A Dr. Sunita Dodani Assistant professor, Family Medicine The Aga Khan University Karachi, 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

CVD Mortality (WHO Reports)

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 Pakistan National Health Survey of Pakistan (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 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: 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 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 percentages 3. 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 Group † ‡ Gender Male Female Employment Status Full Time (> 35hrs/wk) Unemployed Retired / Student Household person Refused Variable n=600% Work Type Professional Clerical Skilled Foreman Manager/official/proprietier Sales worker Non skilled Refused Missing Language Urdu Sindhi Punjabi Pushto Baluchi Others Education <Matriculation Matriculate Intermediate Graduate Post-graduate † mean ‡  S.D.

Coronary Artery disease (CAD) Risk Factors ETT Positive Negative Menopause (n=129) Yes No Age at Menopause † ‡ BMI Categories* (WHO) Underweight (<18.5) Normal ( ) Pre-obese ( ) Obese ( ) Obesity (> 40) Diabetes Yes No IGT Variable n=600 % Hypertension Yes No

Coronary Artery disease (CAD) Risk Factors contd. Total Cholesterol ** Desirable (<200) Borderline high ( ) High (> 240) 194.2† ‡ HDL Cholesterol Low (<40) High (> 60) 39.8† ‡ LDL Cholesterol Optimal (<100) Near/above optimal ( ) Borderline High ( ) High ( ) Very High (> 190) 124.5† ‡ Triglycerides Normal (<200) Borderline High ( ) High ( ) Very High (>1000) 177.4/ † Family History of IHD Yes No Don’t Know Current smoking status Never smoked Former smoker Regular cigarette smoker Occasional cigarette smoker Pipe or cigar smoker Not stated/Refused Regular exercise Yes No ** according to NCEP ATP III guidelines

Table: Univariate analysis (n=600) Variable Coronary Artery Diseases OR (95% CI) { P value NegativePositive Age n % <40 years155(32.0%)11 (9.6%)  40 years 330 (68.0%)104 (24.0%)4.4 (2.32, 8.5)<0.001 Gender Female107 (22.1%) 22 (19.1%) Male 378 (77.9%) 93 (80.9%) 0.8 (0.5, 1.39) Menopause No59 (55.1%)5 (22.7%) Yes48 (44.9%)17 (77.3%) 4.2(1.44, 12.15) BMI Categories <25151 (31.2%)27 (23.5%) (46.1%)66 (57.4%) 1.7 (1.01, 2.71)  (22.7%) 22 (19.1%) 1.1 (0.61, 2.07) Diabetes 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)0.215 Cholesterol 200 <200 mg/dl345 (71.1%)70 (60.9%)  200 mg/dl 140 (28.9%)45 (39.1%) 1.6 (1.04, 2.42) Family History No249 (53.1%)44 (39.6%) Yes220 (46.9%) 67 (60.4%) 1.7 (1.13, 2.63) Regular Exercise Yes132 (27.2%)37 (32.2%) No 353 (72.8%)78 (67.8%) 0.8 (0.51, 1.22) Regular Smoking No378 (78.8%) 84 (75.0%) Yes102 (21.3%)28 (21.5%) 1.2(0.76, 1.997) Variable Coronary Artery Diseases OR (95% CI) { P value NegativePositive

Table: Multiple Logistic Regression (n=600) Variable ETT OR (95% CI) P value NegativePositive Age 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) Family History No 249 (53.1%) 44 (39.6%) Yes 220 (46.9%) 67 (60.4%) 1.8(1.15, 2.74) 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.