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ORIGINAL ARTICLE
Year : 2022 | Volume
: 11
| Issue : 4 | Page : 91-95
Lifetime predicted risk of atherosclerotic cardiovascular disease among an urban cohort: A cross-sectional study
Nikita Maheshbhai Savani1, Rajendra B Chauhan2, Rajesh K Chudasama2
1 Department of Community Medicine, Shantabaa Medical College, Amreli, Gujarat, India
2 Department of Community Medicine, P. D. U. Medical College, Rajkot, Gujarat, India
Correspondence Address:
Dr. Nikita Maheshbhai Savani
G/12, Doctor Quarter, Shantaba Medical College Camus, Lathi Road, Amreli - 365 601, Gujarat
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/rcm.rcm_26_22
Introduction: Although atherosclerotic cardiovascular disease (ASCVD) results have significantly improved in recent years, ASCVD continues to be the world's leading cause of morbidity and mortality. Therefore, in the present study, lifetime risk of ASCVD was calculated in an urban cohort. White-collar employees have higher risk of developing cardiovascular disease events because of their work profile. Aim and Objectives: To calculate lifetime predicted risk of ASCVD among study cohort and to explore factors contributing to the disparities of cardiovascular risks. Materials and Methods: This was community-based cross-sectional study. The baseline data were collected during the period 2016–2019 from Rajkot city, and their lifetime predicted risk of ASCVD was calculated using ASCVD risk calculator. Crude and adjusted prevalence ratio was calculated. Results: The study revealed that 69.25% and 6.37% of participants had low and intermediate lifetime predicted risk of ASCVD, respectively, while the remaining 16.12% and 8.25% had borderline and high risk, respectively. Conclusion: This study indicates that increased lifetime predicted risk of ASCVD was associated with increasing age, male, stress, elevated blood pressure, high level of body mass index, and central obesity among participants.
Keywords: Atherosclerotic cardiovascular disease, employees, lifetime predicted risk, risk factors
Although atherosclerotic cardiovascular disease (ASCVD) results have significantly improved in recent years, ASCVD continues to be the world's leading cause of morbidity and mortality. A declining prevalence and incidence of ASCVD events, heart failure, atrial fibrillation, cancer, depression, and cognitive impairment have been linked to an increase in the optimum cardiovascular health variables. Therefore, guiding people toward perfect cardiovascular health is crucial for preventing a wide range of serious medical issues.[1]
India has been experiencing an epidemic of ASCVD, which has surpassed infectious diseases as the leading cause of death among Indians.[2] Not only are more Indians experiencing ASCVD events, the disease manifests itself in an earlier life and progresses more aggressively. The cause for increasing cases of ASCVD in India is multifactorial, but dyslipidemia, hypertension, impaired glucose tolerance, type 2 diabetes, visceral adiposity and the metabolic syndrome, smoking, urbanization, lower socioeconomic status, and possibly air pollution are contributory.[3]
Younger people (<50 years old), who may have a high lifetime risk but whose 10-year risk may be lesser even when strong risk factors are present, seem to benefit the most from lifetime risk assessment because of their young age and the 10-year risk prediction window.[4] Therefore, in the present study, lifetime risk of ASCVD was calculated in an urban cohort. White-collar employees have higher risk of developing cardiovascular disease (CVD) events because of their work profile. Various literature[5],[6],[7],[8],[9],[10] show higher prevalence of hypertension and obesity in them. However, there are less literature on their lifetime predicted ASCVD risk. Hence, selecting them as participants can add perspective to the subject. We aimed to calculate lifetime predicted risk of ASCVD among study cohort and to explore factors contributing to the disparities of cardiovascular risks.
Materials and MethodsThis was community-based cross-sectional study. The baseline data were collected during the period 2016–2019 from Rajkot city, and their lifetime predicted risk of ASCVD was calculated using ASCVD risk calculator provided by the American Heart Association and the American College of Cardiology.[11] The institutional review boards of the institute approved the study protocol.
Participants
The study participants were from urban cohort. White-collar employees working in different banks of the city formed the urban cohort. To be part of the study, the participants had to be between 20 and 59 years and free from ASCVD. The participant who did not gave consent for participation was excluded from the study. Hence, the present analysis included 800 participants.
Measurements
A pretested semistructured prevalidated questionnaire was used for the data collection. Information on participants' demographics, habits including smoking, physical activity, medical history, and medication use was gathered. Seated resting blood pressure (BP) 2 times using a sphygmomanometer was measured and used the mean of the 2 readings for analyses. Height and weight were measured using a validated scale machine. After that, body mass index (BMI) was calculated.
Risk factor definitions
Systolic BP >120 was considered elevated BP. Hypertension was defined as a systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or use of an antihypertensive medication. Self-reported diabetes mellitus was taken into consideration. Cigarette smoking was defined as currently smoking cigarettes. Antihypertensive use was classified as a medication from any class (angiotensin-converting enzyme inhibitor, angiotensin-receptor blocker, beta-blocker, calcium channel blocker, or diuretic). Using Cohen's stress scale,[12] participants were grouped into low and high stress. A person doing physical exercise as per the WHO norms was considered regular.[13] A person doing at least 150–300 min of moderate-intensity aerobic physical activity or at least 75–150 min of vigorous-intensity aerobic physical activity or an equivalent combination of moderate- and vigorous-intensity activity at least on 5 days of the week was considered regular/adequate physical activity.
Lifetime risk factor classification
Lifetime predicted risk for ASCVD events (myocardial infarction, coronary insufficiency, angina, atherothrombotic stroke, intermittent claudication, or CVD death) was estimated. These classified the study samples into four groups. Individuals were preliminarily classified based on estimated risk: lifetime ASCVD risk <5% is low risk; 5%–7.5% is borderline risk; 7.5%–20% is intermediate risk, and ≥20% is high risk.
Statistical analysis
In all analyses, the predicted ASCVD risk group functioned as the dependent variable and the demographic data as well as the risk factors grouped as the independent variable. Mean and standard deviation were used for continuous variables and proportions for categorical variables for the baseline characteristics.
We applied Chi-square for testing significant association across low and high lifetime ASCVD risk groups. For computing crude prevalence odds ratio (POR) with 95% confidence intervals (CIs), ASCVD risk score <5% and 5%–7.5% were clubbed as low-risk groups and remaining as high-risk groups. To test whether these risk factors have independent effect, adjusted POR with 95% CI was calculated using multinomial logistic regression among various ASCVD strata. MS Excel version 2010 and JASP software (Amsterdam, The Netherlands)[14] were used for the data analysis.
ResultsThe study revealed that 69.25% and 6.37% of participants had low and intermediate lifetime predicted risk of ASCVD, respectively, while the remaining 16.12% and 8.25% had borderline and high risk, respectively. Baseline characteristics of the participants are shown in [Table 1]. The mean age of participants was 36 years. Female-to-male ratio was 1:3.6. Majority of the participants were graduated and above (97%). The prevalence of smoking was low (9.6%). Around half (48.9%) of the participants had a positive family history of chronic disease.
We could not calculate crude POR for age and lifetime predicted ASCVD risk groups, as there was no subject of <30 years having high risk. A significant association was found between ASCVD risk groups and variables such as gender, BMI classification, elevated BP, stress, physical inactivity, and central obesity. The result shows an approximately 7-fold increased risk of ASCVD among males. Similarly, those who are obese/overweight compared to normal were 2.4 times more likely to develop ASCVD (crude POR: 2.47, 95% CI: 1.76–3.45). Those who have elevated BP were 4.5 times odds of having ASCVD compared to other. Risk of ASCVD only slightly increased in those with central obesity (crude POR: 1.53, 95% CI: 1.11–2.12) [Table 2].
Table 2: Prevalence and crude prevalence odds ratio according to lifetime predicted atherosclerotic cardiovascular disease risk groupsFrom multinomial logistics regression [Table 3], the odds ratios of subjects of age ≥30 years had 3.92 (95% CI = 1.00–1.79) times higher risk of ASCVD observed in >20 ASCVD risk score. Males having 1.63 times higher odds ratio in ≥7.5–<20 ASCVD risk score strata (95% CI=2.56-17.15). similarly, people with high BMI and Elevated BP have 2.23 (95% CI= 1.10-4.71)and 11.38 (95% CI= 2.68-48.24) times greater chance of ASCVD in <20 risk score strata respectively. Subjects with stress and central obesity had also greater chance of ASCVD, while a significant association was observed between ASCVD risk and Physical inactivity. However, smoking was not found associated with high risk but found 3-fold greater risk in intermediate risk score (5–7.5). Family history of chronic disease has slightly increased odds in all three ASCVD strata.
Table 3: Adjusted prevalence odds ratio according to lifetime predicted atherosclerotic cardiovascular disease score strata Discussion This study yielded several important insights about cardiovascular risk stratification in the selected urban cohort. We found that three-fourth participants had low risk (risk score <7.5), while the others had high risk. Until now, there have been no data on lifetime predicted ASCVD risk among this cohort in India. It is established that CVD is related to lifestyle and individual behavior. The high risk of ASCVD and variables such as gender, elevated BP, obesity, and stress were found significantly associated in the present study.
This study found that higher BMI increased the risk of ASCVD. The findings were consistent with previous studies done by Prihartono et al.[15] who observed increased risk of CVD in overweight groups. They did the similar study among blue- and white-collar workers in Indonesia. Kokkinos[16] reported that every increase in BMI increased CVD-related mortality, especially those with BMI >29 kg/m2 had the highest CVD-related mortality.
This study showed that those who had elevated BP were 2–11 times more likely to have predicted risk of ASCVD. The result was in agreement with the study conducted by Conen et al.[17] that observed an increase of CVD by 56% among those who had hypertension compared to no hypertension over 4 years of follow-up.
A study conducted by Hirokawa et al.[18] on job-related stress in relation to cardiovascular stress reactivity found that job stressors contributed to the change of cardiovascular reactivity including BP and heart rate. In our study, also, a significant association was found between stress and ASCVD.
Association of smoking and family history of chronic disease with ASCVD risk could not be explained by this study. The results reflected the drawback of the cross-sectional study design in which those who had a family history may change their risk factor. Moreover, the findings are subjected to limitation as other risk factors, such as lipid profile and metabolic disorder, were not taken into account since they were not measured in the present study. This analysis was done with appropriate sample size. They represented the white collar workers of Rajkot city. This type of study was very first time for this group.
Strength and limitation
The present study had several strengths. Analyses were performed on a sample of healthy but have high risk of ASCVD in future. No participants had a major history of stroke or myocardial infarction, which might have affected cardiovascular reactivity. Furthermore, various potential confounders were taken into account in our analyses. Our study is the first to report the lifetime predicted risk of ASCVD among the white-collar workers in these selected settings. Hence, this study can serve as base for other studies.
The study participants were limited to only one geographical district which may not represent the whole state or country. The present study uses cross-sectional data and cannot assess the progression of subclinical atherosclerosis or incidence of ASCVD cases. Future data on CVD incidence from the present study will allow for further validation of this among white-collar workers. The conflicting evidence from the present study underscores the need for longitudinal data on cardiovascular risk estimates and ASCVD events derived from diverse populations across India.
Recommendation
Prevention strategies should be made at the regional bank level and employees-centered approach should be addressed. White-collar employees should be engaged in promoting a healthy lifestyle throughout the life as they are at high risk. Lifestyle changes such as improvements in diet, physical activity, avoidance of smoking, and control of BP as well as BP can minimize the risk of future ASCVD events. Employees whose lifetime predicted ASCVD risk is intermediate to high should be emphasized for living healthy life. Regular health promoting activities could help motivate them apart from optimum treatment.
ConclusionThis study indicates that increased lifetime predicted risk of ASCVD was associated with increasing age, male, stress, elevated BP, high level of BMI, and central obesity among participants. However we were unable to establish correlation between ASCVD and few risk factors (smoking and physical activity). To prove causality and incidence of ASCVD we need to do further study. To the best of our knowledge, this is the first report with appropriate sample size detailing the lifetime predicted risk of ASCVD, so this can be helpful in future.
Ethical clearance
The institutional review boards of the institute approved the study protocol. (Outward No. PDUMCR/IEC/2G94/2016)(Dated:14 -02-2016).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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