Dr. Sunita Dodani Assistant professor, Family Medicine

1
Risk factors for coronary Artery diseases in
Pakistanis A crosssectional Study
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
2
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

3
Presentation Outline Contd.

• Study Objectives
• Study Design and Methods
• Results
• Limitations
• Conclusion and Recommendations

4
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

5
CVD Mortality 1985-1997
(WHO Reports)
6
CVD Mortality According to Regions
()
7
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

8
What About Situation in Pakistan?
9
Pakistan A Developing Country

• Multiethnic and linguistic diversity
• 4 provinces 2 territories
• Population 130 million
• Growth Rate 2.6
• Per capita income 390
• lt3 Gov Health Budget
• Most of the money spent on tertiary care
  hospital curative services
• Very limited health insurance

10
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

11
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

12
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

13
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

14
Study Methodology and Sample Design
Design
Cross sectional descriptive study

• 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

Set up
15
Study Methodology and Sample Design
(Contd.)
Study sample

• 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

16
Study Methodology and Sample Design
(Contd.)
Risk Factors in the Study

• Obesity (BMI)
• Hypertension
• Diabetes mellitus
• Total cholesterol
• High density lipoprotein (HDL)
• Low density lipoprotein (LDL)
• Triglycerides (TGs)

• Positive family history of
• coronary heart disease

• Smoking

• Sedentary lifestyle

17
Study Methodology and Sample Design
(Contd.)
Sample size estimation

• Assumed prevalence of 50 given largest sample
  size possible
• Margin of error 4
• Stratified on age and genderdichotomized into
• lt 35 years, and gt 35 years
• Total patients interviewed 600

18
Study Methodology and Sample Design
(Contd.)
Analysis

• 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 (Plt 0.05)
• Logistic regression model (Odds ratio with
  95 CI)
• Dependent variable heart diseases

19
Study Results
20
Socio-demographic variables in the study group
n600
Work Type Professional Clerical Skilled
Foreman Manager/official/proprietier Sales
worker Non skilled Refused Missing
  49 16 26 316 7 2 1 183
  11.2 3.8 6.2 75.8 1.7 0.5 0.2
46.1 73 513 14
10.2 12.2 85.5 2.3
Age Group 18-34 35-64 65
Gender Male Female
  471 129
  78.5 21.5
 
 
Employment Status Full Time (gt 35hrs/wk) Unemploye
d Retired / Student Household person Refused
  410 5 60 115 3
  68.3 0.8 10 19.2 0.5
 
 
mean ? S.D.
21
Coronary Artery disease (CAD) Risk Factors
ETT Positive Negative
  485 115
  80.8 19.2  
Menopause (n129) Yes No Age at Menopause  
  65 64 46.6  
  50.4 49.6 7.6
  BMI Categories (WHO) Underweight
(lt18.5) Normal (18.5-24.9) Pre-obese
(25-29.9) Obese (30-39.9) Obesity (gt 40)  
  5 172 290 123 9  
  0.8 28.7 48.4 20.6 1.5
Diabetes Yes No IGT  
98 473 29
  16..3 78.8 4.8

22
Coronary Artery disease (CAD) Risk Factors
contd.
Total Cholesterol Desirable (lt200) Borderline
high (200-239) High (gt 240)  
194.2 402 118 80
37.2 67.0 19.7 13..3
Family History of IHD Yes No Dont Know  
  287 293 20
  47.8 48.8 3.3
HDL Cholesterol Low (lt40) 41-59 High (gt 60)  
39.8 300 292 8
7.9 50.0 48.7 1.3  
Current smoking status Never smoked Former
smoker Regular cigarette smoker Occasional
cigarette smoker Pipe or cigar smoker Not
stated/Refused  
  388 54 130 20 7 1
  64.7 9.0 21.7 3.3 1.2 0.2
LDL Cholesterol Optimal (lt100) Near/above optimal
(100-129) Borderline High (130-159) High
(160-189) Very High (gt 190)
124.5 113 228 177 71 11  
32.2 18.8 38.0 29.5 11.8 1.8
Triglycerides Normal (lt200) Borderline High
(200-399) High (400-1000) Very High (gt1000)  
177.4/ 447 131 13 9
200.4 74.5 21.8 2.2 1.5
according to NCEP ATP III guidelines
23
Table Univariate analysis (n600)
24
Table Univariate analysis (n600)
Contd.
1.4(0.84, 2.197)
1.6 (1.04, 2.42)
1.7 (1.13, 2.63)
1.2(0.76, 1.997)
25
Table Multiple Logistic Regression (n600)
26
Limitations

• Generalization of results
• Hospital data
•  
• Upper socio-economic class
•  

27
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.
•