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

1. Risk factors for coronary Artery diseases in Pakistanis: A cross–sectional Study Dr. Sunita DodaniAssistant 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 • <3% 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 PakistanNHSP 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 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: Cross sectional descriptive study 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.) • Obesity (BMI) • Hypertension • Diabetes mellitus • Total cholesterol High density lipoprotein (HDL) Low density lipoprotein (LDL) • Triglycerides (TGs) Risk Factors in the Study • Positive family history of coronary heart disease Smoking • Sedentary lifestyle

17. 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:

18. Study Methodology and Sample Design (Contd.) • 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:

19. Study Results

20. Variable Variable n=600 % % Language Urdu Sindhi Punjabi Pushto Baluchi Others 286 81 124 39 29 41 47.7 13.5 20.7 6.5 4.8 6.8 Education <Matriculation Matriculate Intermediate Graduate Post-graduate 12 51 104 389 44 2.0 8.5 17.3 64.8 7.3 Socio-demographic variables in the study group n=600 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 (> 35hrs/wk) Unemployed Retired / Student Household person Refused 410 5 60 115 3 68.3 0.8 10 19.2 0.5 † mean ‡  S.D.

21. Variable n=600 % Hypertension Yes No 121 479 79.8 20.2 Coronary Artery disease (CAD) Risk Factors ETT Positive Negative 485 115 80.8 19.2 Menopause (n=129) Yes No Age at Menopause 65 64 46.6 † 50.4 49.6 7.6 ‡ BMI Categories* (WHO) Underweight (<18.5) Normal (18.5-24.9) Pre-obese (25-29.9) Obese (30-39.9) Obesity (> 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. Regular exercise Yes No 169 431 28.2 71.8 Coronary Artery disease (CAD) Risk Factors contd. Total Cholesterol** Desirable (<200) Borderline high (200-239) High (> 240) 194.2† 402 118 80 37.2‡ 67.0 19.7 13..3 Family History of IHD Yes No Don’t Know 287 293 20 47.8 48.8 3.3 HDL Cholesterol Low (<40) 41-59 High (> 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 (<100) Near/above optimal (100-129) Borderline High (130-159) High (160-189) Very High (> 190) 124.5† 113 228 177 71 11 32.2‡ 18.8 38.0 29.5 11.8 1.8 Triglycerides Normal (<200) Borderline High (200-399) High (400-1000) Very High (>1000) 177.4/ 447 131 13 9 200.4† 74.5 21.8 2.2 1.5 ** according to NCEP ATP III guidelines

23. Variable Age Coronary Artery Diseases n % n % OR (95% CI){ P value Negative Positive <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) 0.492 Menopause No 59 (55.1%) 5 (22.7%) Yes 48 (44.9%) 17 (77.3%) 4.2(1.44, 12.15) 0.009 BMI Categories <25 151 (31.2%) 27 (23.5%) 25-29.9 223 (46.1%) 66 (57.4%) 1.7 (1.01, 2.71) 0.045 30 110 (22.7%) 22 (19.1%) 1.1 (0.61, 2.07) 0.721 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)

24. Variable Hypertension Coronary Artery Diseases OR (95% CI){ P value Negative Positive No 392 (80.8%) 87 (75.7%) Yes 93 (19.2%) 28 (24.3%) 0.215 Cholesterol 200 <200 mg/dl 345 (71.1%) 70 (60.9%) 200 mg/dl 140 (28.9%) 45 (39.1%) 0.033 Family History No 249 (53.1%) 44 (39.6%) Yes 220 (46.9%) 67 (60.4%) 0.011 Regular Exercise Yes 132 (27.2%) 37 (32.2%) No 353 (72.8%) 78 (67.8%) 0.8 (0.51, 1.22) 0.289 Regular Smoking No 378 (78.8%) 84 (75.0%) Yes 102 (21.3%) 28 (21.5%) 0.389 Table: Univariate analysis (n=600)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. Variable ETT OR (95% CI) P value Negative Positive Age n % <40 years 155 (32.0%) 11 (9.6%) n % 40 years 330 (68.0%) 104 (24.0%) 3.9 (2.01, 7.52) <0.001 Diabetes 69 (14.2%) No 416 (85.8%) 86 (17.1%) 249 (53.1%) 1.8(1.15, 2.74) Yes 29 (25.2%) 1.7 (1.01, 2.9) 0.047 Family History No 44 (39.6%) Yes 220 (46.9%) 67 (60.4%) 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 Table: Multiple Logistic Regression (n=600)

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.