Ar icles

Coronary aftery disease in Saudi Arabia

Mansour M. Al-Nozhq, FRCPtttttkl). rtt(t . Mohammed R. AraJah,lvlD. FACP.yoqoub Y- Al-Mozrou, MBBS. PhD,

Mohammed A. Al-Maelouq, t ). t R( P. Nazeer B. Khan, Bs, . I'ht). Mohamed Z. Nhalil, ML. LtR( Ptuli).tlkrom H. Al-lihadro. ut) t-R(p Xhalid Al-Moaouki, *ro. rN ttsxtz. Moheeb A.AMallah t"tD. t.RC!

Saad S. Al-Harlhi, ttD t-.ru t,rR t-t. Maie S. Al-Shahid, n,D. t RCp. Mohommcd S. Nouh, Lts, . ntL.Abdulellah Al-Mobeireek, Ltt). t RCp

ABSTRACT

Objcctivos: Cororrry anery disease (CAD) is a nrujorputrlic hcllth problern worldwide. To our knowlcdge.there is no national dal availablc from conrmunity bascdstudies on prevalence of CAD in the Kingdom of SaudiArabia (KSA)- Thercfbrc. we designed this study wilh thcobjectivc to determinc the prevalencc of CAD amongSaudis of both sexes. bctwccn the ilgcs of 30 7o-years inrural as wcll as urbarr communitics. Further. to deierrninelhe prevalence aud clinical pattern o[ $e majormodifiable risk factors for CAD lnrortg the satnepopulation. This work is pan of a nrajor national study onCAD in Saudis Study (CADISS).

Methods: This is a communily blscd study conductedby examining subjects in the age group of 30-70-ycars ofselcctcd households during S-year period betw€en lq)-5and 2fi)0 in KSA. Data were obtained fmrD history usinta validated questionnuire, and elect(,cardiography. Thedrla werc analyzed to provide prevalence of CAD andrisk assessment model.

Results: Nine hundred and fbny-lirur subjects. out ol-17232 were dia-gnosed to havc CAD- Thus. the overall

prevalence of CAD obtained from lhis study is 5.5'I, inKSA. Thc prevalcncc in males ald lcrnalcs were 6.6*,and 1.47" (P<o.Uml). Urban Saudis have a higherprevalence of 6.27, compared to rural Saudis o[ 4%(P<).0(nl). The following variables are found to bestatistically signilicant risk lactoni in KSA: agc. malcgender, k)dy mass index (BMI). hypertensior. currenlsmoking. fasling bl<xx.l glucose. fasling cholesterol andtriglycerides.

Conclusions: The ovcrall prevalcncc of CAD in KSAis 5.57. A nationnl prcvcnlion program at eommunitylevel as wcll as high risk groups should be implerncntedsooner lo prevenl the expected epidcmic of CAD that wcare st'cing. beginning. Measures urc nccded to changelifestyle and to address the managenrcnt of the metatnlicsyndrome. to reduce rntxlifiable risk lactoni for CAD. Alongitudinal study is needed lo demonstr.lte lheinportance of reducing modifiable risk lactors lbr CADin KSA

Saudi Mcd .J 2fi)4; Vol. 25 (9): I165-l l7l

l^ oronarv artery discasc (CADt is a mujor puhlic\- health problem in industrializerl nalions.r ln theUnited States of America (USA). lbr example. CADis the, leadine cause ol- dcath in adults. accountingtbl approxirnately onc-third of all deaths in subjectsovcr ll'rc lge of -|5-yL'ilrs.r Henct'. cnrphasis on its

primary as well as seconda-y prr'vention was givengreal altention by health authorities in westemcounlries. While age adjusted moflalily from CADis gradually talling in developed countries, it is selto become an epidenric in developing countries. andover the next 2o-years will probably become tlre

Khnlid

). KiDS

Rccci! dd I lsr Fthruray 2UH. Acurpted tff pohliu.tion in final fonn 7th Apnl 2tXX

A&lrcss e(rr':sFxxtIfc nml R'I,rir requcsl lo: l,fof Man$u. ltl. Al-Nozha. Prridcnr- Taiba t,ni!.'Fiir\. PO Box .Ha. Mdina Al-tvlunr\ rh.Xnrrlh"n if:il i -ln hit) Td +966 {+) tH6fi)lt, Far.+ 6(J)8J6ll?2. E-mail: mahxrdra@ txrrnrailroirr

I t65

(.AI) in Suudi Arabia -.. A/,M,--,/rrr r,r rrl

rrr()sl irtDonitl)l rlohlrl lreltllll prohlcltl. As tttttlcrlevckrDinr cottniries ittkrpt rirttillrl lileslyles lo lhc

wcst ihaa rcsult itt incrcasins trvcrrvcighl ittttlotresity. tohacc(r ttsc. alt'ttg with tlrc lltPid incteltscir tlirrlrt.'s lhal is rrecrtnirlg in agirtg ptrpulltion. it

rvoultl be e.rlxcte-tl lhat their CAD pattcnls plrallelthirl ol'thc industrializcd nalioDS. ln tlrc' Kingdom ofSlutli Arahia {KSA). the infortnation on CAD

Ito lts .' -c. [o ourkn rlo a the Precisetni )l t o I KSA. Asthi be ts economy.chanecs in lilcstvle eonducivc to cnhancedather'osr.'lcr0sis rrrc ittevilahle- Therclirre. a proiectwas desigued to study the problem oI CAD and itsrelated iisk lilctors in a cottl;lrchcnsive attd

!'Dconrpnssin8 lashi()n at the nfltiorlal lcvcl- It was

divideti into -l difl'erent sub-prtrjects: conlmulitybascd study, hospitfll biNed study. n(l rlctabolie-basis of CAD. 'Ilic oh.iectives ol cornmLtnity based

study were: to dctc'rnline the prcvalenee of CADol-hoth sexes. belwctr) the ages ofrttral its 'l'ell ls utttln comntuttities.

lcrnlinc tlre prevalence and clinical

age grouP: and shows the mean ilnd Pcrcent:lqcvilues of known risli factoni ltnlong patierls withCAD and thosc withoul CAD. Furthennore' a riskJssessment mrxlel is developed wilh statisticallysienif-rcant risk titctors.

llethods. The Kingdom oi Saudi Arabiaencompasses approxirnately tbur-fifihs of theArabian Peninsula has irrhabilants ol' 2O.tt-fiX).000people with PopulatiolliSardis)." A emiologicalHoalth Survey conductedbetween 1995 male Saudiatlults aged (30-7O-ycars), in rural and urban areas

ol' KSA fonned the target population for this study-F o is identified as

a g a holder) of a

S ty (SNIC). Mostprevious stutlics on CAD from other part of theworld t'ocused on similar poptrlation that allows forinler countries cotnparison. A sample size of 20.fi)oparticipants was lhc larget of the study to ensure a

l165 sru.l, N.rt tlrfu.\.r,t lirur $s\!\r,urtrr\:r

ccnlels'crtchlrrc'nts ilreas. The catchllleDtsrx)Dulatroll ol eaell Dritnary citre cclltcr wils lirkell itr'

l ' clLrster. The kSA -is

subdivided into lladnrinistrat n)s s wL're

fionr each Th sanrPliwcrc 1.623 he PHC) u

dislributed S blishmehealth ccntcrs rvas tl.tc

n in each tegion. the thc'

nunbcr of PHCS s'ere nal

numher oI PHCS in I er'eirch region was strutil-ied into urban and rumlconrmun-ities and sinrplc random sample of PHCSwas selected. The nuniber of PHCS to hc selected

lrorn each contnrunily was based on the totalluurber of PHCS in eitch rural and urbanco[rnrunitv. A total of 66 PHCS were selected [iomurban antl-58 lionr rural areas. Then bkx-k (blo!'ks)was ftrndomlv sclected tiom the catchmenls areas ofcach selectetl primlty care center and usetl tscluster. One hundretl houscholds fiorr urhln PHCSanrl 50 households ltrrnr rural PHCS wcre selectedlll)nr these bk,--ks. All subjects {mtles antl t'cmales)of age group of -10-7O'ycars of selected houselroldswcri in'ierviewed rnd examined. The study protu--olconsisted of interviews. clinical examinations.laborfltory tests. Eleclroclrdiograms (ECGS)- and

measurements. The qtrestionnaire usetl. ittcluded

of possible myocardial infirrction (MI).'' A person-

wd tlefined as having anginal chest pain ofischcnria if thc clrest pain was typical irt charitcter.(,1-curred on effbrt (exertional) and relieved by rest

l2 lcads electrtrardiographic tracing was carried()ut ti)r every participant. Trained prinrary carephysicialls. using rnercr'ry sphysmolnitnon)eters toihc nearest 2 mtn. tneasured blo<xl pressure ol'thesubjects. Participauls were seated. nd lhe right ann

CAD in Srrudi Aritlth . Al-No:lur tt Lt'

was placc(l ()n lhe tabletoP: lhL'aPProPriate ctrfl sizelv s used. Firt svstolie bltxrd plcssrrte. thc tirstKorotkoil sound IKl ) was used tlelrttcd as

ppeirrartce ol 2c olicbl(xxl pressrre. the wasused dafined s Ihc e ofthc sould. Two blo,otl pressutc lneasurements weretake'n with -10 seconds rest in between. The 2readings werc averagctl. Weight was nteasuted withordinary scalcs willr indtxrr clothing on withoutslrtrs on to the nearesl 0.1 kg. Height, waist andhip meilsurenrents werc carried out to the nearestmm hy using rneasuring titpe. Trained technicians.under the supcrvision of primary care physicians,eollected a 20 cc ol- lasting bkxxl ( l2 hour lasting),in I tubcs ol' lO cc erch. Tubes were immediatelykept irr reliigelatrtt- lirr at least J0 tttinul.cs and ttomorc than -l hours belirre cenlrifugation.Centrifugalion was carried oul lin 30 minutes at3(XX) RPM in refrigerated ccntrituger at .l'[.Plasrna and scrum werc separated and were frozent -2(y'C irnnrediatcly. Thesc' sanrplcs were

tr.r)sf)rted lirrz-en in icc to the crxrrdinatiuglatxrratory in the region where they were kePt frozenat -20([. Al lhe end ol- the sample collection liomll p rticipunts in the region, it was trarlst'erred

lroz-en in ice in incubators to the central laboratoryilt the Collese of Science. King Saud University,Riyadh. All bio'-hemical parameters were analyzedon a clinictl an lysis (Konelab, IntelligentDiagnostics system. Helsinki. Finland). Theinstrument was calibraled prior lo analysis usingquality control samplcs provided with the solutions.Slandard Int.-mational Units (nrnrol/L) was used torecord the results, The intta and inter assaycoefficienls ol' varialion wcre 0.-\clo and 0.'1%.Electrncardiograms tracings were carried out at theprimary care ccnters by primary care physicians ortrained technicians and werc interpreted by 2indep€ndent cardiologists fiom the investigator teamaccording to thc Minnesota Code."' The diagnosis ofprevious Ml was based on WHO MONICA Project(monitoring trends and determinants incardiovascular disease)." In ca-se of difference inreadings between them, a third cardiologist opinionrvas sought. The number of patients who werediagnosed to have CAD was established in findingol- one or morc ol' the following criteria: eitherphysician's clinical assessrnent of the chest pain asanginal. previous Ml. or lindings of evidence ofprevious MI by ECG.

Thc dala were analyzed using the Stirtis(icalPackage for S<rial Sciences (Version I0.0) on PC.Bolh univariale and multivariate analysis werecarried out. The lrequency distribulion tables of thevariables measured in various age groups. gender,rural, and urban areas are presented. The estimateof CAD prevalence rate is calculated for the totalsanrple. and sub-groups of gender, arca of residence

irnd age groups. A risk assessment model rs

dcveloped usirrg logistic tegressiott.

Besults. Nine hundred and lbrty-tbur subjects(9.14). out ol 172f2 wcre diagnosed to have CAD.

subjects O.4c/('

gave his Maleiubjects es ofMI than lenceof MI diagnosed by ECG was l.l7o. Male subjectshad signilicantly higher MI than lemale subjects (/,d.0ml). A total of 5.57.. of the subjects werediagnoscd lo have CAD. The prevalence of CAD innrales and females were 6.6'h and 4.401,. and it was

Qx0.(X)0 | ). The age adjustedaccording to Saudi PoPulationwas 5-97o and 4.1o/o. for males

and females and 5.17o as agslEgate. Table 2

discusses the prevalence ol' CAD by residence(urban/rural) and age groups- The prevalence was6.20/" in urba,n areas. and 4'h in nsral areas. Thisdiffereuce was stalistically significant (Pd.ffXnl ).The prevalence was in increasing order fromyoungest to eldest groups when considering the agesof the subjects. These percentages are statisticallydifferent from each other (P<).O(m I ). The overallpercent prevalence of different risk tacloni for CADin KSA is shown in Table f . These risk lactors willbe discussed in detail in subsequent publications.Table 4 shows the descriptive statistics andsignificance differences of demographic variablesand risk factors for the patients with CAD andwithout CAD. The prevalence of CAD increaseswith ageing (p<O.fi)O l ). Male gender showed morerisk to have CAD than female (p< O.fi)Ool). Thebody mass index (BMI) of patient with CAD hadhigher values than patients without CAD (p{.013).Patients with CAD showed wider waislcircumference than palients without CAD (P<0.ffN)l ). Waisrheight ratio was statistically greaterin patients with CAD (p{.ffi6). Systolic anddiastolic bltxrd pressures (BP) were signilicantlyhigher in patients wilh CAD than without those ofCAD (p <0.mol ). The percentage of smokers andex-smokers (quit smoking at least one year) weresignificantly higher in subjects with CAD categorythan the subjects without CAD (p{.0O I ). Meantasting blood sugar and serum TG level weresignificantly higher in subjects with CAD thanwithout CAD (pd.m0l). Mean TC level was alsosignificantly higher in subjects with CAD(/r.4.034). Mean high density

wlrrv smj orE-sr Saudi Nled J lxH: Vol :5 (,r) I167

CAD srouos (a=O.853).A -risk 'asiessment model was developed by

loading CADstatistically signvariables, namcircumference,diastolic BP, ex-smokers, current smokers' fastingblmd sugar, fasting TG, fasting serum cholesteroland HDL-C, in bivariate logistic regression analysis.Tabh 5 shows the final model developed by logisticrcsrcssion usine'likelihood forward method'.Se'ven factors, nimely age (OR: 1.02' p4 000I )'sendcr (OR: 0.770, p<0.ffi01), BMIp{.014). systolic BP (OR: 1.009'currcnt smokes (OR:0. 797, r4.01 7)'sugar (OR: 1.020, f4.027) and fasting TG {OR:1.082, p{.001), had combined significantrelationship with CAD.

Dircussion. Community based epidemiologicaldata provide a real assessment of CAD as it is less

encumbered by selection bias observed in clinical

underestimation due to silent ischemia, which is

however, higher than Chinese (2%) and Europeans(57o).'6r' Nonetheless, it is expected to observe a

dramatic increase in the prevalence of CAD in KSAover the coming 2 decades due to increasingprevalence of risk factors. increasing agingpopulation as better heath care is provided andchange to western lifestyle.

Our data demonstrate an increa-sing prevalence ofCAD with age ranging frcm 1.9%, at ages 30-39years to 4.6% at 40-49-yea$, 63% at 50-59-years,and 9.3ok at 60-70-years (pd.finl). These resultsare concurring with the reporled increasingprevalence of CAD with age in the USA as

estimates for men are from 77o at ages zlo-49-yearsao l3%, at 50-59-years, 16% at 60-69-years, and22%t at 70-79-years. The corresponding estimatesfor women are substantially lower than for men: 5.8, I I , and 149<,.?! Among Indians, an ethnicpopulation with high existing rate of CAD, the

CAD in Saudi Arirbiit ... Al-No.hu er ol

Tablc I - Prelalcnce ofangina. Ml and lolrl CAt)

Mebtr (%)

]'cmrk p vrhtc Tolzli t%t a l%l

anBrnir

prtvtuus Ml

ECGPniYalcnc€ ofprcvious Ml

Tdd CAD

l-{o

11

.lo I

12

(-19)

l0 5)

I:1 (11)

542 (66)

(5.9)

74 (0.t) <)Imr

41 1.1.4) drml

(4 4)

(4.ri) o.7({) &r (4.9)

(o.3) on21 69 (0,{)

(t.l)

(55)

t5.l)Age udjustedCAD

j CAD wns adjusted on year l4:OH (2(mG) soudi poPularionMl - mvErnlirl inlaj1clion. CAD ' coronrry arlcry di$c$t'

ECG -.le('tnx rd'oEflm

TalrL 2 . F,rcvalcrKt otCAD hy arLa of r.-sid('ft'e .rnd nge gmup

_lSanrplc CAI)

prevalenccAEr li.mplc

EIOUP

CADprcvalence

Urbilrl

Rur.rl

I17|)1

5s25

122 (6.1t

222 t4l

3{) 19

.t0Jr)

5tt77 111

.{tsli 222

p valu€ <oIIDl

50,_59 3.179 120

6{!70 29t8 170

p valE <)-ml

CAD - .\lrurrry adcry dise:Ls.

t.blG 3 . Prcvalence of risk lacroni tor CAD in KsA.

Rist I!d0r

Di$eres rnellilus (FBC > 7 0 mnxrln)

HyFEnension ( BP > I 4{Ir'so)

Cuftcfl snx*in€r

HyFNlFtcsrcrelemi. (TC > 5-2 mtuln)

HyFrtri8lyceridemia (TriB > I -7 mox)m)

O+,csity (BMl >3o)

l13;t*

26cb

t23%

5:r-9%

f9.9E,

15.696

FBC fasling bkxxl giucd".:. BP ' bkxn P.elsuteTC ' fasrin8 lotal chol€slerul

Tria - tasrinS tntlyceridF.. BMI ' h(dy mals indrx

ll6t saudiMcd J 2fixi vol ls(t)) www slnj.org.sl

CAD in Saudi Arabia ... Al-No:ha et ul

prevalence of CAD has bcen affccted by migrationio westem countries. and the rcported figures on

showed that BMI is found to be significantly higheramong patients with CAD compared to subjectswithout CAD (BMI=29.1 versus 28.5 kg/m2)(P=O.O1). Itpromoies orfactors predisevents-17r3 Thwith established coronary atherosclerosis, BMI is

associated with acute coronlryd the risk is increased even at mildlylevels.'" We found the features of the

metabolic syndrome correlates well with the clinicaland biochemical features of Saudi patients withCAD in this study. lt is o[ Paramount imporlance torecognize the metabolic syndrome with its classicalclinical leatures as part of risk assessment forCAD."' The term metabolic syndrome refers to avirulent and lethal group of atherosclerotic riskfactors, including dyslipidemia, insulin resistance.obesity, and hypertension. Dyslipidemia in themetabolic syndrome is characteriz€d byhvnertrislvccridemia. low HDL cholesterol, in the.6i',t"*t " 6t normal or slightly elevated LDLcholesterol. Guidelines from Adult Treatment Panel

<1.3 mmol/L in women, BP >l3O/85 mm Hg,fasting glucose > 6.1 mmol/L.r' This syndromeaffecti some 47,OOO,(H peoPle in the USA, placingthem at increased risk for CAD, and has anestimated age adjusted US prevalence of 23.7?o.12taOur data clearly demonstrate a statisticallysignificant correlation of CAD withhypertriglyceridemia, elevated total serumcholesterol, and lower HDl-cholesterol.Furthermore. other classical risk factorc such ashypertension and cigaretle smoking are shown inthis study to be significantly associated with CADamong Saudi patients- Prcvious studies have shownthat elevated serum TC concentration as well as

elevated LDl-cholesterol, Iow HDL cholesterol,increased totat to HDL cholesterol ratio.

Table 4 - Clinical alrd biochcnic l chrrat'lenstic ol with anrwilkrul corcnary ndery disease suble_ts

Table 5 - L(ai{ic rcgrcssion of dclerminanl ol coronrry .rnerydtvase

Variablc:i P valur Odd rario

AgeGcndcrBMISBPCurrenl smoleniFBSF:astrngtriglycerides

0.020{.261oJI5o.fl)9{t.22'1o.0200.079

o (x)l <).(ml I .021

0.0?5 0.014 0-??00 u)6 <),(mr 00150.002 0.017 l-mg0 rI95 0.027 0.79'l0.m9 0.mt I om0.024 <o.o(nl 1.082

hypertriglyceridemia, hypertension, and smoking are

ciear risk factors for CAD.rs5r It is likely, as statedearlier, that the metabolic syndrome, considering itswi gnificant role in thede Patients. Therefore.it of the metabolicsyndrome constitutesprevention of CADregression analysis,been shown in ouassociation with CAD: age, male gender, BMI,hypertension, current smoking, diabetes mellitus, andhypertriglyceridemia. Clearly, our community, as

demonstrated by our findings, is not different thanwestem communities having similar risk factors forCAD. Therefore. we suggest adopting a nationalprogmm promoting Primary prevention of CAD in

SE - slandad cror. BMI - Hy mass indexSBP - syslolic blfixl prcssure. FBS - ff,sting bl(I)d sugat

Paramclers Wilholll CAD 2 valuc(lE16288)

Age (ye,I)Men (',4 )

Bodv nliNs index(kSr/m2)Waist circumfercme(cm)Waisl-h€ighl mtioSysl.,lic BP(mm H8)Di:L\rolic BP (mm Hal

Curr€nt smokeni n (r{ )Faslirg blood surgir(mm{rllL)Serum choleslerol{mmol,/L)Scrrlm tri8lyceridcs(mm)l/L)High dcnsily liF)prolein( mnnl/L)L-ow densiry lipoprorein(mnlol/L)

5 rLl2.2'l542 (57..r)

29052 r 6.055

9Jr)9 i l4.lt:t

0586919.173t2639 r 20. t88033 r r l,r9

I r4 ( r2.l)t5i ( r6-3)

7--1515 t 4.t698

5A't13!t.6114

2.U 6 i 1.6178

o_9r6810.3r9?

3-ml5l r37r3

,r-5.92 :t I | .52 d.00017646 (.16.9) d).m)l

28.5701 5756 0I)13

9r 9l i 1467 <{.trx)l

0578219:43 0.00678.22 t 10.37 <)Iml

120.881 1742 <).mol14l8 (8 8) O.ml2012 (8.8) o-(nl

6.6li4 t t 1.4612 <O.fix)]

5.351611.4832 0.O3.r

r 82551 r.2688 d-(X)Ol

0 94r910.4221 0.024

1.7921I 12r.13 0.85-3

BP bloul prcssure, CAD - coooary anery disease

www smj.org.sa SaudiMcdJ 2fl)4: Vol 25(9) 1169

CAD in Sau<li Atabin ... Al-No.fut et dl

irnolernenting str lcgy tarseting children'sschoolteachds its well its molhers at htlme. A

KSA.In conclusion. the overall prevalence of CAD itt

KSA is 5.57o, a figure midway to those reported ftomother courtries. Classical risk faclors lbr CAD:

active develoPment of CAD in thispopulat s are nceded to change lifestyleinit to mantgement of the metabolicsvndromc. ils prevcnlive method lo reduce

n'lo,litiuhl" risk frrctors lor CAD. A longitudinalstudy is nccded lo demollstrate thc ilnpoflanue ol're,lue inu rnoJifiable risk factors lbr CAD in KSA.

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CAD in Srludi Arrhtit .. ,l/-No:/trt rt rr1

.ll. Cnrxl\ Sl\1. Bcni.r i lJ. Brrllr: CL. ( ht'il A. Lclcl RIIl{orruril R\' (l ill l)ixll{c\ nrl ( irrdirrraseular Distasc: ASrxlcnrnt l()r Hcxhhcrrq P()tcssi(nlals FroDl llrc Anrericilllttcirrl Ass(rInlion. (irtc ali.trt ,9q)- l(n: IIX-llJ6

-11. Fein F. Srhetler J. ll('lln discirs(' in dilh('lcs rllcllilus:lhct,rr rl t)r clicc. ln: Rittlll H. P(,nc D cdrtorr. N.\\'\',)rl iN\'): al*'\'icr: l(xxl. P. tlll 811.

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