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Dr. Sunita Dodani AAssistant professor, Family Medicine
The Aga Khan UniversityKarachi, Pakistan
Dr. David MacLean Professor, Simon Fraser University,
Vancouver, Canada &
Dr. Michel Joffres Associate Professor, Dalhousie
University, Halifax, Canada
Risk factors for coronary Artery diseases in Pakistanis: A cross–sectional Study
Presentation Outline• Burden of CVD• CVD Mortality: Developed Vs Developing Countries• Eastern Mediterranean Region• Pakistan: a Developing Country• CVD in Pakistan: National Health Survey• Study Rationale
Presentation Outline Contd.
• Study Objectives• Study Design and Methods• Results• Limitations• Conclusion and Recommendations
Burden of CVD
Cardiovascular diseases (CVD), defined as Coronary Artery diseases (CAD) and Cerebrovascular diseases account for over 16 million deaths, or about 30% of total global deaths
C V D M o rta lity 1 9 8 5 - 1 9 9 7
5 14 8 4 6
1 6 1 7
2 4
0
1 0
2 0
3 0
4 0
5 0
6 0
1 9 8 5 1 9 9 0 1 9 9 7
Y e a rs
Perc
en
tag
es
D e ve lo p e d
D e ve lo p in g
CVD Mortality 1985-1997
(WHO Reports)
Total Mortality in 2000
30
70
1
2
30% CVD
70% Other
CVD Mortality According to Regions
(%)
Eastern Mediterranean Region (EMR)(Saudi Arabia, Iran, Iraq, Bahrain, Jordan, Pakistan)• Epidemiological transition
• Mortality and morbidity data on CVD risk factors are inadequate
• Age-specific mortality rate is declining• Increasing prevalence of the risk factors for CVD • Diets have high fat content, increasing diabetes with
increase in obesity• Smoking, widespread, especially among younger people • Physical activity is insufficient• Clustering of risk factors
What About Situation in Pakistan?
Pakistan: A Developing Country• Multiethnic and linguistic diversity
• 4 provinces & 2 territories• Population ~ 130 million• Growth Rate: 2.6%• Per capita income: $390
– <3% Gov Health Budget– Most of the money spent on
tertiary care hospital curative services
• Very limited health insurance
CVD in PakistanNational Health Survey of Pakistan 1990-1994 (NHSP)
Limited, population and hospital -based studies on CVD in Pakistan and many have significant limitations
• In 1990, first countrywide survey was done using random cluster sampling method
CVD in Pakistan NHSP 1990-1994 Contd.
• 4-year community based survey• Adult mortality of Ischaemic Heart Disease (IHD)
was reported as 12% • Risk factor prevalence assessed
Survey limitations:•Generalization. Covering 2.6% population•Methodological errors•All risk factors not defined by globally acceptable criteria
Study Rationale• Available data is of inadequate quality, limiting the
assessment of true magnitude of the problem Inability to debate and appropriately assess the
priorities in CAD prevention and health promotion on the basis of NHSP data in high socio economic class
Risk factors of CVD - prime target for surveillance, especially people in higher socio-economic class, considered as “early adopters” and ‘high risk’
Study Objectives:
• To estimate the prevalence of CAD and its risk factors and risk behaviors in patients attending preventive check-up clinics of a teaching hospital in Karachi, Pakistan.
• To assess the association of risk factors with CAD
Study Methodology and Sample Design
Routine general physical check-up clinics at the Aga Khan University Hospital (AKUH)- a teaching hospital in Karachi, Pakistan. Run by trained family physicians, 5 days a week
Design:Set up:
Cross sectional descriptive study
Study Methodology and Sample Design
(Contd.)• Mainly from the educated higher socioeconomic class
• General preventive check-up package: history and physical examination; laboratory investigations [complete blood count, total blood lipid profile, fasting glucose levels, electrolytes, urine detailed report]; chest X-ray and exercise tolerance test (ETT)
• Usually 3-5 patients are booked in one clinic • Total appointment time: 40-50 minutes
Study sample:
• Obesity (BMI)
• Hypertension
• Diabetes mellitus
• Total cholesterol
High density lipoprotein (HDL)
Low density lipoprotein (LDL)
• Triglycerides (TGs)
Study Methodology and Sample Design
(Contd.)Risk Factors in the Study
•Positive family history of
coronary heart disease•Smoking•Sedentary lifestyle
Study Methodology and Sample Design (Contd.)
• Assumed prevalence of 50% given largest sample size possible• Margin of error ± 4%• Stratified on age and gender…dichotomized into < 35 years, and > 35 years• Total patients interviewed: 600
Sample size estimation:
Study Methodology and Sample Design
(Contd.)1. Demographic variables…
Mean & SD for continuous variables Frequencies and percentages for categorical variable
2. Risk factor distribution…. frequencies and percentages3. Multi-variate analysis…
Univariate variate (P< 0.05) Logistic regression model (Odds ratio with 95% CI)
Dependent variable: heart diseases
Analysis:
Study Results
Socio-demographic variables in the study group
Variable n=600 %Age Group18-3435-6465+
46.1†73
51314
10.2‡12.285.5 2.3
GenderMaleFemale
471129
78.521.5
Employment StatusFull Time (> 35hrs/wk)UnemployedRetired / StudentHousehold personRefused
4105
60115
3
68.30.810
19.20.5
Variablen=600 %Work Type
Professional ClericalSkilled ForemanManager/official/proprietierSales workerNon skilledRefusedMissing
491626
316721
183
11.2
3.86.2
75.81.70.50.2
LanguageUrduSindhiPunjabiPushtoBaluchiOthers
286
81124
392941
47.713.520.7
6.54.86.8
Education<MatriculationMatriculateIntermediateGraduatePost-graduate
12 51 104 389 44
2.08.5
17.364.8
7.3† mean ‡ S.D.
Coronary Artery disease (CAD) Risk Factors
ETTPositiveNegative
485115
80.819.2
Menopause (n=129)YesNoAge at Menopause
6564
46.6 †
50.449.67.6 ‡
BMI Categories* (WHO)Underweight (<18.5)Normal (18.5-24.9)Pre-obese (25-29.9)Obese (30-39.9)Obesity (> 40)
5172290123
9
0.828.748.420.6
1.5DiabetesYesNoIGT
98473
29
16..378.8
4.8
Variable n=600 %
HypertensionYesNo
121 479
79.8 20.2
Coronary Artery disease (CAD) Risk Factors contd.Total Cholesterol**Desirable (<200)Borderline high (200-239)High (> 240)
194.2†402118
80
37.2‡67.019.713..3
HDL CholesterolLow (<40)41-59High (> 60)
39.8†300292
8
7.9‡50.048.7
1.3
LDL CholesterolOptimal (<100)Near/above optimal (100-129)Borderline High (130-159)High (160-189)Very High (> 190)
124.5†113228177
7111
32.2‡18.838.029.511.8
1.8
TriglyceridesNormal (<200)Borderline High (200-399)High (400-1000)Very High (>1000)
177.4/447131
139
200.4†74.521.8
2.21.5
Family History of IHDYesNoDon’t Know
287293
20
47.848.8
3.3
Current smoking statusNever smokedFormer smokerRegular cigarette smokerOccasional cigarette smokerPipe or cigar smokerNot stated/Refused
38854
13020
71
64.79.0
21.73.31.20.2
Regular exerciseYesNo
169431
28.271.8
** according to NCEP ATP III guidelines
Table: Univariate analysis (n=600)
Variable Coronary Artery DiseasesOR (95% CI){ P value
Negative PositiveAge n % n %
<40 years 155(32.0%) 11 (9.6%) 40 years 330 (68.0%) 104 (24.0%) 4.4 (2.32, 8.5) <0.001
Gender
Female 107 (22.1%) 22 (19.1%)
Male 378 (77.9%) 93 (80.9%) 0.8 (0.5, 1.39) 0.492Menopause
No 59 (55.1%) 5 (22.7%)
Yes 48 (44.9%) 17 (77.3%) 4.2(1.44, 12.15) 0.009BMI Categories
<25 151 (31.2%) 27 (23.5%)
25-29.9 223 (46.1%) 66 (57.4%) 1.7 (1.01, 2.71) 0.04530 110 (22.7%) 22 (19.1%) 1.1 (0.61, 2.07) 0.721Diabetes
No 416 (85.8%) 86 (17.1%)
Yes 69 (14.2%) 29 (25.2%) 2.03(1.24, 3.33) 0.005
Table: Univariate analysis (n=600) Contd.
Hypertension
No 392 (80.8%) 87 (75.7%) Yes 93 (19.2%) 28 (24.3%) 1.4(0.84, 2.197) 0.215Cholesterol 200
<200 mg/dl 345 (71.1%) 70 (60.9%) 200 mg/dl 140 (28.9%) 45 (39.1%) 1.6 (1.04, 2.42) 0.033Family History
No 249 (53.1%) 44 (39.6%)
Yes 220 (46.9%) 67 (60.4%) 1.7 (1.13, 2.63) 0.011Regular Exercise
Yes 132 (27.2%) 37 (32.2%)
No 353 (72.8%) 78 (67.8%) 0.8 (0.51, 1.22) 0.289Regular Smoking
No 378 (78.8%) 84 (75.0%)
Yes 102 (21.3%) 28 (21.5%) 1.2(0.76, 1.997) 0.389
VariableCoronary Artery Diseases
OR (95% CI){ P valueNegative Positive
Table: Multiple Logistic Regression (n=600)
VariableETT
OR (95% CI)
P valueNegative PositiveAge n % n %
<40 years 155 (32.0%) 11 (9.6%)
40 years 330 (68.0%) 104 (24.0%) 3.9 (2.01, 7.52) <0.001
Diabetes
No 416 (85.8%) 86 (17.1%)
Yes 69 (14.2%) 29 (25.2%) 1.7 (1.01, 2.9) 0.047
Family History
No 249 (53.1%) 44 (39.6%)
Yes 220 (46.9%) 67 (60.4%) 1.8(1.15, 2.74) 0.010
Cholesterol 200
<200 mg/dl 345 (71.1%) 70 (60.9%)
200 mg/dl 140 (28.9%) 45 (39.1%) 1.5 (0.94, 2.27) 0.096
Limitations:
• Generalization of results
• Hospital data • Upper socio-economic class
Conclusion and Recommendations• Study adds significant knowledge of increased prevalence of CVD risk factors and behaviors
in a high-risk group of a developing country• This group need to be targeted for risk factor modification… public health and clinical
approaches• Need for lifestyle interventions, screening and management of risk factors• Limited resources available… there is a need of population-based studies with the help of
NGOs• Further research needed to look into the causes of high CVD in Pakistanis e.g. insulin
resistance.
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