SYNOPSIS ON

“A CASE CONTROL STUDY ON various risk factors causing CORONARY ARTERY DISEASE AMONG PATIENTS OF SELECTED HOSPITALS, BENGALURU”

SUBMITTED TO: SUBMITTED BY:

PROF.SENTHIL KAVITHA. R MISS. DEEPSHIKHA PANCHBHAI

GARDEN CITY COLLEGE OF NURSING GARDEN CITY COLLEGE OF NURSING

SUBMITTED ON: 07.01.14

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BENGALURU, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / MS. DEEPSHIKHA PANCHBHAI
1ST YEAR MSC.NURSING
GARDEN CITY COLLEGE OF NURSING
VIDYA NAGAR, 16TH K.M. OLD MADRAS ROAD, BANGALORE-36
2. / NAME OF THE INSTITUTION / GARDEN CITY COLLEGE OF NURSING
VIDYA NAGAR, 16TH K.M. OLD MADRAS ROAD, BANGALORE-36
3. / COURSE OF STUDY AND SUBJECT / MASTER OF SCIENCE IN NURSING
MEDICAL SURGICAL NURSING
2013
4. / DATE OF ADMISSION OF COURSE / 20TH JUNE 2013
5. / TITLE OF THE TOPIC / A CASE CONTROL STUDY ON CONSUMPTION OF TOBACCO PRODUCTS CAUSING CORONARY ARTERY DISEASE AMONG PATIENT’S OF SELECTED HOSPITALS, BENGALORE.
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INTRODUCTION
“People take ownership of sickness and disease by saying things like MY high blood pressure, MY diabetes, MY heart disease, MY depression, MY! MY! MY! Don't own it because it doesn't belong to you”!
―Stella Payton
Heart is one of the most important organs in the entire human body. The heart pumps the blood, which carries all the vital materials (eg. Oxygen and glucose) which help our body functions and removes the waste products that we do not need.1 Coronary artery disease is the narrowing or blockage of the arteries and vessels that provides oxygen and nutrients to the heart. It is caused by atherosclerosis, accumulation of fatty materials on the inner linings of arteries.2
According to WHO, cardiovascular diseases kill more people each year than any others. In 2008, 17.3 million people died of Coronary heart disease.3 Cardiac rehabilitation increases the life expectancy and quality of life in patients with coronary artery disease.2
Coronary artery disease (CAD), one of the non-communicable diseases, and has become a major public health problem in many developing countries. About two-third of the global estimated 14.3 million annual coronary artery disease death occur in the developing world. By the year 2015, cardiovascular diseases could be the most important cause of mortality in India. The prevalence of coronary artery disease in India increased from 1% in 1960 to 9.7% in 1995 in urban populations, and in rural populations it has almost doubled in the last decade. There is an epidemiological transition from infective to degenerative diseases, increases in the prevalence of cardiovascular risk factors, and ageing of the population, which eventually leads to an increase in the absolute numbers of people with coronary artery disease and increased health awareness and demand for health care facilities. However, reports on the prevalence or incidence of coronary artery disease in developing countries including India are very scarce, and routinely collected data are often incomplete and unreliable.4
Current projections suggest that by the year 2020, India will have the largest cardiovascular disease burden in the world. One fifth of the deaths in India are from coronary artery disease. It will account for one third of all deaths. Many of these Indians will be dying young. Heart disease in India occurs 10 to 15 years earlier than in the west. There are an estimated 45 million patients of coronary artery disease India. An increasing number of young Indians are falling prey to coronary artery disease. With millions hooked to a roller-coaster lifestyle, the future looks even more grim.5
Several medical conditions and lifestyle choices can cause higher risk for coronary artery disease in men, including-high cholesterol, high blood pressure, diabetes, cigarette smoking and tobacco products, overweight and obesity, poor diet, physical inactivity, alcohol use.6
Case control studies are observational because no intervention is attempted and no attempt is made to alter the course of the disease. The goal is to retrospectively determine the exposure to the risk factor of interest from each of the two groups of individuals: cases and controls. These studies are designed to estimate odds. The main benefits are, it is good for studying rare conditions or diseases, Less time needed to conduct the study because the condition or disease has already occurred, it let’s you simultaneously look at multiple risk factors, Useful as initial studies to establish an association, and Can answer questions that could not be answered through other study designs.7
Every research advance brings us closer to know the disease in a much better way and this in turn helps in narrowing the prevalence of particular disease. This case control study on various risk factors causing coronary artery disease will widen the understanding on issue.
NEED FOR THE STUDY
CAD is the leading cause of death in high income countries with 1.33m deaths accounting for 16.3% of total deaths and becoming a significant cause of death in low to middle income countries. It is expected that coronary artery disease and stroke will be the leading cause of death worldwide with 20 million deaths predicted in 2015. CAD in its many forms is a chronic disease with symptoms that require on-going monitoring and treatment to prevent further complications. Although the mortality rates from CAD have steadily declined over time, a substantial increase in those living with some form of CAD is evident and this is due to the prevalence of CAD behavioural risk factors.8
The Global Burden of Diseases (GBD) study reported the estimated mortality from coronary heart disease (CHD) in India at 1.6 million in the year 2000. A total of nearly 64 million cases of CVD are likely in the year 2015, of which nearly 61 million would be CHD cases (the remaining would include stroke, rheumatic heart disease and congenital heart diseases). Deaths from this group of diseases are likely to amount to be a staggering 3.4 million.9
A study was conducted on “surveillance of CVD risk factors and health promotion instrumentation in a rural community in Trivandrum district” in 2006 concluded that 57% identified obesity as risk factor for coronary heart disease. 81%, 77%, 76%, 85%, 77% identified smoking, physical inactivity, high alcohol intake, high fat, increased salt consumption as risk factor for coronary heart disease correctly and respectively in the age group of 15 to 64years.10
A study was conducted on “Cardiovascular disease factor awareness in American Indian communities: The strong heart study” in July 1993, among 46 to 80 years age group and concluded that awareness of risk factors of cardiovascular disease range from 70% to 90%. 90% identified obesity, 88% hypertension, 87% smoking, 85% decreased physical activity, 84% high cholesterol, 84% high fat diet, 82% stress/anxiety, 76% diabetes, 70% family history as risk factors for coronary heart disease.11
As the saying states “what goes around, comes around. In few years of living, I have seen many people dying of coronary heart disease, the disease has become a big threat not only for the elders but also for the younger population and as it is expected that coronary artery disease and stroke will be the leading cause of death worldwide with 20 million deaths predicted in 2015, therefore researcher have taken this study to find out the association between various risk factors causing coronary artery diseases.
REVIEW OF LITERATURE
Review of literature for this study has been discussed under three broad themes as organised below:
6.2.1 Review of literature related to prevalence of Coronary artery disease.
6.2.2 Review of literature related to risk factors of Coronary artery disease.
6.2.3 Review of literature on case control studies related to various risk factors and Coronary artery disease.
REVIEW OF LITERATURE RELATED TO PREVALENCE OF CORONARY ARTERY DISEASE
An epidemiological study conducted in North India from 1999-2002 to determine the prevalence and age-specific trends in cardiovascular risk factors among adolescent and young urban Asian Indians. Major risk factors identified were smoking or tobacco use, obesity, truncal obesity, hypertension, dysglycemia and dyslipidaemia among the 2051 subjects (male 1009, female 1042) aged 15-39 years of age used for the study. The study concludes that there is a low prevalence of multiple cardiovascular risk factors (smoking, hypertension, dyslipidaemias, diabetes and metabolic syndrome) in adolescents and rapid escalation of these risk factors by age of 30-39 years is noted in urban Asian Indians.12
A study conducted at University of North Carolina School of Medicine, 1,22,458 patients with CHD were enrolled in 14 international randomized clinical trials of CHD conducted during the prior decade to determine the prevalence of the 4 conventional risk factors (cigarette smoking, diabetes, hyperlipidemia, and hypertension).Among all CHD cases, at least 1 of the 4 conventional risk factors was present in 84.6% of women and 80.6% of men. In younger patients (men ≤55 years and women ≤65 years), only 10% to 15% of patients lacked any of the 4 conventional risk factors. Premature CHD was related to cigarette smoking in men and cigarette smoking and diabetes in women. Smoking decreased the age at the time of CHD event (at trial entry) by nearly 1 decade in all risk factor combinations.13
A study was conducted to observe the risk factors and prevalence of cardiovascular disease, and predict the 10-year risk of ischemic cardiovascular disease (ICVD) of a rural residents in Xianghe of Hebei province. Two thousand five hundred and thirty two adults ( ≥ 35 years old) were surveyed at internal medicine outpatient department of Xianghe asthma hospital in Hebei province by face-to-face interview, physical examination and biochemical test. Subjects aged 35 to 59 were also evaluated using the National 10-year Risk Assessment for ICVD. The results revealed that the prevalence of stroke and coronary heart disease was 2.2% (56/2532) and 6.9% (176/2532) respectively, the age- and sex-standardized prevalence was 1.3% and 5.9% respectively. The prevalence of hypertension, diabetes, dyslipidemia, overweight, obese and central obesity was 59.9% (1516/2532), 26.9% (682/2532), 68.5% (1735/2532), 40.9% (1038/2532), 14.8% (374/2532) and 49.5% (1254/2532) respectively, the age- and sex-standardized prevalence was 43.8%, 19.9%, 56.5%, 35.1%, 15.6%, 41.9%, respectively. Ten-year ICVD risk was higher than 10% in 14.1% (188/1336) residents aged between 35 to 59 years. They concluded as the Risk factors and prevalence of cardiovascular disease as well as 10-year risk of ICVD are high in this rural population in Xianghe of Hebei province. Intensive prevention and therapy strategies are urgently needed to attenuate the ICVD risk factors and treat ICVD in rural area of China.14
A study was conducted to evaluate the association between newly revealed abnormal ankle-brachial index (ABI) and clinical outcomes in patients with significant coronary artery stenosis. The period between January 1, 2006, and December 31, 2009, ABI was evaluated in 2,543 consecutive patients with no clinical history of claudication or peripheral artery disease who underwent diagnostic coronary angiography. Abnormal ABI was defined as ≤0.9 or ≥1.4. The primary endpoint was the composite of death, myocardial infarction, and stroke over 3 years. The results revealed that of the 2,543 patients, 390 (15.3%) had abnormal ABI. Of the 2,424 patients with at least 1significant stenosis (≥50%) in a major epicardial coronary artery, 385 (15.9%) had abnormal ABI, including 348 (14.4%) with ABI ≤0.9 and 37 (1.5%) with ABI ≥1.4. During a median follow-up of 986days, the 3-year major adverse event rate was significantly higher in patients with abnormal than normal ABI (15.7% vs. 3.3%, p < 0.001). After multivariate analysis, abnormal ABI was identified as a predictor of primary endpoint (hazard ratio [HR]: 1.87; 95% confidence interval [CI]: 1.23 to 2.84; p=0.004). After adjustment by propensity-score matching, abnormal ABI could predict adverse clinical events in patients with established coronary artery disease (HR: 2.40; 95% CI: 1.41 to 4.10; p=0.001).They concluded as the prevalence of newly revealed abnormal, asymptomatic ABI among patients who have significant CAD on coronary angiography was 15.9%. The presence of abnormal ABI was associated with a higher incidence of adverse clinical outcomes over 3 years.15
A study was conducted to compare the prevalence of coronary artery disease (CAD) between Thai Muslim and Thai Buddhist patients. A hospital based retrospective study was carried out to investigate the prevalence of CAD and cardiovascular risk factors of these two ethnic and religious groups at Nopparat Rajathanee Hospital between June 2012 and December 2012. All Thai Muslim patients aged > or = 35 years who visited the internal medicine outpatient department (OPD) were studied. The compared population was randomly selected and matched by age and sex from the Thai Buddhist patients in the same period. The results showed that Five hundred seventy nine patients with median age of 62 years (interquartile range = 24) were studied. There were 289 Thai Muslims and 290 Thai Buddhists. The prevalence of definite CAD in Muslims (14.20%) was significantly higher than the prevalence in Buddhists (6.2%) (p = 0.002). The prevalence of diabetes mellitus, hypertension, high total cholesterol (> or = 240 mg/dl), and high triglyceride in Muslims were significantly higher For high-density lipoprotein cholesterol (HDL-C), only Muslim females showed significantly higher prevalence of low HDL-C than that of Buddhist females. They concluded as Thai Muslims showed significantly higher prevalence of definite CAD than that of Thai Buddhists. The greater prevalence of certain risk factors may contribute to higher prevalence of CAD in Thai Muslim patients.16
An epidemiological study was conducted on prevalence of coronary artery disease and its relationship to lipids in South India. A total of 1399 subjects were selected, chi-square analysis was done. Result showed that prevalence of coronary artery disease rose with increasing blood sugar levels. The prevalence of coronary artery disease increased from 9.1% in subjects with normal glucose tolerance, to 14.99% in impaired glucose tolerance and 21.4% in diabetics.17
A cross sectional study was conducted on prevalence of coronary artery disease and coronary risk factors in an urban population of Tirupati. Aim to determine the prevalence of coronary artery disease and its risk factors in the urban population. A total of 1519 subjects selected randomly. Multivariate regression analysis was done. Result shows that the overall prevalence in the study population was 12.63 (192 cases). In males it was 6.86 (37 cases) and in females 15.81 (155 cases). Study concludes that association of age, high LDL cholesterol in males and triglycerides in females with coronary artery disease shows the importance of these risk factors in this population.18
REVIEW OF LITERATURERELATED TO RISK FACTORS OF CORONARY ARTERY DISEASE.
A study was conducted on “Prevalence and awareness of risk factors and behaviours of coronary heart disease in an urban population of Karachi, the largest city of Pakistan: the community survey” among 18 years and above age group concluded that 12% identified smoking, 9.9% Lack of physical activity, 36.8% high fat diet, 19.2% obesity, 9% family history as risk factors of coronary heart disease. 16%, 15.6% , 64.6% identified high blood pressure, high cholesterol, stress as risk factors of coronary heart disease correctively and respectively.19
A hospital-based, cross sectional study to assess knowledge of modifiable risk factors of CASHD among patients in emergency room was conducted at All India Institute of Medical Sciences (AIIMS) where 217 Participants were recruited. 41% of the sample surveyed had a good level of knowledge. 68%, 72%, 73% and 57% of the population identified smoking, obesity, hypertension, and high cholesterol correctly, respectively. 30% identified diabetes mellitus as a modifiable risk factor of CASHD. 20
A cohort study was conducted to identify the relationship between various risk factor for Coronary Heart Disease (CHD) and the occurrence of the disease consisting of 14,786Finnish men and women 25 to 64 years old at baseline, the cardiovascularrisk factors identified were: smoking, serum total cholesterol,HDL cholesterol, blood pressure, body mass index, and diabetes where risk factor measurements were done in 2002 or 2007, and thecohorts were followed up until the end of 2010. CHD incidence in men compared with women was 3times higher and mortality was 5 times higher but the sex differencein risk factor levels diminished with increasing age. Differencesin risk factors between sexes, particularly in HDL cholesteroland smoking, explained nearly half of the difference in CHDrisk between men and women.21
A study was conducted to evaluate the prevalence of risk factors of Coronary heart disease among bank employees of Belgaum city. The prevalence of risk factors of coronary heart disease was found to be: hypertension 31%, diabetes 21%, high serum total cholesterol 29%, high triglycerides 39%, high LDL cholesterol 19.3%, low HDL cholesterol 17.7%, smoking 26%, sedentary habits 44%,positive family history 12%, overweight / obesity (BMI >25 kg/m2) 33% and 26% of the study subjects had truncal obesity. Among these, 55% of the study subjects had at least two of these risk factors.22
A cross sectional study was conducted on risk factors of coronary artery Disease among Bank Employees in India. Aim to estimate the prevalence of risk factors of coronary artery disease among bank employees. A total of 1292 bank employees selected by randomly, ‘chi-square test’ and ‘ztest’ were used to analysis. Result shows that the prevalence of risk factors of coronary artery disease was as follows: hypertension 31%, diabetes 21%, high serum total cholesterol 29%, high triglycerides 39%, high LDL cholesterol 19.3%, low HDL cholesterol 17.7%, smoking 26%, sedentary habits 44%,positive family history 12%, overweight / obesity (BMI >25 kg/m2) 33% and 26% of the Study subjects had truncal obesity. Among these, 55% of the study subjects had at least two of these risk factors. Study concludes that disturbing burden of coronary risk factors in the study population. There is an urgent need to undertake population based measures to reverse the trend.23
A study was conducted on modifiable risk factors and cutaneous markers in Indian patients with young coronary artery disease. A total of 292 patients (age ≤40 years) who presented with acute CAD between January 2005 and June 2009 and 92 age, and gender-matched controls. Details of smoking, family history of premature CAD, waist size, blood sugar and lipid profile. Clinical evidence of arcus juvenilis, premature greying of hair and premature baldness sought. Results showed that Dyslipidaemia (91%), smoking (74.3%), low high-density lipoprotein cholesterol (HDL-C) (68.9%), central obesity (47.7%) and greying of hair (34.9%) were the most commonly associated factors. Compared with male patients, females had greater prevalence of dyslipidaemia, low HDL-C, central obesity, hypertension, diabetes and family history of premature CAD. The presence of cutaneous markers was significantly associated with premature CAD. They concluded as CAD in young Indian people is multifactorial; dyslipidaemia, low HDL-C, smoking, hypertension, central obesity and family history of premature CAD are the most common risk factors. Smoking in men and central obesity in women are the most prevalent factors. Clinicians should be highly suspicious of patients with presence of cutaneous markers, and they should be followed intensively for lifestyle modifications. 24