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210404P - EPIDEMIOLOGY OF CARDIOVASCULAR DISORDERS

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Presentation prepared by Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Bioethics, King Fahad Medical City


THE MAIN CATEGORIES OF CARDIOVASCULAR DISEASE:

  • Coronary Heart Disease (CHD)
  • Cerebrovascular Disease (Stroke),
  • Rheumatic heart disease (in LDC): Rheumatic heart disease, due to sequelae of beta hemolytic streptococcal infection, has declined in industrialized countries but is still an important in LDC.
  • Hypertensive heart disease,
  • Congenital heart disease: Better medical care results in more infants with congenital heart diseases surviving beyond the neonatal period and thus requiring surgical correction of the defects.
  • Infective heart disease: Syphilitic heart disease has decreased with better and earlier treatment of syphilis.

 

CHD / IHD:

  • CHD (IHD), heart failure, and cardiac arrhythmias are the commonest causes of hospital admission.
  • IHD, almost synonymous with CHD, is a leading cause of death mostly by myocardial infarction.
  • Infarction has a high mortality with most patients dying before reaching hospital.

 

INCIDENCE OF CHD/IHD:

  • The incidence rate of cardiovascular disease is rising due to demographic transition to an older population that is at higher risk.
  • In addition there is an age-specific increase in incidence rate due to the industrial/western lifestyle. CHD due to atherosclerosis accounts for 50% of cardiovascular disease.
  • Mortality due to CHD is rising by age but is lower in females than males. The difference between the genders decreases at the extremes of age.
  • CHD is not an inevitable  degenerative condition due to age; it has preventable environmental determinants.
  • Cerebrovascular Accident rises with age males being more affected than females. Mortality among black Americans is higher than white Americans. The decline in stroke mortality in Europe and America is due to effective treatment of hypertension.

 

RISK FACTORS OF CHD/IHD:                  

  • Cigarette smoking
  • Hypertension
  • Cholesterol
  • Excessive obesity, weight, and high BMI
  • Low physical activity
  • Alcohol
  • Diabetes
  • SES: CHD enters a community through the socially advantaged and leaves through the disadvantaged.

 

HYPERTENSION*:

  • Hypertension is defined as a systolic blood pressure >140 mm Hg and diastolic >90 mm Hg. Optimal blood pressure is systolic <120 and diastolic <80.
  • Normal blood pressure range is systolic 120-129 and diastolic 80-84.
  • High normal blood  pressure is systolic 130-139 and diastolic 85-89.
  • Stage 1 (mild) hypertension is systolic 140-159 and diastolic 90-99.
  • Stage 2 (moderate) hypertension is systolic 160-179 and diastolic 100-109.
  • Stage 3 (severe) hypertension is systolic 180-209 and diastolic 110-119.
  • Stage 4 (very severe) hypertension is systolic >210 and diastolic >120
  • Hypertension is complicated by cerebral hemorrhage, heart failure, and renal failure.
  • Heart failure is more often due to hypertension and is the commonest cause of death in hypertension.
  • Excess mortality rises with the rise of blood pressure with no threshold.

* Epidemiology, Biostatistics, and Preventive Medicine (Saunders Text and Review Series) 1st Edition by James F Jekel  (Author), Joann G. Elmore (Author), David L. Katz (Author) Epidemiology, Biostatistics, and Preventive Medicine.  Elsevier Health Sciences (September 25, 2002)

 

CEREBROVASCULAR DISEASE (STROKE):

  • Cerebro-vascular disease, stroke, is the third commonest cause of death in DC and is increasing in LDC.
  • The use of CT scans has increased the diagnosis of stroke.
  • Comparison of incidence figures in different studies is not easy because methods of diagnosis and ascertainment of stroke differ. 
  • Stroke is the commonest cause of disability in the US. It has the same risk factors as CHD.
  • Some cases of stroke are related to hypertension but others are related to atherosclerosis.
  • There are two variants of stroke, ischemic and hemorrhagic. The two are usually mixed in a case of stroke.
  • Stroke is not an immediate threat to life. Those who survive have functional impairment due to neurological deficit.
  • They use up a lot of resources (hospital and community) and increase the burden on the family. Stroke patients can be cared for at intensive care units, stroke rehabilitation centers, and home care.

RISK FACTORS OF CEREBROVASCULAR DISEASE (STROKE):

  • Hypertension,
  • smoking,
  • alcohol,
  • obesity,
  • high serum cholesterol,
  • atrial fibrillation.
  • Diabetes


PRIMARY PREVENTION OF CARDIOVASCULAR DISORDERS:

  • Prevention of CHD/IHD requires changes in these life-style and behavioral risk factors of cardio-vascular disease: cigarette smoking, physical inactivity, use of oral contraceptives, high fat diet leading to high serum cholesterol, high calorie diet leading to obesity and complications of diabetes mellitus, and high salt diet leading to hypertension.
  • The primary prevention of stroke consists of management of hypertension, increase of physical activity, abstention from alcohol and smoking.


SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE:

  • Regular blood pressure assessment
  • Lifestyle modification
  • Diet modification,
  • Annual cholesterol determination and treatment of lipid abnormalities with drugs
  • Drugs used for CHD/IHD are aspirin, nitrites, beta-blocking drugs, calcium antagonists, and antithrombotic drugs, anticoagulant drugs, and ACE inhibitors.
  • Two surgical procedures are used for CHD/IHD: bypass grafting and percutaneous transarterial angioplasty. Ambulances equipped with defibrillators are needed in every community.
  • The secondary prevention of stroke is early detection and effective treatment with warfarin and aspirin.


MINISTRY OF HEALTH SURVEY REPORT - 2019: ANGINA

  • Overall, 1% of the respondents reported being diagnosed with angina, with 71% of them receiving treatment in the two weeks prior to the survey.
  • Although the percentage of respondents with angina was the same in both males and females, males were more likely to have received recent treatment for the condition than females (75% and 64%, respectively).
  • Angina increases with age, with the highest percentage observed in individuals between the age of 70 and 79 (11%), though those in the 80 and older age group had a slightly lower percentage than those in the 70-79 category (9%).
  • Rural residents are more likely to receive treatment compared to urban residents (87% vs. 69%, respectively).
Source: https://www.moh.gov.sa/en/Ministry/Statistics/Population-Health-Indicators/Documents/World-Health-Survey-Saudi-Arabia.pdf page 106


MINISTRY OF HEALTH SURVEY REPORT -2019: STROKE

  • Generally, respondents reported a low percentage of stroke (0.3%) with 83% of them receiving treatment in the two weeks prior to the survey
  • Although stroke percentages are similar in males and females, females are slightly more likely to report it than males (86% and 81%, respectively).
  • The percentage of respondents between 60 and 79 years who reported a stroke is 3 to 4%, and 87% of those reporting having a stroke received treatment for it in the two most recent weeks.
  • The percentage of respondents who reported a stroke doubles in individuals in the older age group of 80 and above.
  • Non-Saudi respondents reported receiving treatment for stroke more often than Saudi respondents (100% and 80%, respectively).
Source: https://www.moh.gov.sa/en/Ministry/Statistics/Population-Health-Indicators/Documents/World-Health-Survey-Saudi-Arabia.pdf page 106


MINISTRY OF HEALTH SURVEY REPORT -2019: HYPERTENSION

  • 8% of the population reported being diagnosed with hypertension by a professional healthcare provider, 83% of those reported receiving treatment recently.
  • The percentage receiving treatment for hypertension are almost the same for males and females. The percentage of respondents between the age of 30 and 44 with hypertension is 5%. The percentage increases to 20% in individuals aged between 45 and 59 years, then doubles to 45% in the 60 to 69 age group. The percentage further increases to 57% in individuals between the age of 70 and 79, then drops slightly to 54% in the 80 and above age group. The percentage further increases to 57% in individuals between the age of 70 and 79, then drops slightly to 54% in the 80 and above age group.
  • Saudi respondents have a slightly higher percentage of hypertension (9%) as compared to non-Saudi respondents (6%). Saudi respondents also reported receiving treatment more often than non-Saudi respondents (83% and 77%, respectively).
Source: https://www.moh.gov.sa/en/Ministry/Statistics/Population-Health-Indicators/Documents/World-Health-Survey-Saudi-Arabia.pdf page 106


MINISTRY OF HEALTH SURVEY REPORT -2019: DYSLIPIDAEMIA

  • The percentage of respondents with dyslipidaemia among all respondents is 8%, with 60% of them having received treatment during the two weeks prior to the survey.
  • The percentage is similar in females and males, but females are more likely to have received recent treatment than males (62% and 58%, respectively).
  • The percentage of respondents with dyslipidemia is very low (2%) in adolescents and young adults (15-29 years). The percentage rises to 7% in individuals between the age of 30 and 44 years, 16% in individuals aged between 45 and 59, 30% in the 60 to 69 age group, and 31% in the 70-79 age group. The percentage then goes down to 25% in the 80 years and above group. Coverage also increases with age.
Source: https://www.moh.gov.sa/en/Ministry/Statistics/Population-Health-Indicators/Documents/World-Health-Survey-Saudi-Arabia.pdf page 107


CORONARY ARTERY DISEASE IN SAUDI ARABIA: Pattern of coronary arterial lesions…-1:

  • Authors: Khalid Hadi Aldosari , Khalid Mansour Alkhathlan , Sameer Al-Ghamdi , Fayez Elsayed Abdelhamid Elshaer , Mohammed Hamid Karrar, Abdulrahman Mohammed Aldawsari .
  • Title: Pattern of coronary arterial lesions amongst Saudi Arabians: a cross-sectional coronary fluoroscopic angiography study.
  • Citation Pan Afr Med J. 2020 May 18;36:21.


CORONARY ARTERY DISEASE IN SAUDI ARABIA: Pattern of coronary arterial lesions…-2: Introduction: 

  • Coronary artery disease (CAD) is a major cardiovascular disease (CVD) that affects a large population globally.
  • This study aimed at determining coronary arterial lesions (CAL), particularly in terms of age, gender, coronary artery/arteries involved, number of lesions, and dominant coronary artery in the Kingdom of Saudi Arabia (KSA).


CORONARY ARTERY DISEASE IN SAUDI ARABIA: Pattern of coronary arterial lesions…-3: Methods: 

  • A cross-sectional study was conducted at the King Khalid Hospital and Prince Sultan Centre for Health Care in Al-Kharj between January 2017 and March 2018.
  • The patients with CAD lesion/s, fulfilling the inclusion criteria, were recruited from the cardiovascular medicine unit. Demographic information and the location and extent of
  • their CAD lesions were extracted and documented in electronic case report form (eCRF). SPSS 22.0 was used for statistical analysis, and p value ≤ 0.05 was considered as significant.

 

CORONARY ARTERY DISEASE IN SAUDI ARABIA: Pattern of coronary arterial lesions…-4: Results: 

  • Of the 262 patients, male and female preponderance was 74.8% and 25.2%, respectively.
  • The majority of the patients were adults above the age of 50 (72%).
  • About half of all patients were active smokers (53%).
  • Diabetes, hypertension, and hyperlipidaemia were recorded in 63%, 53.7% and 25% respectively.
  • The incidence of cardiovascular lesions was documented after coronary angiography; left circumflex artery lesions had the highest incidence (85.3%), followed by left anterior descending artery lesions (82.4%) and right circumflex artery lesions (74.3%). Left main coronary artery lesions had the lowest incidence (10.3%).
  • Most patients (59.6%) had three concomitant lesions, whereas a minority of patients had two (22.8%) and one lesion (17.7%).

 

CORONARY ARTERY DISEASE IN SAUDI ARABIA: Pattern of coronary arterial lesions…-5: Conclusion: 

  • The pattern of CALs is different among the Saudi population as compared to other countries.


CORONARY ARTERY DISEASE IN SAUDI ARABIA: Coronary artery disease in Saudi Arabia 1:

  • Authors: Mansour M Al-Nozha, Mohammed R Arafah, Yaqoub Y Al-Mazrou, Mohammed A Al-Maatouq, Nazeer B Khan, Mohamed Z Khalil, Akram H Al-Khadra, Khalid Al-Marzouki, Moheeb A Abdullah, Saad S Al-Harthi, Maie S Al-Shahid, Mohammed S Nouh, Abdulellah Al-Mobeireek.
  • Title: Coronary artery disease in Saudi Arabia.
  • Citation: Saudi Med J. 2004 Sep;25(9):1165-71.

 

CORONARY ARTERY DISEASE IN SAUDI ARABIA: Coronary artery disease in Saudi Arabia 2: Objective: 

  • Coronary artery disease (CAD) is a major public health problem worldwide. To our knowledge, there is no national data available from community based studies on prevalence of CAD in the Kingdom of Saudi Arabia (KSA).
  • Therefore, we designed this study with the objective to determine the prevalence of CAD among Saudis of both sexes, between the ages of 30-70-years in rural as well as urban communities.
  • Further, to determine the prevalence and clinical pattern of the major modifiable risk factors for CAD among the same population.
  • This work is part of a major national study on CAD in Saudis Study (CADISS).

 

CORONARY ARTERY DISEASE IN SAUDI ARABIA: Coronary artery disease in Saudi Arabia 3: Methods: 

  • This is a community based study conducted by examining subjects in the age group of 30-70-years of selected households during 5-year period between 1995 and 2000 in KSA.
  • Data were obtained from history using a validated questionnaire, and electrocardiography.
  • The data were analyzed to provide prevalence of CAD and risk assessment model.

 

CORONARY ARTERY DISEASE IN SAUDI ARABIA: Coronary artery disease in Saudi Arabia 4: Results: 

  • Nine hundred and forty-four subjects, out of 17232 were diagnosed to have CAD. Thus, the overall prevalence of CAD obtained from this study is 5.5% in KSA.
  • The prevalence in males and females were 6.6% and 4.4% (P<0.0001).
  • Urban Saudis have a higher prevalence of 6.2% compared to rural Saudis of 4% (P<0.0001).
  • The following variables are found to be statistically significant risk factors in KSA: age, male gender, body mass index (BMI), hypertension, current smoking, fasting blood glucose, fasting cholesterol and triglycerides.

 

CORONARY ARTERY DISEASE IN SAUDI ARABIA: Coronary artery disease in Saudi Arabia 5: Conclusion: 

  • The overall prevalence of CAD in KSA is 5.5%. A
  • national prevention program at community level as well as high risk groups should be implemented sooner to prevent the expected epidemic of CAD that we are seeing, beginning.
  • Measures are needed to change lifestyle and to address the management of the metabolic syndrome, to reduce modifiable risk factors for CAD.
  • A longitudinal study is needed to demonstrate the importance of reducing modifiable risk factors for CAD in KSA.

 

MYOCARDIAL INFARCTION IN SAUDI ARABIA-1

  • Authors: Sheeren Khaled , Mohammad Almalki , Ghada Shalaby  Azmat K Niazi , Sara Ahmed , Asma Alsilami , Mohannd Alhazmi , Zeyad Bukhary , Najeeb Jaha..
  • Title: Epidemiological Variation of Acute Myocardial Infarction Relevant to In-Hospital Outcomes-Tertiary Center Experience-Saudi Arabia.
  • Citation: J Saudi Heart Assoc 2020 Aug 1;32(3):340-349


MYOCARDIAL INFARCTION IN SAUDI ARABIA-2: Introduction

  • Epidemiological related differences in patients presenting with ST-elevation myocardial infarction (STEMI) have not yet been fully characterized in the Middle East countries.
  • The aim of this study was to assess gender, ethnic and racial variation in clinical profiles, presentation and treatment strategies with relation to the in-hospital outcomes.

 

MYOCARDIAL INFARCTION IN SAUDI ARABIA-3: Method: 

  • This is a retrospective, single center study reviewing the epidemiological details of STEMI patients who were admitted to our center during the period between October 2015 and August 2019.

 

MYOCARDIAL INFARCTION IN SAUDI ARABIA-4: Result: 

  • Out of 3079 patients presented with STEMI, 498 (16%) were women, 2170 (70%) were from Middle Eastern Countries and only 1200 (39%) were non- Arabic speakers.
  • Women were older in age compared to men (60.04 ± 11.2 vs 55.35 ± 11.8; P < 0.001). They showed significantly higher rates of cardiovascular risk factors (P < 0.001 for diabetes mellitus (DM), hypertension (HTN) and obesity) and lower prevalence of smoking and old history of previous revascularization (P < 0.001 and 0.007, respectively).
  • Middle Eastern Countries- STEMI patients were elderly, showed higher prevalence of DM, HTN, smoking and obesity compared to South Asian patients (p = 0.001, 0.057, <0.001, <0.001 respectively).
  • Arabic speaking - STEMI patients showed more prevalence of DM, smoking and obesity compared to non-Arabic speaking patients (p < 0.001).
  • Regarding STEMI localization, post myocardial infarction complications and in-hospital length of stay, there were no detected significant gender, ethnic or racial variation.
  • Women showed higher rates of all in-hospital mortality compared to men (5% vs 3%; p = 0.027) however, no ethnic/racial mortality difference was recorded among STEMI patients.
  • Being elderly, presence of multivessel coronary artery disease and left ventricular systolic dysfunction (LVEF < 30%) are the three independent predictors of mortality among our patients (p = 0.013, 0.048 and <0.0001 respectively).


MYOCARDIAL INFARCTION IN SAUDI ARABIA-5: Conclusion

  • Our study demonstrates that there are gender, ethnic/racial-related differences in the demographics and clustered cardiovascular risk factors.
  • However, there were no significant detected variation between both genders and different ethnic groups regarding post MI complications, management provided, and hospital outcomes except for increased the mortality rates among women.
  • Old age, presence of multi-vessel disease and severe left ventricular systolic dysfunction have the greatest effect on in-hospital mortality among STEMI patients.

 

EPIDEMIOLOGY OF STROKE IN SAUDI ARABIA - 1:

  • Authors: Bader A Alqahtani, Aqeel M Alenazi, Jeffrey C Hoover, Mohammed M Alshehri, Mohammed S Alghamdi, Ahmad M Osailan, Kamlesh Khunti
  • Title: Incidence of stroke among Saudi population: a systematic review and meta-analysis.
  • Citation: Neurol Sci 2020 Nov;41(11):3099-3104.


EPIDEMIOLOGY OF STROKE IN SAUDI ARABIA - 1: Background and aims: 

  • Stroke is a leading cause of death and disability worldwide. However, our knowledge of the incidence of stroke for Saudi Arabian population is not known.
  • Thus, we aimed to determine the pooled annual incidence of stroke in Saudi Arabia.
  • We conducted a comprehensive literature search of PubMed, Web of Science, and SCOPUS, without language or publication year limits. Outcomes of interest were stroke incidence rate for both first and recurrent.
  • A total of five studies met the inclusion criteria for this review.
  • The pooled annual incidence of stroke in Saudi Arabia was 0.029% (95% CI: 0.015 to 0.047) equivalent of 29 strokes per 100,000 people annually (95% CI: 15 to 47).

 

EPIDEMIOLOGY OF STROKE IN SAUDI ARABIA - 2: Conclusion

  • The findings indicate that there are 29 stroke cases for every 100,000 people annually for individuals residing Saudi Arabia.
  • Our values were lower than those of other high-income countries.
  • Establishing a nationwide stroke registry is warranted for monitoring and improving healthcare services provided to stroke survivors.


HYPERTENSION IN SAUDI ARABIA - 1:

  • Authors: Azra Mahmud, Ruba Alahaideb, Haifa Alshammary, Mayar Abanumay, Afnan Alfawwaz, Sara Alhelabi, Amgad Alonazy, Muayed Al-Zaibag
  • Title: Prevalence and clinical correlates of ambulatory blood pressure phenotypes in a Saudi hypertensive population.
  • Citation: J Clin Hypertens (Greenwich) 2020 Dec;22(12):2372-2376.


HYPERTENSION IN SAUDI ARABIA - 2:

  • International Guidelines recommend ambulatory blood pressure monitoring (ABPM) for the management of hypertension. ABPM phenotypes predict outcomes independent of office blood pressure (BP).
  • The authors explored the prevalence and clinical correlates of ABPM phenotypes and relationship with office BP in Saudi patients (n = 428, mean age 53.5 ± 14.6, 55% male) referred to a Specialist Hypertension clinic in Riyadh, Saudi Arabia.
  • ABPM phenotypes included sustained normotension (27%), masked hypertension, MHT(32%), sustained hypertension, SHT(52%), and white coat hypertension(2.6%).
  • MHT was more prevalent using asleep than 24-hours (26.4% vs 12.9%, P < .01) or awake BP (26.4% vs 8.5%, P < .001) and observed in 85% of pre-hypertensive patients.
  • Isolated nocturnal hypertension was more prevalent in MHT vs SHT (70% vs 30%, P < .001).
  • Office BP overestimated control rates compared with ABPM (48% vs 12.9%, P < .001).
  • Our study shows that one in three Saudi patients will be managed inappropriately if office BP alone was relied upon for management of hypertension.