risk factors associated with coronary artery disease

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in adults, accounting for approximately one-third of all deaths in people over the age of 35 .... 15 years. in patients homozygous for the disease. While the FH ..... psychosocial risk factors (depression, permanent stress, financial stress, stressful events, and ...... Wilson W, D'Agostino B, Parise H, Sullivan L, Meigs B (2005).

RISK FACTORS ASSOCIATED WITH CORONARY ARTERY DISEASE AMONG PATIENTS ATTENDING SURGICAL SPECIALTY HOSPITAL-CARDIAC CENTER IN ERBIL CITY A CASE-CONTROL STUDY A Thesis Submitted to the Council of the College of Nursing at Hawler Medical University in Partial Fulfillment of the Requirements for the Degree of Master of Science in Adult Nursing By Haroon Muhammad Khalil B.Sc. in Nursing

Supervised By Lecturer Dr.Vian Afan Naqshbandi B.Sc., M.Sc., PhD in Adult Nursing

2015 A.D.

2715K.

1436 A.H

‫بسْم ه‬ ‫َّللا الشهحْ مه الشهحٍم‬ ‫َٰهَ َزا َخ ْلق ه‬ ‫ٌه هم ْه دووه هه ۚ‬ ‫ق اله هز َ‬ ‫َّللاه فَأَسووهً َما َرا َخلَ َ‬ ‫ض ََلل مبهٍه‬ ‫بَ هل الظهالهم َ‬ ‫ون فهً َ‬ ‫صذق ه‬ ‫َّللا العظٍم‬ ‫سوسة لقمان‪-‬اٌت﴿‪﴾١١‬‬

‫كما قال سٍّذوا سسول َّللا صلّى َّللا علٍه وسلّم‬

‫صلَ َح ْال َج َسذ كلُّه‪َ ,‬وإه َرا فَ َس َذ ْ‬ ‫صلَ َح ْ‬ ‫ث‬ ‫ج َ‬ ‫"أَال َوإه هن فهً ْال َج َس هذ مضْ َغتً إه َرا َ‬ ‫فَ َس َذ ْال َج َسذ كلُّه‪ ,‬أَال َو هه ًَ ْ‬ ‫القَ ْلب"‬ ‫[ البخاسي فً الصحٍح]‬

This thesis is dedicated to:  Soul of my father.  My respected mother for their unconditional love and immeasurable support.  All my brothers and sisters.  Everyone who gave me the opportunity to follow the right way.

Acknowledgment

First and foremost praise and thanks to God for helping me in fulfilling this study and bringing it to its final shape. I would like to thank specially my supervisor Dr.Vian Afan Naqshbandi the Dean of College of Nursing/ Hawler medical university. I am grateful to her for the excellent guidance, support, constructive advice and everlasting encouragement throughout the year of the study. I would like to extend special thanks to the director and staffs of Surgical Specialty Hospital-Cardiac Center in Hawler city and Hawler Teaching Hospital for their precious assistance. Thanks for all participants who dedicated part of their time to fill the questionnaire. Great thanks to friends and all those who assisted me to deliver this thesis. Thanks and appreciation to my family and relatives for their continuous support.

i

Abstract Coronary artery disease is a major public health concern, as it continues to be the main cause of death over the world, the major risk factors can cause elevated cholesterol level, hypertension, smoking, a sedentary life style, body mass index, waist to hip ratio and diabetes mellitus. This study aimed to identify the main factors that associated with coronary artery disease among a sample of patients with coronary artery disease. A case control study was carried out from 5thFebruary2014 to10thFebruary 2015. The participants of this study were100 patients with coronary artery disease who were attending to Surgical specialty Hospital-cardiac center and comparing100 patients free from coronary artery disease in medical ward in Hawler Teaching Hospital. The matched criteria points for both groups were (age and gender). The questionnaire was designed which consisted of four parts, part one was about Socio-demographic characteristics such as; age, gender, marital state, religion, occupation, residencies, educational level. Part two included anthropometry such as, body mass index and waist to hip ratio. Part three included history of main risk factors such as, blood pressure, diabetic mellitus, family history, smoking, physical activity, alcohol consumption and diet habit. Part four included laboratory diagnostic tests like, cholesterol, high density lipoprotein, low density lipoprotein, triglyceride and fasting blood sugar, correlation coefficient was conducted to obtaining the reliability of the study through pilot study and content validity was determined through thirteen experts. The results of the study showed that the age of the majority of participants was more than 60 years. It also indicated that there was no significant association between socio-demographic characteristics and coronary artery disease of case and control groups. The study concluded that Multiple logistic regression of risk factors for coronary artery disease which reveals risk associated with higher odds of Coronary Artery Disease are waist to hip ratio for (male O.R=10.3, for female O.R= O.R=2.0), positive family history for cardiovascular diseases (father O.R=4.4 or mother O.R=3.2), hypertension (O.R=3.4), cholesterol level (O.R=2.66), drinking alcoholic beverages(O.R=2.3), smoking cigarettes (O.R=2.25), while risk associated with lower odds of Coronary Artery Disease are history of Diabetes mellitus (O.R=0.8), The results showed that only 4% of patients with CAD doing regular exercise (p=0.234). ii

List of Contents List

Subject

Page

1.

Acknowledgment

i

2.

Abstract

ii

3.

List of Contents

iii

4.

List of Tables

v

5.

List of Figure

vi

6.

List of Abbreviations

vii-x

Introduction

1-3

Chapter one- Literature review 1.1

Historical Back Ground for Coronary Artery Diseases

4

1.2

Coronary artery disease development

5

1.3

Physiological structure of Heart

6

1.4

Coronary artery disease risk factors

8

1.5

Framingham heart study

9

1.6

Burden of the disease

10

1.7

Coronary artery disease risk factors

10

1.8

Risk factors for Coronary Artery Disease (Controllable risk factors)

11

1.9

Uncontrollable Coronary Artery Disease risk factors

20

1.10

Inflammatory biomarkers

24

1.11

The symptoms of Coronary Artery Disease

25

1.12

Treatment of Coronary Artery Disease

26

Chapter Two- Patients and methods 2.1

Design of the study

29

2.2

Setting for Conducting the Study

29

2.3

The Study Period

29

iii

2.4

Study sample

29

2.5

The criteria for selecting the sample of the study

30

2.6

Sample size estimation

30

2.7

Instruments for data collection

31

2.8

Validity of the questionnaire

32

2.9

Reliability of the questionnaire

32

2.10

Method of data collection

33

2.11

Elements for data collection

35

2.12

Administrative arrangement and Ethical considerations

36

2.13

Data management and statistical analysis

36

Chapter Three-Results

39-53

Chapter Four-Discussion 4.1

Socio-demographic characteristics

54

4.2

Anthropometry characteristics

55

4.3

history of hypertension

57

4.4

History of diabetes mellitus

58

4.5

Life style risk factors

59

4.6

Risk of family of cardiovascular disease

62

4.7

Risk of Lipid profile

63

4.8

Nutritional pattern

64

Chapter Five-Conclusions and Recommendations 5.1 Conclusions 5.2 Recommendations References Appendices Administrative arrangement Roster of experts Questionnaire in English language Questionnaire in Kurdish language

iv

67 68 69-89 A B C D

List of Tables

. List of Tables

Tables No.

Title of Tables

Page

2.10.2

Classification of waist to hip ratio

34

2.10.3

Classification of lipid profile and blood sugar

34

Socio-demographic characteristics of study participants in both groups case and control of participant with coronary artery disease (CAD) and control group patients without (CAD). Anthropometry characteristics for both (case and control groups).

39

3.1 3.2

40

Information about study participant's blood pressure in both; case and control groups. Information about study participant's Diabetes Mellitus in both (case and control groups). Family History for study participants (case and control groups).

41

44

3.13

Information regarding Smoking Habit among study participants in both (case group and control group). Information regarding Physical inactivity among study participant in both (case group and control group). Information regarding Alcohol Consumption among study participants in both (case group and control group). . Information regarding Diet Habits among study participants in both (case and control groups). Information regarding Laboratory Diagnostic Tests among study participants in both case group and control group. Association between Socio-Demographic characteristics and CAD compare with control group. Association between Anthropometry and CAD compare with control group. Association between medical and family history with CAD.

3.14

Association between nutritional status and habit with CAD.

51

3.15

Association between laboratory diagnostic tests with CAD.

52

3.16

Logistic regression showing association between CAD and some variables.

53

3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12

v

42 43

44 45 46 48 49 50 51

List of Figure List of Figure No.

Title of Figure

Page No.

1.

Structure of Heart and Coronary arteries.

vi

8

List of Abbreviations

.

List of abbreviations %

̅

percentage Mean Chi-square




More than



Summation



More than and equal to

ABC1

Adenosine triphosphate – binding cassette transporter A1

ABO

ABO blood group system

ACCF

American College of Cardiology Foundation

ACE

Angiotensin Converting Enzyme

ACS

Acute Coronary Syndrome

ACSM

American College of Sport and Medicine

AHA

American Heart Association

AIDS

Acquired Immunodeficiency Syndrome

AMI

Acute Myocardial Infarction

BC

Before Christ

BMI

Body mass index

CABG

Coronary Artery Bypass Graft

CAD

Coronary Artery Disease

CDC

Center for disease control

vii

List of Abbreviations

.

CEP

Cholesterol Education Program

CHD

Coronary Heart Disease

Cm

Centimetre

CO

Carbon monoxide

CRP

C- Reactive Protein

CVD

Coronary Vascular Disease

DM

Diabetes mellitus

DOH

Director of Health

E

Error Allowance of sampling

E

Expected Frequency

eNOS

enzyme endothelial nitric oxide synthase.

EPA

Eicosapentaenoic acid

ERT

Estrogen Replacement Therapy

F

Frequency

FH

Familial Hypercholesterolemia

FHS

Framingham Heart Study

GC

Glucocorticoids

HDL

High Density Lipoprotein

HDL- C

High Density Lipoprotein Cholesterol

HMu

Hawler Medical University

HR

Human Resources

HS

Highly Significant

viii

List of Abbreviations

.

HSFC

Heart and Stroke Foundation Research Scholarship

IHD

Ischemic Heart Disease

Kg

Kilogram

KSA

Kingdom of Saudi Arabia

LDL

Low Density Lipoprotein

LDL- C

Low Density Lipoprotein Cholesterol

MI

Myocardial Infarction

mmol/l

Millimole per liter

MOH

Ministry of Health

MONICA

Monitoring trends and determinants in Cardiovascular diseases

N n

Population size number of cases sample

NICE

The National Institute for Health and Care Excellence

NIH

National Institute of Heart

NO

Nitric Oxide

NS

Non-Significant

O.R

Odds Ratio

P

Population proportion

PAD

Peripheral Arterial Disease

PCAD

Percutaneous coronary angiography

PCI

Percutaneous Coronary Interventions

ix

List of Abbreviations

.

PTCA

Percutaneous Trans luminal Coronary Angioplasty

PUFA

Polly Unsaturated Fatty Acid

S

Significant

s

Sample size

SD

Standard Deviation

SPSS

Statistical Package for Social Science

TC

Total Cholesterol

TG

Triglyceride

UK

United Kingdom

UNRWA

United Nations Relief and Works Agency for Palestine Refugees in the Near East

USA

United States of America

VHS

Very Highly Significant

WHO

World Health Organization

WHR

Waist to hip ratio

x

INTRODUCTION

Introduction

1

Introduction Coronary heart disease, also called coronary artery disease, is a condition in which a waxy substance called plaque builds up on the inner walls of the coronary arteries. These arteries supply oxygen-rich blood to heart muscle. Plaque narrows the arteries and reduces blood flow to heart muscle. Reduced blood flow can cause chest pain, especially when active. Eventually, an area of plaque can rupture (break open). This causes a blood clot to form on the surface of the plaque. If the clot becomes large enough, it can block the flow of oxygen-rich blood to the portion of heart muscle fed by the artery. Blocked blood flow to the heart muscle causes a heart attack (NIH, 2013). Moreover, Coronary artery disease (CAD) due to atherosclerosis is a major cause of death all over the world and is the most common form of heart diseases. Its incidence is increasing among different populations and by 2020 it is estimated that it will be the major cause of death all over the world (Mohammad et al, 2013).

In addition, smoking, hypertension, and diabetes mellitus are the common risk factors among patients with coronary heart disease (CHD). High dietary fat intake and lack of physical exercise have all been documented as independent risk factors for the development of CHD (Sabra et al, 2007). Furthermore, coronary artery disease (CAD) is a common cause of death or disability in men and women, but CAD manifests differently in women for far too long, many believed that coronary artery disease was primarily a “man’s disease.” With increased awareness of the fact that the leading cause of death in women is CAD, this notion is slowly eroding. (Mosca et al, 2010) and (Sharma and Gulati, 2013). Moreover, some risk factors may affect women differently than men. For example, diabetes has a two times greater risk of CHD and stroke among

Introduction

2

women than among men. In addition, high blood triglycerides are an important cause of atherosclerosis in young women, but not in young men. Elevated triglyceride levels are an independent risk factor in women and may be a better predictor of CHD than are LDL cholesterol levels. Furthermore, Tobacco use is more dangerous in women. Women have more risk factors for CHD and stroke than men, including oral contraceptive use in combination with smoking and gestational diabetes that is a risk factor for CHD (Dedkhard, 2006). In addition, there are some other factors which have their effect on coronary heart disease such as abdominal obesity which is recognized by measuring waist circumference. It is a strong indicator for the development of coronary heart diseases (Boon et al, 2006). Moreover, with the explosive rise in the incidence of coronary artery disease (CAD), it is now estimated that this will be the leading cause of mortality and morbidity even in the developing world by the year 2015 (Achari and Thakur, 2004). Coronary artery disease (CAD) has been remaining the first killer and the major cause of public health problems in the world, which is one of the most common causes of morbidity and mortality in different communities, Moreover, CAD is the main cause of death in the United States of America among human adults representing approximately one-third of all dead people, who are over the age of 35 years, the geographical prevalence of CHD indicates that Asian Indians have approximately three times the rates of cardiac diseases as do the age matched European Americans. The risk of CHD among Indians is three to four times that of white Americans, six times that of Chinese and 20 times that of Japanese. (Ismail et al, 2004) and (Goel and Dolan 2003).

Introduction

3

Coronary Heart Disease kills more than 7 million people each year, Most of these deaths are in developing countries; thus, cardiovascular disease is expected to be the number one cause of death in developing countries for both men and women (Mackay and Mensah, 2004). The records from surgical specialty hospital-cardiac center showed that there were about 20,000 patients with coronary heart disease during 20072014. The same report shows that the number of patients with the disease increasing annually so the researcher is interested to study the risk factors for coronary heart disease. This study will focus on determining the main risk factors of coronary heart disease in order to provide information to nurses and other health care providers regarding CAD consecutively to help screen highrisk population. Knowing possible risk factors of CAD may help in counseling people regarding changing their life style in order to eliminate or reduce the mortality and morbidity of the coronary heart disease. Objective of the study A. General objective is to: Assess the risk factors associated with coronary artery disease among patients in surgical specialty hospital-cardiac center compare with control group. B. Specific objectives are to: 1. Describe socio-demographic characteristics of patients with CAD. 2. Determine common risk factors lead to CAD such as (age, sex, hypertension, diabetes mellitus, smoking, physical inactivity, drinking alcohol, family history, high blood cholesterol level, and obesity). 3. Find out the association of coronary artery diseases and sociodemographic data. 4. Identify the relationship between some factors (medical history, family history, life style, patients BMI and waist/ hip ratio) with coronary artery diseases.

CHAPTER ONE LITERATURE REVIEW

Chapter One: Literature Review

4

1-Literature Review 1.1-Historical Back Ground for Coronary Artery Diseases To say exactly when civilization first became aware of coronary artery disease or artery narrowing is difficult. At the 2009 American Heart Association meeting in Florida, researchers presented study results showing that Egyptian mummies,

some

3,500

years

old,

had

evidence

of

heart

disease

specifically atherosclerosis, which narrows the arteries. Pharaoh Merenptah, who died in the year 1203 BC, was plagued by atherosclerosis. Nine of 16 other mummies studied also had evidence of the disease. Researchers theorized that diet could be involved. High-status Egyptians ate a lot of fatty meats from cattle, ducks, and geese, and used a lot of salt for food preservation. However, it’s known that Leonardo da Vinci (1452–1519) investigated coronary arteries. (Allam et al, 2011). Later, Friedrich Hoffmann (1660–1742), chief professor of cardiology at the University of Halle, noted that coronary heart disease started in the “reduced passage of the blood within the coronary arteries.” However the cardiologist William Osler (1849–1919) worked extensively on angina, and was one of the first to indicate that it was a syndrome rather than a disease in itself. Later, in 1912, the American cardiologist James B. Herrick (1861–1954) concluded that the slow, gradual narrowing of the coronary arteries could be a cause of angina. He’s credited with inventing the term “heart attack.”(Scallan et al, 2010). In 1948, researchers under the direction of the National Heart, Lung and Blood-Institute initiated the Framingham Heart Study, the first major study to help understand heart disease. In 1949, the term “arteriosclerosis” (known as “atherosclerosis” today) was added to the International Classification of Diseases, which caused a sharp increase in reported deaths from heart disease (WHO 2012a).

Chapter One: Literature Review

5

1.2-Coronary artery disease development Atherosclerosis word is of Greek origin and literally means gradual focal buildup and accumulation of lipid and fibrous tissue in plaques in the wall of arteries. (i.e., ATHERE [gruel]) and thickening of arterial intima (i.e., sclerosis [hardening]). Atherosclerosis is the CAD or coronary artery atherosclerosis refers to the presence of atherosclerotic changes within the walls of the coronary arteries, it causes impairment or obstruction of normal blood flow with produced myocardial ischemia (Finn et al, 2010). Initiated mostly from mixture of cholesterol, lipids, calcium, fibrous tissue, such as collagen, and other waste products, are depositing in the layers of the arteries. Buildup of fatty plaque called atherosclerosis; the progressive narrowing of the arteries with nourishes muscle of heart and can lead to progress of chemical and structural injury to the blood vessels in critical organs as the heart, brain, and kidney (Michael et al, 2010). The genetic atherosclerosis such as a familial hypercholesterolemia (FH) is associated with mutations in genes, as well as mutations in some genes that lower HDL levels, such as the adenosine triphosphate .binding cassette transporter A1 (ABC1) canal is known to cause accelerated atherogenesis. Atherosclerosis developed by a multifactorial from genetics and environmental factors that play a role in the pathophysiology of the disease (Yusuf et al, 2004). On the other side, the environmental factors such as cigarette smoking, arterial hypertension and dietary cholesterol consumption are associated with an increased risk of CAD. In addition, the atherosclerosis more related to lipid profile such as cholesterol, triglyceride, HDL and LDL depending on several epidemiological and genetic studies were confirmed the association between elevated HDL level and protection against atherogenesis. Therefore, the process of lipid deposition in the wall of blood vessels called atherogenesis (Jeevan et al, 2011).

Chapter One: Literature Review

6

1.3- Physiological structure of Heart. Heart is a muscular (myocardium) organ in all vertebrates animal, and it is considered an aerobic metabolic organ. Heart organ is responsible for pumping the blood through the blood vessels into whole body by repeated rhythmic contractions, while the coronary blood flow is closely coupled to myocardial ventilation oxygen consumption in normal hearts (Gonzalez-Pacheco et al, 2014). Myocardium the heart muscle is involuntary and it is found only in heart and needs energy by nutrition and oxygen coronary artery supply, which is almost exclusively depending on oxidation of substrates for generation of energy. However, it can develop only a small oxygen debt and still have enough energy to function its muscles normally (Danesh et al, 2004). Coronary arteries arise from aorta arteries and both are adjacent to the heart. The arterial coronary wall normally consists of three well-defined concentric layers that surround the arterial, the artery composed of the layer immediately adjacent to lumen called the intima, the middle layer known as the media, and the outermost layer comprises the arterial adventitia. Each of layers has a distinctive composition of cells and extracellular matrix (Kearney et al, 2005). Coronary artery disease (CAD) also called as coronary heart disease (CHD), coronary atherosclerosis and Ischemic heart disease (IHD), which is a branch of coronary vascular disease (CVD) and a common form of heart disease. And, it is considered insidious and dangerous disease in the world, and Coronary heart disease (CHD) is one of the most common causes of morbidity and in different communities. In the United States of America, CHD is the leading cause of death in adults, accounting for approximately one-third of all deaths in people over the age of 35 years. Despite the lack of accurate data, there is some evidence to indicate that CHD is increasing in magnitude in the Islamic Republic of Iran. While age-adjusted mortality from CHD is gradually falling in developed countries

Chapter One: Literature Review

7

the rate has increased by 20%–45% in the Islamic Republic of Iran (Hadaegh et al, 2009). Improvements in primary prevention and treatment during recent decades have successfully reduced the mortality due to CHD in North America and Western Europe; but in the same period it has increased in Asia and Eastern Europe (Fakhrzadeh et al, 2008). However, during the past 40 years, there had been an increasing awareness to evaluate the CAD risk factor in asymptomatic individuals (Dagenais and Haldeman, 2001). Acute myocardial infarction (AMI) is a major public health problem from 1987-1997, the death rate from CAD declined 24.9%. France and Mediterranean regions appear to have a lower incidence of CAD (Meinrad, 2004). This phenomenon partly explained by greater use of alcohol, with its possible HDL raising benefit, and the Mediterranean due to consumption Mediterranean diet, which is less atherogenic. Also, Eskimos have a lower prevalence of CAD, which includes predominant use of monounsaturated fatty acids (Vibhuti et al, 2010). Coronary artery disease development is characterized by hard LDLcholesterol (plaques) which are adiposities in the arterial wall of coronary with developing the buildup of blockage, leading to heart attack, ischemic condition, and complete artery block or suddenly death, two coronaries arise from the aorta, which is adjacent to the heart. The plaques can cause a tiny initial clot to form, which can obstruct the flow of blood to the heart muscle (AHA, 2006).

Chapter One: Literature Review

Figure.1.1-Structure of Heart and Coronary arteries.

8

(NIH,2013)

1.4-Risk factors of coronary artery diseases Over the past 150 years there have been numerous efforts to explain the complex events associated with the development of atherosclerosis. Many previous studies confirmed that the CAD development has a strong relationship with many risk factors; therefore the risk factors are important to prognosis and prediction of CAD development. In addition, a number of clinical and laboratory variables have proven predictive of the incidence of cardiovascular disease, moreover, the observational study was referred to a strong and consistent main risk factor associated with cardiovascular disease (Kearney et al, 2005). Risk factors have included blood pressure, cigarette smoking, cholesterol (TC), LDL-C, HDL-C, and diabetes.2–4 Factors such as obesity, left ventricular hypertrophy, family history of premature CHD, and estrogen replacement therapy

Chapter One: Literature Review

9

(ERT) have also been considered in defining CHD risk (Wilson et al, 1998 and Laurila et al,2013). 1.5-Framingham heart study One of the most important cardiovascular risk factor identification studies is the ongoing Framingham Heart Study, initiated in 1949 in Framingham, Massachusetts. This ground-breaking study aimed to identify modifiable and nonmodifiable CVD risk factors as well as to provide information on the progression of coronary heart disease (CHD) over time. (FHS, 2013) The original study sample included 5,209 individuals between the ages of 30-60 years, 2,336 men and 2,873 women. It was one of the first CVD studies to include women. The Framingham Heart Study clearly established that the three major modifiable CVD risk factors are: high cholesterol, hypertension and cigarette smoking, frequently referred to as the classic triad. Each of these has a strong causal relationship with CHD, followed by the non-modifiable risk factors of age, gender, and family history. The other modifiable risk factors that the Framingham study identified are high dietary fat, lack of physical activity and diabetes. Follow-up of the initial recruits and their offspring is still ongoing today and data from the study continue to give valuable information about the relationship between various risk factors and CHD.A later study included three groups of male subjects from the Framingham heart study who were 50-59 years old at baseline in 1950, 1960, 1970 (NIH, 2013). However the Framingham Risk Score is one of the most widely used risk assessment methods for prediction of CAD risk, considers the established risk factors of gender, age, smoking, total cholesterol, LDL cholesterol, HDL cholesterol, and DM. The Framingham Risk Score underestimate CAD risk for

Chapter One: Literature Review

10

individuals with a family history of CAD at younger ages, moreover does not consider family history as a risk factor (Marens et al, 2003). 1.6-Burden of the disease Cardio vascular disease (CVD), especially coronary heart disease CHD, is the most common cause of death worldwide. In Europe, 22% of women and 20% of men die from CHD. Overall, CVD accounts for 52% of deaths in women and 42% of deaths in men (Nichols et al, 2012). The regional differences in mortality rates can partly be explained by prevalence of the classic risk factors (e.g. smoking and hypertension) (Havulinna et al, 2008 and Muller-Nordhorn et al, 2008). Mortality rates for CHD have declined in many countries during the past decades. The decreasing trend has been especially strong in Finland, which had the highest CHD mortality in the world in the 1970s. Today, the mortality rate is closer to that of other Nordic countries, but remains high (World Health Organization 2012a). Epidemiological and clinical data from studies have shown an increased occurrence of CAD in young Iranian people. Premature coronary artery disease (PCAD) in subjects dramatically affects the quality of life and morbidity and leads to premature death, but the mechanisms and predictors of this complication are still known (Visi-Raigani et al, 2010). Despite progress in many developed countries, the global burden of the disease persists. CHD rates have increased and are higher than ever in many former Soviet Union states (Mirzaei et al, 2009). A study on CHD mortality in the Eastern Province of KSA showed that 26% of total deaths were recorded as CHD deaths comprising 27% of total male and 23.5% of total female deaths respectively (Sabra et al, 2007). The CHD epidemic is dynamic, reflecting changes in CHD risk factor levels within a population. Poor

Chapter One: Literature Review

11

dietary habits, heavy smoking and a sedentary lifestyle due to urbanization have triggered the epidemic in developing countries, where the majority of all cardiovascular events occur (Okrainec et al, 2004 and Perk et al, 2012). The emerging epidemic of obesity and diabetes poses a new threat to cardiovascular health worldwide. Since 2000, the prevalence of diabetes has increased in most European countries; the economic burden of CHD consists of direct costs in health care (33% of total cost), productivity loss (29%), and informal care (38%). The annual total cost of CHD is estimated to be over 60 billion Euros in the European Union (Nichols et al, 2012).

1.8-Coronary Artery Disease Risk Factors (Controllable risk factors). 1.8.1. Hypertension: Is defined as a systolic blood pressure in excess of 140 mmHg or a diastolic blood pressure above 90 mmHg. Uncontrolled high blood pressure can result in hardening and thickening of the coronary arteries, narrowing the channel through which blood can flow. In addition, it was indicated that the elderly are particularly predisposed to hypertension, with up to 75% of people over 75 years of age qualifying for CAD diagnosis. There appears to be an approximately linear relation between blood pressure elevation and increased the incidence of atherosclerotic vascular disease (Chobanian et al, 2003). In observation study it was referred that the hypertension was considerably more frequent among cases than control subjects. Therefore, the hypertension considers the main risk factor of CAD development in many populations (Hopkins et al, 2005). 1.8.2. Serum Hypercholesterolemia: Defined as an increased in serum cholesterol level due to environmental or genetic factor. Many previous studies indicated that the prime causative and actual

Chapter One: Literature Review

12

factor of the heart disease is high cholesterol level. The association between lipid profiles and CAD development is determining via cholesterol levels (AHA, 2006). The cholesterol is the essential player of lipid profiles in atherogenesis process of CAD progressive, which are the main CAD indicator and CAD monitor. However, the hypercholesterolemia reported to be strongly associated with enhancing oxidative stress, via increased lipid peroxidation and tends to increase the susceptibility of LDL to oxidation (Kaneda et al, 2002). A high level of LDL-C can lead to clogging of the arteries, increasing the risk of heart attack and ischemic stroke, while a high level of HDL-C reduces the risk of coronary heart disease and stroke (Mackay and Mensah 2004, WHO 2004a AHA, 2006). According to previous studies hypercholesterolemia is considered from the main risk factor of whole lipid profile. However cholesterol is in part dependent on age and sex, the serum cholesterol level between male and female not equalized, and during age decades was observed many differences in cholesterol levels between sex groups, also females have higher cholesterol levels than males until about age 20 year, and no difference between sex groups after age of 40 years (Kaess et al, 2010). The genetic relation is considered as one of risk factors, however the presence of genetic factor such as familial hypercholesterolemia (FH) is the first entity directly associated with the development of premature atherosclerosis and CAD. Familial hypercholesterolemia a heterozygotes genetic disorder, which is manifest a 2-5 fold elevation in plasma LDL cholesterol that is due to a functional impairment of the LDL receptor. In FH heterozygotes, 85% of individuals have experienced a Myocardial Infraction (MI) by the age of 60, and this age reduced to 15 years. in patients homozygous for the disease. While the FH homozygotes

Chapter One: Literature Review

13

demonstrate a 5-6 fold elevation in plasma cholesterol that produces precocious atherosclerosis (Kearney et al, 2005). 1.8.3. Cigarette smoking: Cigarette smoking or Tobacco use was defined as self-reported current use of tobacco products including cigarette, cigar, pipe, or spit tobacco or The Inter Heart study defined current smokers as individuals who smoked any tobacco in the previous 12 months and included those who had quit within the past year (Yusuf et al, 2001). Furthermore, cigarette smokers have been defined as individuals are considered to be daily smokers if they regularly smoke at least one cigarette per day. Current smokers include both daily and occasional smokers (HSFC, 2003). Former smokers were defined as those who had quit more than a year earlier (Yusuf et al, 2001). Cigarette smoke contains over 4,000 known components, which is considering one from the main risk factors of CAD development in the most of population. (Al-Refaee and Al-Hazzaa, 2001). Cigarette smoking and abnormal serum cholesterol concentrations are risk factors for acute coronary syndromes, but the underlying mechanisms are poorly understood. In addition to its association with premature atherosclerosis, cigarette smoking is a risk factor for acute myocardial infarction and possibly sudden death from coronary disease. Likewise, elevated serum cholesterol concentrations and low serum high-density lipoprotein (HDL) cholesterol concentrations are associated with an increased risk of acute coronary events and premature atherosclerosis. 2,3Sudden death, a frequent result of severe coronary disease, is often precipitated by acute coronary thrombosis (Lloyd-Jones et al, 2004). However Smoking increases the risk of several chronic diseases. Smokers have a two-fold risk for developing heart disease compared with nonsmokers, and the relative risk is 25% higher in women than men (Huxley and Woodward 2011).

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Furthermore, people who have never smoked but who live with a smoker have a 30% excess risk for heart disease, which is comparable to the risk of subjects who smoke one cigarette per day (Law et al, 1997; Huxley and Woodward, 2011). Exposure to cigarette smoke has many adverse effects on health. It promotes inflammation, increases oxidative stress and has unfavorable effects on lipid profile (Ambrose and Barua 2003). Smoking thus acts in concert with other risk factors, and its coexistence with such risk factors as high blood pressure or high cholesterol multiplies the risk for cardiovascular events. For example, smoking reduces the amount of oxygen in the blood, which increases the workload of the heart and raises blood pressure. Consequently, when smoking and hypertension are combined they increase the risk for arterial stiffness more than either factor alone (Scallan et al, 2010). Many studies observed the presence of a strong association with the cigarette smoking and many other diseases, the cigarette smoking more linked to heart diseases. The nicotine constricts blood vessels, and carbon monoxide (CO) can damage their inner lining, making them more susceptible to atherosclerosis. However in both animal and human models, several studies have demonstrated that the cigarette smoking exposure were associated with a decrease in vasodilator function. Cigarette smoking could promote atherosclerosis, in part, by its effects on lipid profile. Smokers have significantly higher serum cholesterol, triglyceride, and LDL levels, but HDL is lowering in smokers than in nonsmokers (Ambrose and Barua 2004), it was estimated that the smoking increases atherosclerotic disease by 50% and doubles the incidence of CAD (Mohammad et al, 2013).

1.8.4. Physical Inactivity: The American Heart Association in conjunction with the American College of Sports Medicine recommends all healthy adults ages 18-65 should get at least 30

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minutes of moderate intensity activity five days a week. Children should get at least 30 minutes of age appropriate activity every day of the week to maintain a healthy heart as well as a healthy weight (AHA, 2006). The regular exercise or physical activities consider the most important and the beneficial treatment methods for people that under CAD risk. In the United States of America (USA) an epidemiological research on physical activity revealed that the physical inactivity appears to be a more important CAD risk factor the physical activity retarding CAD development via reduces VLDL levels, raises HDL levels, sometime decrease LDL level, and lower blood pressure, reduce insulin resistance, and favorably influence cardiovascular function with and coronary blood flow, in the same time effectively will be reducing all of other risk factors. However, the first-line therapies for all lipid and non-lipid risk factors are associated with weight reduction and increased physical activity (Havulinna et al, 2008).

1.8.5. Diabetes Mellitus (DM): Is defined as an increased of blood glucose level (hyperglycemia). Recent and previous studies observed the presence of a strong association between CAD development and DM; therefore the DM is considering one of the main risk factor of CAD development. In DM patients the risk of coronary atherosclerosis are elevated three-to five fold greater than in non-diabetics despite controlling for other risk factors(Chow et al, 2011). Diabetes mellitus includes a range of medical conditions. Two main subtypes are type1 diabetes (juvenile-onset diabetes) and type II diabetes (adultonset diabetes), but other subtypes also exist. Of the two main subtypes, type II is the most prevalent form of diabetes and thus, a more relevant risk factor, but both

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subtypes have been shown to increase CHD risk (Grundy et al, 1999; Orchard et al, 2006). Diabetes is manifested by high levels of glucose in the blood caused by insulin resistance. Insulin is a hormone produced by the pancreas that lowers blood glucose levels. In type 1 diabetes, beta cells that produce insulin have been destroyed by autoimmune reactions, and the patients are dependent on insulin injections to maintain normal glucose levels the onset of type II diabetes is usually later in life (> 40 years of age) and is often preceded by metabolic syndrome (Wilson et al, 2005).

Weight control is an essential part of the treatment of patients with type II diabetes. Diagnostic criteria for diabetes are fulfilled if the measured fasting plasma glucose is 7mm/l or more or 11.1 mm/l or more two hours after the oral dose in the glucose tolerance test. As dyslipidemia and hypertension are especially harmful in diabetics, more stringent thresholds are applied for blood lipid levels and blood pressure. For example, the target value for blood pressure is below 130/80 mmHg. Statins might be considered for patients with unfavorable lipid values, as they have been shown to decrease the risk for vascular events in people with diabetes (Kearney et al, 2008; Working group set up by the Finnish Medical Society Duodecimo and the Finnish Respiratory Society 2011).

1.8.6. Body Mass Index (BMI): The body mass index: is a key index measurement for relating a person's body weight to their height. It had been used by the World Health Organization (WHO) as the standard for recording obesity statistics since the early 1980s. The BMI invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing "social physics"(Eknoyan 2008).

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Body mass index is a statistical measurement that compares a person's weight and height, though it does not actually measure the percentage of body fat, but it is a useful tool to estimate a healthy body weight based on how tall a person is. Due to its ease of measurement and calculation, this is the most widely used diagnostic tool to identify weight problem. Body mass index was defined as the individual's body weight divided by the square of his height. While the calculation of BMI equation is by dividing the person's weight (in kilograms) at their height (in meters squared), and the formulas universally used in medicine produce a unit of measure of kg/m2 (Hopkins et al,2005). The overweight was defined as BMI 25.30 kg/m2 for males and females but the obesity was defined as BMI ≥ 30 kg/m2. The elevated body-mass index associated with several risk factors for CAD, including hypertension, dyslipidemia, and D.M. and other factors (Bibbins et al, 2007).

Obesity or overweight: is defined as an excess in body weight with an abnormal high preponderance of body fat. The obesity has become a major public health issue in the United States, and the prevalence of obesity in the developed world is increasing at an alarming rate (Stocker et al, 2004)

The prevalence of worldwide obesity has almost doubled since 1980. In 2008, 10% of men and 14% of women had a body mass index (BMI) of 30 kg/m2 or more (World Health Organization 2012a). In adults, BMI of 25 kg/m2 or more is defined as overweight and BMI of 30 kg/m2 or more as obesity. In the general population, overweight and obesity are associated with increased overall mortality, which is mainly attributable to cardiovascular and diabetic deaths (Whitlock et al, 2009).

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However, for patients with established CHD, the relationship between obesity and cardiovascular mortality is more controversial. Overweight and mild obesity appear to be protective and improve survival of CHD patients (RomeroCorral et al, 2006). This “obesity paradox” could be partly due to the inaccuracy of BMI as an indicator of harmful obesity. Although useful as a standard measure, BMI is a rough estimate of overall obesity, as it provides no information on fat distribution. Two individuals with the same BMI could have very different body composition of fat and lean mass. Abdominal obesity, measured by waist circumference or waistto-hip ratio, has been found to increase the risk of diabetes and CHD over and above BMI. Abdominal measurements may also be useful in more accurate risk classification of BMI-defined obese and overweight people (Canoy et al, 2007; The Inter Act Consortium 2012).

Since 1970, the prevalence of overweight among children between ages 2 to 5 years has been doubled, while among children and adolescents between ages 6 to 19 years it has been tripled. Recently studies considered more than 9 million children and adolescents (17%) are being overweight (Bibbins et al, 2007). The relationship of obesity with CAD is running in the same line with some other risk factors, as a number of other risk factors for cardiovascular disease, such as hypertension, low HDL cholesterol and DM, often coexist with obesity (Wilson et al, 1999). However, the exact mechanisms explain this phenomenon is controversial, while today the relationship between obesity and cardiovascular disease has become of considerable concern (Stocker et al, 2004).

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1.8.7. Stress: Is the way of metabolic body reacts to change, includes our mental, emotional, and physical responses to the pressures of everyday life, and with change is a natural and normal part of life, therefore a moderate amount of stress is part of normal living. Stress may be good by acting body motivate and more productive, while the strong stress response is a harmful with set the body for general poor health as well as specific psychological or physical illnesses like heart disease or infection (AHA, 2006). The stress can be acute or long-term chronic, the acute stress is a "fight-orflight" reaction to an immediate threat. Triggers of acute stress include crowds, noise, and dangerous situations. The chronic stress requires suppressing natural "fight-or-flight" reaction over hours, days, or even years. The chronic stress triggers include demanding jobs, family problems, marital problems, money worries, or feelings of inadequacy or loneliness, in body system the acute stress mechanism will react with stimulators by inducing major body organs such as the brain organ to send out a various of signal hormones includes cortisol and adrenaline hormone, the immune system to prepare its system for the attack, the heart organ to increase blood pressure, the lungs to increase the breathing and become more rapid to take-in more oxygen in lungs, the circulatory system to increase blood flow 300% to 400% to get the muscles ready for any added demands and the spleen to release more red blood cells. All these organs will be prepared and ready for kick into high gear. Therefore, unrelieved that the stress mechanism in body system may damage the arteries as well as worsen other risk factors for CAD progression(Davidson et al, 2004) and (WHO, 2010). Numerous studies have established that depression predicts the incidence of CHD in previously healthy people in recent years; depression has emerged in the discussion on the impact of psychological aspects on coronary risks Several

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prognostic studies have shown that depression is a predictor for survival after myocardial infarction (Rozanski et al, 1999. WHO, 2004a. AHA, 2006). Major depression is associated with a 4- fold increase in the risk of mortality during the first 6 months after acute MI, and its prognostic significance is comparable to that of left ventricular dysfunction and history of MI. Depression predicts the development of CHD in initially healthy people. Depression was found to be a better predictor for CHD outcome than hostility, anger, or anxiety (Rugulies, 2002).

1.9-Uncontrollable CAD risk Factors 1.9.1. Age: Age was defined as the length of time a person has lived in years. Age was determined by participants’ self-report is among the most important risk factors for predicting incident cardiovascular disease. Based on previous experience studies in the United States the average risk of developing cardiovascular disease for a 30-34 year old male is 3%, this number raises some sevenfold to 21% for a comparable individual aged 60.64 years the exact importance of age-related risk compared with other cardiovascular disease risk factors illustrated by the Framingham Heart Study that has resulted in a 14-point scoring system to predict incident 10-year cardiovascular disease. In this system, the increasing risk characterized by a higher score, up to 7 points can be attributed to age alone (Jeevan et al, 2011). In addition, the cumulative risk for CAD in males by age 70 is 35% and by age 90 is 49%. While the women typically develop CAD about 10 years later than men with a cumulative risk of 24% and 32% by ages 70 and 90, respectively. Therefore they considered a disease of advancing age is approximately 15% of cases are diagnosed before age 65. While at young ages the disability and mortality from CAD is particularly devastating to families and has a substantial impact on

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our economy. In addition, the individuals with genetic predisposition to atherosclerosis are at the greatest risk for developing CAD, especially at early ages, and they have the most to gain from preventive interventions (Marens et al, 2003).

1.9.2. Family history of early heart disease: The participants in this study self-reported whether a first degree relative had been diagnosed with cardiovascular disease. Specifically, participants identified whether a family member had ever been diagnosed with a heart attack, stroke, or congestive heart failure the premature CAD is known to have a particularly strong genetic component. Previous data suggested that the genetic factors are more likely to affect young rather than old people. They conducted a population subdivision, analyzing separately individuals who developed CAD before the age of 45 (Freitas et al, 2008). In statistical studies done in 2003 in USA, an estimated 12,600,000 Americans have CAD, estimated 650,000 Americans will have their first heart attack and another 450,000 will have a recurrent event (Marens et al, 2003). Positive parental family history of heart disease refers to a situation where at least one parent of an individual has suffered from the disease. This simple measure, usually evaluated with a questionnaire, has been thought to represent a combination of both environmental (shared risk factors in the family) and genetic effects. Many studies have shown that family history is a risk factor for CHD, and the effect is independent of traditional risk factors (Jousilahti et al, 1996. Hawe et al, 2003. Lloyd-Jones et al, 2004). Also, adjusting for behavioral risk factors (tobacco use, alcohol use, physical activity, and fruit and vegetable intake), psychosocial risk factors (depression, permanent stress, financial stress, stressful events, and perceived locus of control) and a panel of common genetic variants

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explains only modestly the association between MI and family history, Thus the composition of family history measurement remains largely unknown (Chow et al, 2011).

1.9.3. Gender or Sex; Important risk factor in incidence of CAD and many studies noted difference between male and female in CAD distribution among population.

Also the

distribution differs from population to other. However, numerous observational studies have indicated that males exhibit excess risk for cardiovascular disease compared with age-matched women. A woman’s

risk rises once she enters

menopause, this speculation depends on estrogens hormone, and will offer a protective effecting role to women body system, and cardiovascular disease accelerates in women after menopause. However, this speculation has been difficult to substantiate, as the treatment with estrogen has not reduced the incidence of cardiovascular disease of postmenopausal women. The estrogens have biphasic effects on hepatic cholesterol metabolism, the strength of the relationship between low HDL levels and increased CVD risk also is significant in elderly individuals and may be greater in women than in men. Alternatively, some of this apparent protection could be due to the fact, that women exhibit relatively higher concentrations of HDL cholesterol than do age-matched men. (Kearney et al, 2008). During the last few decades several reports have suggested that ABO blood groups, in particular non-O blood groups, are associated with the risk of ischemic heart disease and of developing severe manifestations of atherosclerosis. Results from the Framingham study and several other reports indicated that the incidence of ischemic heart disease may be higher in subjects of blood group A or its subgroups. Statistics found that the B blood group may be related to coronary

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atherosclerosis in Lithuanian women. In apparent contradiction, Mitchell showed that towns with a higher prevalence of blood group O had higher rates of cardiovascular mortality (Nydegger et al, 2003). It was suggested that cardiovascular disease might be more lethal in subjects with blood group O. Herein, we report a study on the distribution of ABO groups in a series of patients who underwent coronary artery bypass grafting (CABG) at Tehran Heart Center in order to evaluate whether ABO blood groups are associated with an increased risk of developing coronary artery disease and to discover any difference in prevalence of major cardiac risk factors, i.e. hypertension, smoking, diabetes mellitus and hypercholesterolemia among documented CAD patients with different ABO blood groups.( Amirzadegan et al, 2005). Risk factors for coronary artery disease have been divided into conventional and novel risk factors. Hypertension, diabetes, smoking, dyslipidemia, sedentary lifestyle, and abdominal obesity are considered to be traditional risk factors for CAD; Research into newer risk factors like homocysteine, fibrinogen, C reactive protein, genetic factors and platelet polymorphisms is in progress to determine their effects on causation of CAD. (Jeevan et al, 2011). Nitric oxide (NO) plays a major role in the regulation of vascular tone Associations between NO genotypes, coronary artery disease (CAD) and other risk factors have been described by many authors. However, in some individuals, CAD is not associated with conventional risk factors, suggesting that other genetic factors are involved in the predisposition to coronary atherosclerosis. To study the candidate genes that may contribute to its pathogenesis may be a good approach for the understanding the etiology of CAD. One such factor may be nitric oxide (NO), derived from vascular endothelium is a short-lived vasoactive substance synthesized from l-arginine by the enzyme endothelial nitric oxide synthase eNOS (Matyar et al, 2005).

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This suggests that other factors might play a key role in the progression of atherosclerosis. Recently oxidative stress and inflammation have been considered as significant risk factors for CVD. Several lines of evidence support a role for oxidative stress in atherogenesis (Alamdari et al 2008). Eicosapentaenoic acid (EPA) is one of the n-3 polyunsaturated fatty acids (PUFA) found large quantities in fish oil. Ever since Dyerberg and Bang reported that EPA levels were high in the blood and diets of Greenland Inuit (who have low prevalence of atherosclerotic diseases, the preventive effects of n-3 PUFA, including EPA, has been examined in many epidemiological and clinical studies. Most studies have found that intake of fish and fish oil is related to reduce risk for total mortality, sudden death and coronary artery disease CAD (Saito et al, 2008). 1.10-Inflammatory biomarkers The development of atherosclerosis is a complex interplay between metabolic and inflammatory processes. Focal endothelial activation triggers an immune response, which attracts immune cells to the site. The cells infiltrate the lesion and produce inflammatory cytokines (interferon-γ, interleukin-1, and tumor necrosis factor), inducing the production of interleukin-6 (IL-6) (Hansson 2005). IL-6 stimulates the production of C-reactive protein (CRP), a commonly used indicator of acute infections, but the levels are also elevated in chronic diseases. Fibrinogen is another protein involved in the inflammation process, playing a role in blood clotting and platelet aggregation. These inflammatory biomarkers have also been associated with CVD and CHD in the general population and their use in cardiovascular risk evaluation has been studied (Ridker et al, 2000. Danesh et al, 2004. Kaptoge et al, 2012). Glucocorticoids (GC) are regulators of the immune system, inflammatory processes, and many other processes involved in fat and glucose metabolism. Inflammatory processes have been recognized to play a key role in the

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pathogenesis of atherosclerosis and coronary artery disease (CAD). (Goracy et al, 2012). Nevertheless, there are some drawbacks to using these inflammatory biomarkers in risk assessment. First, they are associated with other classic risk factors, and thus, they might not provide much additional information beyond these risk factors. For example, inflammatory processes have been shown to have a role in a low HDL cholesterol state (Laurila et al, 2013). Second, inflammation markers are not specific to CVD, as they are elevated in other nonvascular diseases as well. Third, the causality or dose-effect relationship of these markers and the risk of CVD has not been established. Fourth, evidence on therapeutic agents that target circulating levels of these markers and affect CVD incidence is lacking. Fifth, the assays have a higher cost than classic risk factors such as blood lipids (Perk et al, 2012).

1.11-The symptoms of Coronary Artery Disease include: 1.11. a. Chest pain (angina pectoris) due to inadequate blood flow to the heart. 1.11. b. Heart attack, acute myocardial infarction (AMI), leads to death due to sudden total blockage of a coronary artery. 1.11. c. Sudden death, due to a fatal rhythm disturbance. (Sabra et al 2007).

1.12-Treatment of Coronary Artery Disease: All CVD prevention guidelines highlight that people with most to gain from treatment are those at greatest risk of CHD. These are also the groups in whom treatment is most cost effective. The individuals at most risk are those who have current symptoms of heart disease (such as have suffered a heart attack, have suffered angina, or have received coronary revascularization) or those with symptoms of other arterial diseases (such as stroke, transient ischemic attack, or peripheral vascular disease). All of these patients are automatically eligible for

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secondary prevention measures (secondary for they already have established CVD and the aim is to prevent progression) to reduce their risk of repeated events or death (Hobbs, 2004). Optimal management of risk factors, especially the modifiable ones and appropriately targeted pharmacotherapy has been shown to play a significant role in improving the outcomes and quality of life as secondary prevention in patients who have undergone CABG. These measures include control of hypertension, lifestyle and dietary changes, quitting smoking and a number of interventions including lipid-lowering, anti-platelet agents, angiotensin converting enzyme (ACE) inhibitors and beta-blockers. (Foody et al, 2003 and Herlitz J, 2004) Treatment of CHD includes: • Medical treatment. • Surgical treatment.

1.12.1. Medical treatment of Coronary Heart Disease: Includes: 1. Treatment of other risk factors like hypertension, diabetes, dyslipidemia, etc. 2. Drugs: thrombolytic agents, nitrates, beta blockers, calcium channel blockers, antiplatelet agents and anticoagulants as aspirin or clopidogrel (Plavix), lipidlowering agents like statins, etc. ( Park K, 2009) and (Scott L&Todd L, 2010).

1.12.2. Surgical treatment of Coronary Heart Disease: Coronary artery revascularization procedures include coronary artery bypass grafting (CABG) and percutaneous Tran's luminal coronary angioplasty (PTCA). (Park K 2009) and (Scott L&Todd L 2010).

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Over the last three decades, invasive procedures such as coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) have resulted in significant improvements in survival and quality of life for patients. This has happened despite a worsening risk profile of patients undergoing CABG. Ferguson et al, 2002). For successful treatment means should be available for the rapid transportation of the individuals with probable heart attacks to the coronary care unit of the nearest hospital, and selected members of the community should be trained in effective resuscitative techniques. The effect of an AMI on mortality is largely dependent on the time from symptom onset to the time of reperfusion. Reperfusion therapy with either percutaneous coronary intervention or fibrinolytic drugs leads to lower mortality and fewer complications (Asseburg et al, 2007). Maximum benefit is achieved when reperfusion is performed in acute coronary syndrome (ACS) within 60 minutes of symptom onset (Moser et al, 2005). The benefit from both reperfusion techniques decreases markedly if they are received more than 3 hours after symptom onset, although there may be some benefit up to 12 hours after symptoms start (Ting et al, 2006). The largest contributor to delayed time to receipt of reperfusion for ACS is patient delay in recognizing symptoms and deciding to seek treatment (McKinley et al, 2009). Patients undergoing angioplasty have survived a traumatic and life threatening event that causes patients to respond with feelings of vulnerability, fear of death, and disease recurrence. Fear of death and vulnerability also caused patients to share regrets over past behavior (Peterson et al, 2010).

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1.12.3. Vaccination of patients with CHD: Influenza vaccination has been shown to reduce the risk of hospitalizations for heart disease and all-cause mortality in older persons, and annual influenza vaccination is recommended by the AHA for patients with CHD (Nichol et al, 2003 and Smeeth et al, 2004). Pneumococcal polysaccharide vaccination is recommended in all patients with heart disease. Acute myocardial infarction has peak incidence in winter and the risk of this event increases significantly after respiratory and urinary tract infections (Smeeth et al, 2004). Inflammation and infection as trigger factors of atherosclerotic plaque rupture are an attractive explanation of acute coronary syndromes ACS (Ciszewki et al, 2008).

CHAPTER TWO PATIENTS AND METHODS

Chapter Two: Patients and Methods

29

2. Patients and Methods 2.1-Design of the study: This case control study (quantitative design) was conducted in Surgical Specialty Hospital-cardiac Center in Erbil City, the capital of the Kurdistan Regional to assess risk factors for coronary artery disease. 2.2- Setting for Conducting the Study: The study was conducted in the Surgical Specialty Hospital-Cardiac Center, where was established in 2007 and has over 350 staff including physicians, nurses, credentialed allied health professionals, associated employees, and provides 100 beds for the patients. The Hospital receives the patients who have heart diseases in general and coronary heart disease in particular, and provides the medical and surgical treatment such as (cardiac catheterizations, open heart surgery and all investigations related to heart diseases). 2.3- The Study Period: The study was carried out from 5th February 2014 to 10th February 2015. 2.4-Study sample: The study sample consists of 100 post cardiac catheterized patients diagnosed as CAD admitted in Surgical Specialty Hospital-Cardiac Center including both genders, which are presented with coronary artery diseases CAD, and 100 patients not presented with coronary artery diseases CAD controls from Erbil Teaching Hospital.

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2.5-The criteria for selecting the sample of the study 2.5.1. Inclusion criteria: 1. New diagnosed cases of coronary artery diseases (less than 6 months). 2. Both genders. 3. Patients aged more than 18 years.

2.5.2. Exclusion criteria including: Patients who refuse to be interviewed or could not participate in the study. 2.5.3. Matching criteria for case and control sample including: 1. Age. 2. Gender. 2.6- Sample size estimation To determine sample size the researcher used the following formula: s=

NP (1− P) ÷

(N −1) +

P (1− P).

s = required sample size. = the table value of chi-square for 1 degree of freedom at the desired confidence level (3.841). N = the population size. P = the population proportion (assumed to be .50 since this would provide the maximum sample size).

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d = the degree of accuracy expressed as a proportion (.05). The population size N=120 population/3months. Required sample size, s=92 cases. (Bluman, 2012) 2.7- Instruments for data collection: • Data is collected by using questionnaire format which is filled out by the investigator in direct interview technique. • Questionnaire are developed by investigator according to the study objectives which including : 1. Part I: Assessment of socio –demographic characteristics of patients with coronary heart disease including (Age, Gender, Occupation, Residency, Marital State, Religion and Educational level). 2. Part II: Questions regarding life style of the research participants’ which are expected to contribute in the development of the disease including (dietary habit, favorite foods, exercise, physical activity, sleep pattern, smoking and drinking). 3. Part III: A. Family history and medical history which include (past medical history, hypertension, diabetics and lipid profile). B. Assessment of BMI, waist circumference and waist/hip ratio.

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2.8-Validity of the questionnaire The validity of questionnaire was assessed by thirteen experts in different field such as medicine, cardiac specialist and adult nursing (Appendix-B). All the comments were taken into consideration; some items were omitted such as personality disorder and some others were added regarding life style and nutritional pattern. 2.9-Reliability of the questionnaire 2.9.1. Pilot study A pilot study was carried out on fifteen patients to determine the reliability of the questionnaire. The pilot study samples were selected from the same setting which was Surgical Specialty Hospital-cardiac Center. After 15 days the same sample was selected to ask the same items in the questionnaire. The alpha correlation coefficient was computed, and the correlation was 0.961, which was statistically adequate. n (∑xy) ─ (∑x) (∑y) r= [n∑x2 ─ (∑x) 2 ][n∑y2 ─ (∑y)] 2 (

Bluman, 2012)

r = correlation coefficient for variable x and y, if r = (± 1) =Perfect, (± 0.75 – ± 1) =Strong, (± 0.5 – ± 0.75) =Moderate, (< 0.5) =Weak, (0) =no association. n = number of cases (sample) x = an individual score for variable x (test) y = an individual score for variable y (retest) ∑ = summation of variables (test and retest)

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2.9.2. The objectives of the pilot study are: • To identify obstacles that might be encountered during the data collection process. • To estimate the time required for the data collection. • To determine the reliability of the questionnaire. • To obtain the clarity and adequacy of the questionnaire with the program. • To find out whether the contents of the questionnaire are understandable by the study sample. • To test the cooperation of the study sample. 2.10- Method of data collection: 1. Interview technique is used as a method of data collection, and each interview took 30-45 minutes. 2. Review of patient’s records to obtain (the laboratory results of lipid profile and blood sugar). 3. Measuring (BMI, Waist Circumference and Waist/Hip Ratio). 4. Weight and length were recorded in the patients' record. 5. Waist and hip circumference While participants were still in there light clothes, these measurements were taken. A non-stretch tape was used to measure the waist and hip circumference. The narrowest point between the ribs and hips of the participants was identified as being the natural waist. Using the same nonstretch tape, measurement of the hip circumference was undertaken by viewing the participants from the side to see the maximum extension of the hips. The tap was then used around the hips at a horizontal plan and the measure was taken to nearest centimeter.

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2.10.1. Body Mass Index classification Refer to national institute of health (NIH, 2010) Classification, BMI which was obtained by dividing weight (Kg) by the square of height (Meter) categorized into: 0.05

Non Significat (NS).

(S)

Odds Ratio value were considered in following: • O.R=1 Risk does not affect odds of Coronary Artery Disease • O.R>1 Risk associated with higher odds of Coronary Artery Disease • O.R 60 Male Female Married Single Divorced Widowed Muslim Christian Employee Self employed Un employee Retired Urban Suburban Rural

Case F 6 14 34 46 55 45 98 2 0 0 99 1 34 22 43 1 59 31 10

Control % 6.0 14.0 34.0 46.0 55.0 45.0 98.0 2.0 0.0 0.0 99.0 1.0 34.0 22.0 43.0 1.0 59.0 31.0 10.0

F 6 14 34 46 55 45 99 1 0 0 100 0 39 15 46 0 49 36 15

% 6.0 14.0 34.0 46.0 55.0 45.0 99.0 1.0 0.0 0.0 100.0 0.0 39.0 15.0 46.0 0.0 49.0 36.0 15.0

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Continue Table3

Educational level

Illiterate Primary school secondary school Institute graduation college graduation post-graduation

52 24 10 4 8 2

52.0 24.0 10.0 4.0 8.0 2.0

43 25 19 6 7 0

43.0 25.0 19.0 6.0 7.0 0.0

3.2. Anthropometry characteristics for both (case and control groups). Table 4 this table provides information about 55 men in the both groups of case and control in which waist hip ratio was more than 0.95 of 87.3% case which refers to have a risk, while47.3% of control group ranging between 0.90-0.95 which indicated average. Regarding waist hip ratio in females, 45 participants were researched in both groups of 97.8% case and 95.6% control was more than 0.86 which shows a level of risk. Concerning body mass index in case group, the majority of case group (51%) their BMI was about (30 or greater) which indicated that they are in obese level. similarly, BMI in the majority of control group (41%) was 25-29.9 which indicates they are overweight. Table4. Anthropometry characteristics for both (case and control groups). Groups

Anthropometry

WHR male Sample no.(55)

WHR female Sample no.(45)

BMI

Case

Control

Excellent Good Average At risk Excellent Good Average At risk Underweight Normal weight Overweight Obese

F 0 1 6 48 0 0 1 44 1 15 28 51

% 0.0 1.8 10.9 87.3 0.0 0.0 2.2 97.8 1.0 15.0 28.0 51.0

F 1 6 26 22 0 0 2 43 2 20 41 35

% 1.8 10.9 47.3 40.0 0.0 0.0 4.4 95.6 2.0 20.0 41.0 35.0

Extreme obesity

5

5.0

2

2.0

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3.3. Information about study participant's blood pressure in both; case and control groups. Table 5 this table shows that 59% of the case groups have high blood pressure, as they are now taking medication for high blood pressure. Concerning this, 36% of the participants in case group are taking medication for about 1-10 years. However, 28% of them have never been monitoring their blood pressure, but 40% of the participants have been doing so only by paramedic. Conversely, the table presents that 56% of the control group does not have blood pressure and, therefore, the majority of them, 70 % take no medication for high blood pressure. In spite of this, 30% of the samples in control group are suffering from high blood pressure, but 28% of them take medication for controlling so, the table also shows that 62% of the subjects monitor their blood pressure by doctor at clinic. Table 5. Information about study participant's blood pressure in both; case and control groups. Groups

Blood Pressure Yes No Unknown Yes Controlling high blood pressure by No taking medication. Unknown 1-10 11-20 Yes, since when. 21-30 31-40 Never Per day Per week Monitor blood pressure. Other. Per month Doctor at clinic Doctor comes to home Monitoring blood pressure. Self-check at home Relative Paramedic High blood pressure.

Case

Control

F 59 34 7 59 40 1 36 17 5 1 28 19 25 0 28

% 59.0 34.0 7.0 59.0 40.0 1.0 61.0 28.8 8.5 1.7 28.0 19.0 25.0 0.0 28.0

F 30 56 14 28 70 2 23 4 1 0 32 6 19 0 43

% 30.0 56.0 14.0 28.0 70.0 2.0 82.1 14.3 3.6 0.0 32.0 6.0 19.0 0.0 43.0

33

33.0

62

62.0

1

1.0

1

1.0

7

7.0

14

14.0

19 40

19.0 40.0

0 23

0.0 23.0

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3.4. Information about study participant's Diabetes Mellitus in both (case and control groups). Table 6 this table shows that 56% and 53% of the case and control groups respectively does not have diabetes mellitus. The point that needs to be mentioned is 41% of the case groups have diabetes mellitus since 1-5years. Furthermore, 39% of the case group monitored their blood sugar monthly. However, 82% of them have not controlled their diabetes mellitus. In case group, 92.7% of diabetic patients take medication in which 89.7% of them are on oral medication and 56.1% use a specific type of food. Despite of this, the majority of the participants have not controlled their diabetes. On the other hand, 45%of control group have diabetes mellitus since 1-5 years and more than half of the group monitor their blood sugar monthly. However, 62.2% of the control group controlled their blood sugar. Moreover, 91.1% of the subjects take medicines for controlling their blood sugar. Having said this, 80.5% of the participants take medications orally for controlling their blood sugar, while, 60% of them have arranged their diet for controlling so. Table6. Information about study participant's Diabetes Mellitus in both (case and control groups). Groups

History about Diabetes Mellitus Diabetes Mellitus.

Yes, since when.

Monitoring blood sugar.

Controlled. Medication for DM. Type of the drugs. Follow a specific type of diet for your diabetes.

Case Yes No Unknown 1-5 6-10 11-15 16-20 Never Per day Per week Other Per month Yes No Yes No Oral medication Insulin Yes No

F 41 56 3 18 13 7 3 4 11 10 0 16 7 34 38 3

% 41.0 56.0 3.0 43.9 31.7 17.1 7.3 9.8 26.8 24.4 0.0 39.0 17.1 82.9 92.7 7.3

Control F % 45 45.0 53 53.0 2 2.0 25 55.6 13 28.9 7 15.6 0 0.0 1 2.2 4 8.9 13 28.9 0 0.0 27 60.0 28 62.2 17 37.8 41 91.1 4 8.9

35

89.7

33

80.5

4 23 18

10.3 56.1 43.9

8 27 18

19.5 60.0 40.0

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3.5. Family history for cardiovascular disease Table 7 this table shows that 51% and 77% of the case and control groups respectively has no family history of cardiovascular diseases. This table, in addition, presents that 79% of the case groups and 61% of the control groups have no family history of type II diabetes. Table7. Family History for study participants (case and control groups). Groups

Family History

Case

Control

Yes

No

Yes

No

F

%

F

%

F

%

F

%

Mother suffered from cardiovascular disease at less than 55years.

49

49.0

51

51.0

23

23.0

77

77.0

Father suffered from cardiovascular disease at less than 45 years.

44

44.0

56

56.0

15

15.0

85

85.0

Parents with type II diabetes (adult-onset diabetes).

21

21.0

79

79.0

39

39.0

61

61.0

3.6. Information regarding Smoking Habit among study participants. Table 8 this table indicates that 59% of the participants in case group were smokers and they have been smoking for 31 to 40 years, as they have been smoking 20 cigarettes per a day. The highest percentage of the smoker in case group (84.7%) were stopped smoking, (92%) of them stop smoking because of their health condition. Conversely, 61% of the participants in control group were nonsmokers.

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Table8. Information regarding Smoking Habit among study participants in both (case group and control group). Groups

Information regarding smoking cigarettes Cigarette smoking.

Yes, how long.

Cigarettes smoke per day.

Smoking cigarettes now. Reason to stop smoking cigarettes.

Case F 59 41 12 10 8 21 8 14 20 5 14 6 9 50 4 46

Yes No 1-10 11-20 21-30 31-40 ≥ 41 1-10 11-20 21-30 31-40 ≥ 41 Yes No Economic reasons general health reasons

Control F % 39 39.0 61 61.0 7 17.9 16 41.0 12 30.8 4 10.3 0 0.0 6 15.4 23 59.0 6 15.4 4 10.3 0 0.0 14 35.9 25 64.1 5 20.0 20 80.0

% 59.0 41.0 20.3 16.9 13.6 35.6 13.6 23.7 33.9 8.5 23.7 10.2 15.3 84.7 8.0 92.0

3.7. Information regarding Physical inactivity among study participants. Table 9 this table demonstrates the highest percentages of not doing regular exercises by both groups of case and control which are 96% and 100% respectively. However, this does not mean that physical exercise is completely absent in their life. Having said this, 56% of the case group and 65% of the control group have daily walking about 30 minutes. Table9. Information regarding Physical inactivity among study participant in both (case group and control group). Groups

Physical inactivity Doing regular exercise (30minute/days) for (5days). Walking daily.

Yes, for how long.

Case Yes No Yes No < 30 minute 30-60 minute 61-90 minute => 91 minute

F 4 96 56 44 25 25 6 0

% 4.0 96.0 56.0 44.0 44.6 44.5 10.7 0.0

Control F 0 100 65 35 45 18 2 0

% 0.0 100 65.0 35.0 69.2 27.7 3.1 0.0

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3.8. Information regarding Alcohol Consumption among study participants. Table 10 shows that the highest percentage of both case group (83%) and control group (92%) have no history with alcohol consumption. Table10. Information regarding Alcohol Consumption among study participants in both (case group and control group). Groups

Alcohol Consumption Drinking alcoholic beverages.

If yes, times drinking an alcoholic beverage.

Case Yes No 1-2times per year 1-2/week 3-4/week 1-2/month

F 17 83 4 6 4 3

% 17.0 83.0 23.5 35.3 23.5 17.6

Control F % 8 8.0 92 92.0 7 87.5 0 0.0 0 0.0 1 12.5

3.9. Information regarding Diet Habits among study participants. Table 11 this table shows that 37% of case group eat fried foods less than once a week and 64% of them eat bread, pasta, rice, potatoes or other starchy foods daily. Furthermore, 58% of the participants in case group do not usually consume sweet foods like cakes, biscuit, and chocolate daily. In addition to this, 58% of the subjects in the case group use 0-3 tea spoons of sugar in hot drinks, 83% of them rarely eat fish, 65% eat 1-3 pieces of fruit daily, 56% eat vegetables one to two times a day, and 34% of the participants drink tea or coffee three to four times a day. Nevertheless, the table presents that 79% of the samples in control group eat fried foods less than once a week, 49% consume bread, pasta, rice, potatoes, or other starchy foods three times a day. Moreover, 65% of them do not consume sweet foods like cakes, biscuits, and chocolate daily. This table also demonstrates that 73% of the participants 0-3 tea spoons of sugar in hot drink, 62% rarely eat fish, 68% consume one to three pieces of fruit in a day, 59% eat vegetables one to two times a day, and 36.4% of them drink tea or coffee 1 to 2 times a day.

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Table11. Information regarding Diet Habits among study participants in both (case and control groups). Groups

Diet habit Less than once a week 1-2 times a week Eating fried foods. 3-6 times a week Every day 0-1 serves daily 2 serves daily Servings of starchy foods per day. 3 serves daily 4 or more serves daily Usually none 1-2 serve daily Servings of sweet foods consumed a day. More than 2 serve daily 0-3 Tea spoons of sugar consumed 4-6 daily in hot drinks, and food. 7-9 10 or more Rarely 1-2 times a week Eating fish. 3-6 times a week Every day Usually none 1-3pieces daily Pieces of fruit ate daily. 4 or more daily Usually none 1-2 serves daily Servings of vegetables per day. 3-4 serves daily 5 or more serves daily Usually none Drinking cups of tea or coffee 1-2 serves daily per day. 3-4 serves daily 5 or more serves daily

Case F 37 32 29 2 10 23 64 3 58 26

% 37.0 32.0 29.0 2.0 10.0 23.0 64.0 3.0 58.0 26.0

Control F % 79 79.0 17 17.0 2 2.0 2 2.0 20 20.0 31 31.0 49 49.0 0 0.0 65 65.0 25 25.0

16

16.0

10

10.0

58 27 10 5 83 15 1 1 32 65 3 40 56 3 1 18 29 34 19

58.0 27.0 10.0 5.0 83.0 15.0 1.0 1.0 32.0 65.0 3.0 40.0 56.0 3.0 1.0 18.0 29.0 34.0 19.0

73 23 2 2 62 38 0 0 18 68 14 34 59 6 1 17 36 17 29

73.0 23.0 2.0 2.0 62.0 38.0 0.0 0.0 18.0 68.0 14.0 34.0 59.0 6.0 1.0 17.2 36.4 17.2 29.3

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3.10. Information regarding Laboratory Diagnostic Tests among study participants. Table11 This Table shows that the majority of case group (79%) their cholesterol about (less than 200 mg/dl) which indicated desirable, but 79% their HDL-c about (less than 40mg/dl) which indicated a major risk factors for heart disease, and 86% of cases group their low density lipoprotein (LDL) about (less than 100mg/dl) which indicated that optimal, and 62% their triglyceride about ( 200-499mg/dl) which indicated high , but 68% there fasting blood sugar about (70-130mg/dl) which 45% their random blood sugar about (less than 180mg/dl) and 76% their S.Creatinine about ( 0.7 to 1.3mg/dl) there indicated normal. While the majority of cases group 91% there cholesterol about (less than 200mg/dl) which indicated desirable, and the most 40% of the control high density lipoprotein (HDL-c) about (40-59mg/dl) their indicated the higher the better, and the majority 84% of their low density lipoprotein (LDL) about (less than 100mg/dl) which indicated optimal, and the most 29% of their triglyceride about (less than 150mg/dl), also 58% of their fasting blood sugar FBS about (70-130mg/dl) with 45% of their random blood sugar RBS their about (less than 180mg/dl) and the most 65% of their S-Creatinine about (0.7 to 1.3mg/dl) their indicated all of them normal.

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Table12. Information regarding Laboratory Diagnostic Tests among study participants in both case group and control group. Groups

Lab. Diagnostic tests Desirable Borderline high Cholesterol High A major risk factor for heart disease The higher, the better HDL-c Considered protective against heart disease Optimal Near optimal/above optimal LDL Borderline high High Very high Normal Mildly High Triglyceride High Very high Hypoglycemia Fasting Blood Sugar Normal Hyperglycemia Hypoglycemia Random Blood Sugar Normal Hyperglycemia Low Normal S. Creatinine High

Case

Control

F 79 11 10

% 79.0 11.0 10.0

F 91 5 4

% 91.0 5.0 4.0

79

79.0

43

43.0

20

20.0

45

45.0

1

1.0

12

12.0

86

86.0

84

84.0

6

6.0

10

10.0

7 1 0 14 23 62 1 0 68 32 21 45 34 15 76 9

7.0 1.0 0 14.0 23.0 62.0 1.0 0.0 68.0 32.0 21.0 45.0 34.0 15.0 76.0 9.0

6 0 0 29 28 41 2 1 58 41 14 45 41 17 65 18

6.0 0 0 29.0 28.0 41.0 2.0 1.0 58.0 41.0 14.0 45.0 41.0 17.0 65.0 18.0

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3.11. Association between Socio-demographic characteristics and CAD compare with control group. Table 13 this table reveals that there is no statistically significant between socio-demographic characteristics in terms of (age, gender, marital status, religion, occupation, residential area, educational level) and coronary artery diseases in compare with control group.

Table13. Association between Socio-Demographic characteristics and CAD compare with control group. Socio-demographic characteristics. n=100 cases and 100

Group

Mean

Std. Deviation

Case

4.20

0.899

Control

4.20

0.899

Case Control

1.45 1.45

0.500 0.500

Case

1.02

0.141

Control

1.01

0.100

NS

Case Control

1.01 1.00

0.100 0.000

0.319

Case Control

2.11 2.07

0.898 0.924

0.757

Case

1.51

0.674

Control

1.66

0.728

Case Control

1.96 2.14

1.333 1.363

t-test

controls Age Group

Gender

Marital Status

Religion

Occupation

Residential Area

Educational level

P-value

1.0 NS 1.0 NS 0.563

NS

NS 0.132 NS 0.346 NS

NS= No Significant.

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3.12. Association between Anthropometry and CAD compare with control group. Table14 this table reveals that there is no statistical significant relationship between waist to hip ratio female and coronary artery diseases in compare with control group. This table, however, shows a highly statistically significant relation between waist to hip ratio male and coronary artery diseases. It also presents a statistically significant relationship between Body Mass Index and Coronary Artery Diseases in compare with control groups. Table14. Association between Anthropometry and CAD compare with control group. Anthropometry Risks

Group

N

Mean

Waist to Hip Ratio Male.

Case Control Case Control Case Control

55 55 45 45 100 100

3.85 3.25 3.98 3.96 3.44 3.15

Waist to Hip Ratio Female. BMI Category.

Std. Deviation .405 .726 .149 .208 .845 .833

P-value t-test 0.000 VHS 0.562 NS 0.015 S

VHS= Very Highly Significant. S = Significant. NS = No Significant.

3.13. Association between medical and family history with CAD. Table 15 this table reveals that there is a statistically highly significant relationship between high blood pressure, cases mother's with cardio vascular diseases less than 55 years old, father's less than 45 years old and coronary artery diseases. This table, moreover, presents a significant association between (adult –onset diabetes) and coronary artery diseases, but it does not indicate significant association between diabetes mellitus and coronary artery diseases compare with control groups.

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Table15. Association between medical and family history with CAD. Medical and Family history n=100 cases and 100 controls High blood pressure. Diabetes Mellitus. Mother suffered from cardiovascular disease at less than 55years. Father suffered from cardiovascular disease at less than 45 years. Parents with type II diabetes (adultonset diabetes). VHS=very highly significant. NS= no significant.

Group

Mean

Case Control Case Control Case

1.48 1.84 1.62 1.57 1.51

Std. Deviation .627 .647 .546 .537 .502

Control

1.77

.423

P-value t-test 0.000 VHS 0.515 NS 0.000 VHS

Case Control Case Control

1.56 1.85 1.79 1.61

.499 .359 .409 .490

0.000 VHS 0.005 VHS

3.14. Association between nutritional status and habit with CAD. Table 16 this table presents data that there were a highly statistically significant relationship between eating fried foods and coronary artery diseases. However, the table shows there were no statistically significant relationship between regular exercise, walking daily, eating vegetables, drinking alcoholic beverages, tea or coffee and coronary heart diseases. It also demonstrates a statistically significant relationship between smoking, eating fruits, bread, pasta, rice, potatoes or other starchy foods and coronary artery diseases in compare with control groups. Table16. Association between nutritional status and habit with CAD. Habit and Nutritional status n=100 cases and 100 controls

Group

Mean

Smoking cigarettes.

Case Control Case Control Case Control

Regular exercise (30minute/days) for (5days). Walking daily.

1.41 1.61 1.96 2.20

Std. Deviation .494 .490 .197 2.000

P-value t-test 0.005 VHS 0.234 NS

1.44 1.35

.499 .479

0.195 NS

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Continue Table 16 Drinking alcoholic beverages. Eating fried foods.

Serving of bread, pasta, rice, potatoes or other starchy foods having a day. Pieces of fruit usually eating a day. Serving of vegetables usually eating a day. Cups of tea or coffee usually drinking a day. HS= highly significant. VHS= Very Highly Significance NS= No Significance

Case Control Case Control

1.83 1.92 1.96 1.27

.378 .273 .864 .601

0.055 NS 0.000 VHS

Case Control

2.60 2.29

.711 .782

0.004 HS

Case Control Case Control Case Control

1.71 1.96 1.65 1.74 2.54 2.59

.518 .567 .592 .613 .999 1.088

0.001 VHS 0.293 NS 0.757 NS

3.15. Association between laboratory diagnostic tests with CAD. Table 17 this table reveals that there were statistically significant relationship between cholesterol levels, triglyceride and coronary artery diseases. It also shows a highly significant relationship between HDL and coronary artery diseases. Nevertheless, the table presents that there were not a significant relationship between low density lipoprotein (LDL), fasting blood sugar (FBS) and coronary artery diseases in compare with control groups. Table17. Association between laboratory diagnostic tests with CAD. Laboratory Diagnostics tests n=100 cases and 100controls Cholesterol HDL-c LDL Triglyceride Fasting Blood Sugar S=Significance. HS= Highly Significance. VHS= Very Highly Significance. NS= No Significance.

Group Case Control Case Control Case Control Case Control Case Control

Mean 1.31 1.13 1.22 1.69 1.23 1.22 2.50 2.16 2.32 2.40

Std. Deviation .647 .442 .440 .677 .617 .543 .745 .873 .469 .512

P-value t-test 0.023 S 0.000 VHS 0.903 NS 0.003 HS 0.251 NS

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53

3.16. Logistic regression showing association between CAD and some variables. Table 18 shows that hypertensive patient had 3.3 time risk of CAD than those who were not hypertensive ,family history for cardiovascular diseases mother or father (3.22, 4.45) times respectively had risk for CAD than those who didn't had positive family history of cardiovascular disease, regarding anthropometry table 18 shows that overweight and obese patient 1.48 times risk for CAD than those who had normal and underweight and patient waist to hip ratio >0.95 for men and >0.86 for female had ( 10.9 , 2) times respectively at risk for CAD than those who had normal waist to hip ratio. Factors related to habits table 18 shows that patient who smoker 2.25 times risk for CAD than those who were no smoker and patients drinking alcoholic beverage 2.35 times at risk than those who were no drinker, While diabetic patients and positive family history for diabetes mellitus were less likely to have CAD than those who have diabetes mellitus. Table18. Logistic regression showing association between CAD and some variables. No. 1. 2. 3. 4. 5. 6. 7. 8. 9.

Risks

P-value t-test

O.R

Body mass Index WHR male WHR female Blood Pressure Diabetes Mellitus Cardiovascular disease - Mother Cardiovascular disease - Father Diabetes Mellitus – Parent Smoke cigarettes, pipe, or nergella

0.015 0.000 0.562 0.000 0.515 0.000 0.000 0.05 0.005

1.48 10.29 2.00 3.36 0.84 3.22 4.45 0.42 2.25

95%C.I. for OR Lower Upper 0.68 2.71 3.59 29.94 0.17 23.40 1.87 6.02 0.48 1.48 1.75 5.91 2.26 8.75 0.22 0.77 1.27 3.96

10. Drinking Alcohol 0.055 2.35 0.96 11. Cholesterol Level 0.023 2.66 0.81 • O.R=1 Risk does not affect odds of Coronary Artery Disease • O.R>1 Risk associated with higher odds of Coronary Artery Disease • O.R

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