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From Risk Factors to Revascularization: A Hospital-based Study of Acute Coronary Syndrome in Women
*Corresponding author: Ouafae Zouhri, Department of Cardiology, Sheikh Zayd International Hospital, Rabat, Morocco. ouafaezou@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Zouhri O, El Guessabi S, Aoudad M, Tazi Mezalek A, Benyass A. From Risk Factors to Revascularization: A Hospital-based Study of Acute Coronary Syndrome in Women. Indian J Cardiovasc Dis Women. doi: 10.25259/IJCDW_65_2025
Abstract
Objectives:
Acute coronary syndrome (ACS) remains a major public health concern. Sex-related disparities in its clinical presentation, management, and prognosis have been recognized. However, data from the Maghreb region are limited. This study aims to explore sex-based differences in ACS in a Moroccan tertiary hospital.
Materials and Methods:
We conducted a retrospective, single-center study at Sheikh Zayd International University Hospital between 2021 and 2023, including 344 patients hospitalized for ACS. A comparative analysis between men and women was performed regarding demographic characteristics, cardiovascular risk factors, clinical presentation, diagnostic findings, management strategies, and in-hospital complications.
Results:
Among the patients, 103 were women (30%). Women were significantly older (mean age: 67.4 vs. 60.3 years, P < 0.001) and had higher rates of hypertension (74% vs. 50%, P < 0.001) and diabetes (60% vs. 42%, P = 0.003), but were less frequently smokers (3% vs. 52%, P < 0.001). They presented more often with atypical symptoms (47% vs. 20%, P < 0.001) and showed a higher incidence of heart failure signs on admission (Killip ≥2: 36% vs. 22%, P = 0.012). Non-ST elevation ACS was more frequent in women (62% vs. 44%, P = 0.003). Coronary angiography revealed a higher rate of normal or non-obstructive coronary arteries in women (24% vs. 9%, P = 0.001). Although percutaneous coronary intervention (PCI) was less frequent in women (65% vs. 79%, P = 0.012), there was no significant difference in in-hospital mortality (5.8% vs. 3.8%, P = 0.43).
Conclusion:
This study highlights significant sex-based differences in ACS. Women presented with more comorbidities, atypical symptoms, and were less likely to undergo PCI, despite similar short-term outcomes. These findings highlight the critical need for sex sensitive approaches in the diagnosis and management of ACS.
Keywords
Acute coronary syndrome
Myocardial infarction with non-obstructive coronary arteries
Myocardial infarction
Non-ST elevation myocardial infarction
STEMI
ABSTRACT IMAGE
INTRODUCTION
Acute coronary syndrome (ACS) is a major cardiovascular condition encompassing myocardial infarction (MI) and unstable angina.[1] Coronary artery disease (CAD) predominantly affects men.[2] However, emerging research suggests that ACS in women presents distinct clinical features and risk factors and remains largely underdiagnosed and understudied.[3]
The World Health Organization reports that CAD is the leading cause of death among women, ahead of breast cancer.[4] In the United States, it causes approximately 400,000 female deaths annually.[5] Although women are 8 times less likely to suffer from a MI, their prognosis following myocardial ischemia tends to be poorer.[6] It is generally believed that women are protected before the age of 70 years, after which the prevalence of MI becomes comparable between the sexes.[7] While the cardioprotective role of estrogens is well recognized, its mechanisms remain uncertain.[8]
Atherosclerosis is the most common underlying cause of ACS,[9] but a considerable proportion of MIs – particularly among women – are not linked to obstructive coronary disease.[10]
This study intended to explore the particularities of ACS in women through a Moroccan case series. We focused on clinical presentation, risk factors, diagnostic findings, and treatment modalities, with the goal of improving both short- and long-term outcomes in female patients and developing clinical recommendations.
MATERIALS AND METHODS
Study design
This is a retrospective, descriptive, and analytical study comparing female and male patients diagnosed with ACS. It was conducted at the cardiology department of Sheikh Zayd International Hospital, from January 2021 to December 2023.
Population characteristics
All consecutive patients admitted with a confirmed diagnosis of ACS between 2021 and 2023 were included to minimize selection bias.
Exclusion criteria included chest pain of non-cardiac origin and chronic coronary syndromes.
ACS was defined by elevated troponin above the 99th percentile, in the presence of ischemic symptoms— either typical or atypical chest pain—or ischemic equivalents (e.g., dyspnea, paroxysmal nocturnal dyspnea), along with electrocardiogram (ECG) abnormalities such as ST-segment deviations, new-onset left bundle branch block, Q waves, or T-wave inversions.
Patients were classified into two groups based on biological sex: male and female. For patients with recurrent ACS, only index hospitalizations were included in the analysis to avoid duplication.
Data collection
Data were collected retrospectively using a structured form covering sociodemographic details, clinical presentation, diagnostic findings, therapeutic interventions, and outcomes.
Risk factors mentioned in the study, such as hypertension and obesity, were diagnosed based on patient history. Troponin levels reported in the study refer to the values measured at the time of hospital admission.
For patients with non-ST elevation myocardial infarction (NSTEMI), risk stratification was performed retrospectively using the Global Registry of Acute Coronary Events (GRACE) score[11] which classifies patients into low, intermediate, or high-risk categories.[12] The dual antiplatelet therapy (DAPT) score[13] was calculated to estimate the risk of ischemia and bleeding following percutaneous coronary intervention (PCI), aiding in the selection of antiplatelet therapy duration. High bleeding risk (HBR) was assessed using the Academic Research Consortium for HBR (ARC-HBR) criteria.[14]
For patients with ST elevation myocardial infarction (STEMI), door-to-balloon time[15] – defined as the time from hospital admission to balloon inflation during primary PCI – was recorded.
We also documented both medical and interventional treatments, as well as in-hospital outcomes, including complications and mortality.
Statistical analysis
Excel was used for data entry and visualization, while statistical analysis was conducted using the JAMOVI software.
Descriptive statistics and contingency tables were produced. Quantitative variables with a normal distribution were expressed as mean ± standard deviation; those with a non-normal distribution were expressed as median and interquartile range (IQR). For categorical variables, data are expressed as frequencies and percentages.
Comparisons between two independent groups were performed using Student’s t-test or the Mann–Whitney U test for continuous variables, and the Chi-square or Fisher’s exact test for categorical variables. A P < 0.05 was considered statistically significant.
Ethics
Informed consent for treatment and participation in open-access publication was obtained or waived for all participants. Ethical approval was granted by the Sheikh Zayd Foundation Ethics Committee (CEFCZ/TFE/7MD_23).
RESULTS
Descriptive study of the entire population (n = 344)
Sociodemographic characteristics
Statistical analysis revealed a male predominance, with 259 men (75.3%) and 85 women (24.7%). NSTEMI was the most frequent presentation (n = 197, 57.3%) compared to STEMI (n = 147, 42.7%).
The most common cardiovascular risk factors were hypertension (n = 168, 48.8%) and diabetes (n = 163, 47.4%), followed by smoking (n = 123, 35.8%) and dyslipidemia (n = 90, 26.2%). Menopause was present in 72 women (84.7%).
Medical histories included prior CAD (n = 87, 25.3%), ischemic stroke (n = 30, 8.7%), chronic kidney disease (n = 11, 3.2%), arrhythmias (n = 10, 2.9%), and endocrinopathies (n = 10, 2.9%).
Clinical presentation
Typical angina was reported in 303 patients (88.3%), atypical angina in 34 (9.9%), and epigastric pain in 28 (8.2%). Chest pain was absent in 8 patients (2.3%). Neurovegetative symptoms were present in 16.9%, and dyspnea in 21.8%. Bradypnea (7.6%), palpitations (3.8%), agitation (5.9%), syncope (3.2%), lower limb claudication (2.6%), and emotional stress (2.1%) were also reported [Figure 1].
- Clinical presentation of our patients at admission.
Time to admission
The median delay between symptom onset and hospital admission was 24 h (IQR: 5–48 h). It is primarily attributed to patient-related factors (such as symptom recognition or health-seeking behavior) and to accessibility issues within our healthcare setting.
Physical examination
Signs of heart failure were observed in 25 patients (7.3%), and a heart murmur was detected in 19 cases (5.5%). A normal physical examination was noted in 269 patients (78.4%).
Electrocardiographic findings
ECG abnormalities were present in 67.4% of patients. Ischemic changes included negative T waves (36.9%), Q waves (23.3%), persistent ST-segment elevation (19.2%), conduction disorders (19%), mirror images (16%), and left ventricular hypertrophy (13.4%).
The most affected territory was the anterior region (42.4%), followed by the septal (34.6%), inferior (34%), apical (33.1%), and lateral (31.4%) territories. Basal and right ventricular ischemia was less frequent (3.8% and 0.6%, respectively).
Biology
High-sensitivity troponin I was above 35 pg/mL in 260 cases (81.3%) and negative in 60 (18.8%). The median troponin level was 680 pg/mL (IQR: 94.3–5602), with values ranging from <94.3 pg/mL (25th percentile) to >5602 pg/mL (75th percentile), and a maximum of 98,000 pg/mL.
Echocardiographic data
Transthoracic echocardiography (TTE) was abnormal in 248 patients (73.8%) and normal in 88 (26.2%). Wall motion abnormalities were found in 72.1% of patients. The affected regions included anteroseptal (29.4%), anterior (21.1%), anterolateral (16.5%), inferoseptal (23.8%), inferolateral (20.4%), inferior (21.4%), apical (26%), and basal (1.8%) walls.
Coronary angiography
Coronary angiography was performed in 319 patients (94.4%), showing abnormalities in 67.5%. Atheromatous lesions were found in 94.4% of abnormal cases, and non-significant lesions in 41%. Single-vessel disease was observed in 51.6% of patients, two-vessel disease in 16.6%, and triple-vessel disease in 25.2%.
Coronary artery involvement
The most frequently involved artery was the left anterior descending (LAD, 60.8%), followed by the right coronary artery (35.8%), circumflex artery (21.8%), marginal artery (6.4%), and diagonal artery (3.5%). Involvement of the posterior ventricular artery (1.7%), ramus intermedius (0.9%), and left main coronary artery (0.6%) was rare.
Prognostic scores
GRACE score (NSTEMI patients): <100 in 14.6%, 100– 140 in 61.3%, >140 in 24.6%
ARC-HBR score: HBR in 24.1%; low risk in 75.9%
DAPT score: ≥2 in 47.1%; <2 in 52.9%.
Length of stay
The median hospital stay was 4 days (IQR: 3–5), with a maximum of 30 days.
Management
Pretreatment: A loading dose of antithrombotic therapy was given in 230 patients (69.5%), and therapeutic-dose heparin in 223 (67.4%). All patients received statins. Gastric protection with Proton Pump Inhibitors (PPIs) was prescribed in 73.4% of cases.
Antiplatelet therapy: Aspirin in 97.3%, clopidogrel in 84%, ticagrelor in 10.7%. No patient received prasugrel.
Door-to-balloon time
Median door-to-balloon time was 75 min (IQR: 58.8–180).
Revascularization
Revascularization was performed in 277 patients (81%). PCI was the most common (n = 242, 70.8%), and 10.8% underwent coronary artery bypass grafting (CABG). Medical management alone was chosen in 54 patients (15.7%). No patient received thrombolysis.
Other treatments
Beta-blockers were prescribed in 79.6%, angiotensin-converting enzyme (ACE) inhibitors/ Angiotensin II Receptor Blockers (ARBs) in 57%, diuretics in 24.2%, and calcium channel blockers in 15.8%. Trimetazidine was prescribed in 12.7%, tirofiban in 9.1%, anticoagulants (direct oral anticoagulants or vitamin K antagonists) in 4.8%, and nitrates in 3.6%.
Outcomes and complications
A favorable course was observed in 234 patients (70.5%). Complications included hemodynamic disturbances (17.7%), conduction disorders (11.1%), metabolic disorders (6.1%), arrhythmias (5%), iatrogenic complications (3.5%), and death (2.4%). No mechanical complications were reported.
Comparative study: Women versus men
Among the 344 patients included in the study, 259 were men (75.3%) and 85 were women (24.7%).
Sociodemographic characteristics
The mean age of women was significantly higher than that of men (68.3 ± 9.7 vs. 64.9 ± 10.9 years; P = 0.009). NSTEMI was more frequent in women (65.9% vs. 54.8%; P = 0.064), while STEMI was more common in men (45.2% vs. 34.1%; P = 0.064).
Cardiovascular risk factors
Hypertension (63.5% vs. 44.7%; P = 0.003), diabetes (61.2% vs. 42.5%; P = 0.004), and dyslipidemia (36.5% vs. 22.8%; P = 0.013) were significantly more prevalent among women. In contrast, smoking was significantly more common among men (45.6% vs. 7.1%; P < 0.001).
Medical history
There was no significant difference in the prevalence of previous CAD (P = 0.7), stroke (P = 0.11), chronic kidney disease (P = 0.8), arrhythmias (P = 0.3), or endocrinopathies (P = 0.2) between the sexes.
Clinical presentation
Dyspnea was significantly more common in women (34.1% vs. 18.2%; P = 0.003). Typical angina was slightly more frequent in men (90% vs. 83.5%; P = 0.07), though the difference was not statistically significant [Table 1].
| Risk Factor | Group | N | % | χ2 (df=1) | p-value |
|---|---|---|---|---|---|
| Diabetes | Women | 50 | 58.8 | 5.93 | 0.0149* |
| Men | 113 | 43.6 | |||
| Hypertension | Women | 51 | 60.0 | 5.63 | 0.0177* |
| Men | 117 | 45.2 | |||
| Smoking | Women | 8 | 9.4 | 34.11 | <0.001 |
| Men | 115 | 44.4 | |||
| Dyslipidemia | Women | 26 | 30.6 | 1.14 | 0.2847 |
| Men | 64 | 24.7 | |||
| Obesity | Women | 24 | 28.6 | 11.84 | 0.0006* |
| Men | 32 | 12.4 | |||
| Stress | Women | 7 | 9.3 | 21.77 | <0.001* |
| Men | 0 | 0.0 |
Chi-square or Fisher’s exact test was used depending on expected cell frequencies. *P<0.05 was considered statistically significant.
Physical examination
There was no significant sex-based difference in physical examination findings, including signs of heart failure (P = 0.7), heart murmurs (P = 0.2), or overall normal examination (P = 0.2).
Electrocardiography
No statistically significant differences were observed between men and women regarding ECG abnormalities, including T-wave inversion, ST elevation or depression, Q waves, conduction disorders, or affected ischemic territories.
Biological data
There were no significant differences in median troponin levels (P = 0.1), hemoglobin (P = 0.3), creatinine (P = 0.6), low-density lipoprotein cholesterol (P = 0.2), high-density lipoprotein cholesterol (P = 0.9), or NT-proBNP levels (P = 0.8).
Echocardiography
Abnormal TTE findings were more frequent in men (77.2% vs. 62.4%; P = 0.009), with a higher prevalence of regional wall motion abnormalities in men (76.1% vs. 60%; P = 0.005). However, the distribution of the affected myocardial territories did not differ significantly between sexes.
Coronary angiography
Angiographic findings were more often normal in women (42.4% vs. 29.3%; P = 0.02). Atheromatous disease was more prevalent in men (70.3% vs. 55.3%; P = 0.01). Single-vessel disease was more common in women (66.7% vs. 46.9%), while multi-vessel disease was more frequent in men (P = 0.01).
In terms of coronary artery involvement, LAD lesions were slightly more frequent in men (62.2% vs. 56.4%; P = 0.3), while lesions of the circumflex artery (29.4% vs. 19.3%; P = 0.07) and marginal branches (10.6% vs. 5.6%; P = 0.2) were more common in women, although these differences were not statistically significant [Table 2].
| Affected coronary arteries | Group | N | % | χ2(df=1) | p-value |
|---|---|---|---|---|---|
| Left anterior descending artery | Women | 51 | 60 | χ2=0.03 | 0.869 |
| Men | 158 | 61 | |||
| Bisector artery | Women | 2 | 2.4 | Fisher exact test | 0.152 |
| Men | 1 | 0.4 | |||
| Left main coronary artery | Women | 2 | 2.4 | Fisher exact test | 0.061* |
| Men | 0 | 0 | |||
| Marginal artery | Women | 0 | 0 | χ2=7.81 | 0.005* |
| Men | 22 | 8.5 | |||
| Diagonal branch | Women | 4 | 4.7 | χ2=0.45 | 0.500 |
| Men | 8 | 3.1 | |||
| Posterior interventricular artery | Women | 3 | 3.5 | χ2=1.94 | 0.163 |
| Men | 3 | 1.2 | |||
| Right coronary artery | Women | 31 | 36.5 | χ2=0.03 | 0.874 |
| Men | 92 | 35.5 | |||
| Circumflex artery | Women | 23 | 27.1 | χ2=1.83 | 0.176 |
| Men | 52 | 20.1 |
Comparisons were made using Chi-square or Fisher’s xact test depending on expected cell frequencies. *P<0.05 considered statistically significant.
Prognostic scores
GRACE score >140: Higher in women (30.6% vs. 22.9%; P = 0.1)
ARC-HBR score: HBR was significantly more common in women (37.6% vs. 19.3%; P = 0.001)
DAPT score ≥2: Less frequent in women (40% vs. 49.1%; P = 0.1).
Therapeutic management
Women were less likely to receive pretreatment with DAPT (58.8% vs. 72.6%; P = 0.02) and therapeutic-dose heparin (58.8% vs. 70.7%; P = 0.05). There was no significant difference in the prescription of aspirin (P = 0.3), clopidogrel (P = 0.2), ticagrelor (P = 0.3), beta-blockers (P = 0.3), statins (P = 0.6), or ACE inhibitors (P = 0.9). Diuretics and calcium channel blockers were slightly more frequently prescribed in women, though not significantly.
Door-to-Balloon time
Statistical analysis revealed a statistically significant difference in door-to-balloon time between men and women with P < 0.001. In female patients, the median delay was 180 min (IQR: 120–1020), compared with 60 min (IQR: 50–95) in male patients.
Revascularization
Revascularization was performed in 74.1% of women and 83.4% of men (P = 0.06). PCI was more frequently performed in men (74.5% vs. 61.2%), while CABG was more common among women (15.9% vs. 9.6%; P = 0.1). Medical management alone was more frequent in women (22.3% vs. 13.1%; P = 0.05). No patient underwent thrombolysis.
Outcomes
A favorable clinical course was observed in 70.6% of women and 70.3% of men (P = 0.9). In-hospital mortality was slightly higher among women (3.5% vs. 2%; P = 0.4). No significant sex-based differences were observed in the incidence of arrhythmias, conduction disorders, hemodynamic instability, or metabolic complications.
DISCUSSION
ACS shows a higher incidence in women compared to men beyond a certain age, partly due to the loss of hormonal protection. This pattern was observed in our study as well as in others: El-Menyar et al. reported a mean age of 61 ± 22 years for women,[16] Plaza-Martín et al. found 71 ± 12.8 years,[17] and Ten Haaf et al. reported 68.5 years,[18] all higher than the mean ages found in men.
Our study found a higher incidence of NSTEMI compared to STEMI in women (71.8% vs. 28.2%), a finding consistent with El-Menyar et al.,[16] who reported 88% NSTEMI and 22% STEMI, and Araújo et al.[19] with 55.5% NSTEMI and 44.5% STEMI. Conversely, Mboup et al.[20] and Radovanovic et al.[21] found a predominance of STEMI in both men and women.
Diabetes emerged as a major risk factor for ACS in our population, significantly more prevalent in women (58.8%) than in men (43.6%), aligning with findings from El-Menyar et al.,[16] Mboup et al.,[20] Shehab et al.,[22] and Araújo et al.[19] Hypertension was also more frequent in women (over 60%) compared to men (45.2%), consistent with data from Plaza-Martín,[17] El-Menyar et al.,[16] Shehab et al.,[22] Araújo et al.[19]
Worldwide, smoking is less common among women than men, as observed in our study (9.4% of women vs. 44.4% of men), the Middle East study (0% women vs. 41.4% men), and the Dakar study (6.1% women vs. 69.8% men).[20] Although female smoking rates are higher in Western countries, men still smoke more, as shown in the Spanish study[19] with 18.9% female versus 38.1% male smokers. Our data also indicated that women with ACS are more prone to obesity, in agreement with Mboup et al.[20]
Comorbidities are more frequently observed in women compared to men. Our findings, as well as those of the Spanish[19] and Middle Eastern[22] studies, highlight a higher prevalence of ischemic stroke history in women with ACS. Contrarily, Ferry et al.[23] reported a slightly higher stroke rate in men (6.8%) compared to women (5.2%).
Symptom presentation in women with MI differs markedly from men. Women in our series experienced less typical angina, consistent with Shehab et al.[22] and Araújo et al.[19] Furthermore, our study and those by Shehab et al.,[22] Araújo et al.,[19] and Mboup et al.[20] showed that women have more atypical symptoms such as dyspnea and palpitations. According to our data and that of Chetoui and Benamar,[24] women present more neurovegetative symptoms.
Our study revealed a higher prevalence of negative T-wave repolarization abnormalities in women than men, consistent with Radovanovic et al.[21] (27.6% vs. 26.4%) and Ferry et al.[23] (15.9% vs. 15.3%).
Women tend to suffer less from atheromatous lesions and intrastent thrombosis but are more frequently affected by myocardial infarction with non-obstructive coronary arteries (MINOCA), as confirmed by our data and Araújo et al.[19] Conversely, Bentabet[25] reported more atheroma in women with fewer intrastent thromboses, spasms, and myocardial infarction with non-obstructive coronary arteries (MINOCA), without significant differences. Coronary lesions in women are generally tighter, longer, and more calcified.
In our cohort, although single-vessel disease was most common in both sexes, women showed a tendency toward more tritroncular involvement (31.3% vs. 29.2% in men), aligning with Bentabet’s findings[25] (21.1% women vs. 19.2% men). The arteries most affected in women were the LAD (60%), right coronary (36.5%), and circumflex arteries (27.1%). The circumflex and right coronary arteries were more frequently involved in women, corroborating results from Bentabet[25] and Araújo et al.[19]
Our study demonstrated a higher hemorrhagic risk in women, consistent with findings by Grodecki et al.[26] Despite women presenting with more severe clinical profiles, they receive less aggressive treatment than men, except for clopidogrel, calcium channel blockers, and nitrates. Women were prescribed fewer ACE inhibitors, aspirin, statins, anticoagulants, and beta-blockers, though differences were not statistically significant. Similar trends were observed by Radovanovic et al.[21] and El-Menyar et al.,[16] who reported lower treatment rates in women except for aspirin.
A significant difference in door-to-balloon time was observed, with women experiencing longer delays, in agreement with Stehli et al.[27] (88.4 min in women vs. 81.1 min in men). Revascularization by angioplasty was less frequent in women, with a higher reliance on medical therapy alone. Our findings concur with those of Plaza-Martín et al.,[17] Worrall-Carter et al.,[28] Radovanovic et al.,[21] and Bentabet.[25]
Several factors may contribute to these results. Atypical symptom presentation, such as fatigue, nausea, or abdominal pain, can lead to delayed recognition and diagnosis, contributing to slower management. Sociocultural factors and the perception of lower cardiovascular risk in women by healthcare providers may further delay care and reduce the likelihood of timely invasive interventions.
Hospital complications, including hemodynamic instability and conduction disorders, were more common in women, consistent with Mboup et al.[20] and El-Menyar et al.[16] However, women had lower rates of arrhythmias and inhospital mortality. Our study’s main strengths lie in addressing a highly relevant topic and including a large patient cohort, allowing for robust findings. The methodology was rigorous, ensuring the validity of results.
Limitations include the monocentric design in a tertiary center with catheterization facilities and an always operational team, which may limit the generalizability nationwide. The absence of long-term follow-up restricts insights to in-hospital outcomes only. Furthermore, incomplete medical records may have impacted statistical robustness. These factors highlight the need for larger, multicenter prospective studies.
CONCLUSION
Considering these results, improving outcomes for women with ACS requires greater clinical awareness of atypical presentations. Any woman presenting acute chest pain – or even atypical symptoms such as nausea, back, or abdominal pain – should promptly undergo ECG and clinical evaluation. Healthcare professionals should be specifically trained to recognize and act quickly on these non-classical symptoms to reduce treatment delays. In addition, public health programs should aim to raise awareness among women about the importance of seeking early medical attention at symptom onset. In addition, cardiac rehabilitation – currently underused in Morocco – should be systematically integrated into post-ACS care for all women.
Ethical approval:
The research/study was approved by the Institutional Review Board at Sheikh Zayd Foundation Ethics Committee, number CEFZ/TFE/7MD_23, dated November 20, 2023.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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