clinical practice, patient profiles, and treatment settings throughout India.

Our study revealed a tendency towards triple or quadruple drug regimens, particularly among patients with overlapping risk factors for hypertension. For instance, combinations, such as telmisartan, amlodipine, and bisoprolol, are becoming increasingly popular, which reflects a trend towards individualized polypharmacy. Such a shift from monotherapy has been seen in earlier Indian prescription audits.^38,18 Moreover, Guthrie et al.³⁸ and Bhagavathula et al.³⁹ remarked that uncontrolled polypharmacy may jeopardize outcomes, particularly in older CAD patients.

According to the World Health Organization (WHO), polypharmacy is defined as "the concurrent use of multiple medications commonly described as the routine use of five or more drugs, including prescription, over-the-counter, or complementary agents".⁴⁰ In our study population, 91% (n = 273) were observed to be on polypharmacy. This highlights how multiple comorbidities contribute to complex drug regimens, resulting in a high prevalence of polypharmacy. Larger, multicenter studies are recommended to validate and expand on these observations and to further optimize clinical strategies to reduce the growing burden of CAD in India. Additionally, enhancing patient awareness and education on lifestyle-related risk factors should be prioritized as part of comprehensive CAD management

However, this study did have several limitations, including the fact that it was conducted at a single center, which may limit the generalizability. Furthermore, enrolling only hospitalized patients may overrepresent acute or severe cases, possibly underestimating the incidence of stable CAD and lifestyle-related risk factors.

This study shows distinct CAD patterns, with unstable angina and STEMI being the most common types, primarily affecting female and male patients, respectively. Multimorbidity was common, with hypertension, diabetes, and dyslipidemia being the main risk factors, while poor diet, smoking, and alcohol consumption appeared to be key lifestyle risk factors. Antiplatelets, statins, beta-blockers, and nicorandil were the most commonly prescribed drugs, with CAD patients preferring ticagrelor over clopidogrel and dapagliflozin, indicating better adherence to current evidence-based guidelines. Polypharmacy was common, especially in individuals with multimorbidity, indicating the complexity of CAD therapy. These findings underscore the need to strengthen community-based outreach and educational activities to address modifiable lifestyle risk factors, thereby controlling the incidence of CVD and lifestyle-related comorbidities. Moreover, encouraging rational prescription practices is crucial to reducing inappropriate polypharmacy and improving treatment outcomes. Furthermore, implementing coordinated, guideline-aligned care pathways and integrated preventive interventions is critical for improving long-term cardiovascular health.