2. 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

3. 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

4. Presentation Outline Contd. Study Objectives Study Design and Methods Results Limitations Conclusion and Recommendations

5. 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

6. CVD Mortality 1985-1997 (WHO Reports)

7. CVD Mortality According to Regions (%)

8. 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

9. What About Situation in Pakistan?

10. 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

11. CVD in Pakistan National 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

12. 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

13. 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’

14. 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

15. 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

16. 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:

17. 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

18. 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:

19. 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:

20. Study Results

21. Socio-demographic variables in the study group Variable n=600% Age Group 18-34 35-64 65+ 46.1† 73 513 14 10.2 ‡ 12.2 85.5 2.3 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 Variable 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 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 † mean ‡  S.D.

22. 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 Variable n=600 % Hypertension Yes No 121 479 79.8 20.2

23. 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 HDL Cholesterol Low (<40) 41-59 High (> 60) 39.8† 300 292 8 7.9‡ 50.0 48.7 1.3 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 Family History of IHD Yes No Don’t Know 287 293 20 47.8 48.8 3.3 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 Regular exercise Yes No 169 431 28.2 71.8 ** according to NCEP ATP III guidelines

24. 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) 0.492 Menopause No59 (55.1%)5 (22.7%) Yes48 (44.9%)17 (77.3%) 4.2(1.44, 12.15) 0.009 BMI Categories <25151 (31.2%)27 (23.5%) 25-29.9223 (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

25. 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) 0.033 Family History No249 (53.1%)44 (39.6%) Yes220 (46.9%) 67 (60.4%) 1.7 (1.13, 2.63) 0.011 Regular Exercise Yes132 (27.2%)37 (32.2%) No 353 (72.8%)78 (67.8%) 0.8 (0.51, 1.22) 0.289 Regular Smoking No378 (78.8%) 84 (75.0%) Yes102 (21.3%)28 (21.5%) 1.2(0.76, 1.997) 0.389 Variable Coronary Artery Diseases OR (95% CI) { P value NegativePositive

26. 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) 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

27. Limitations: Generalization of results Hospital data Upper socio-economic class

28. 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.