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Pakistan

Pakistani Heart disease 

  • The death rates from heart disease compared to whites are 100% higher among Pakistani men and 150% higher among Pakistani women in the UK.1
  • One in four middle-aged adults in urban Pakistan have CAD (coronary artery disease) with greater prevalence in women (30%) than in men (24%) over 40 years of age.2 Female patients with CAD are presenting at a much earlier age and a majority has obesity, high blood pressure, and high cholesterol. Majority of those suffering from CAD belong to the lower middle socioeconomic stratum of the society.
  • Heart attack is generally considered to be the disease of the fifth and sixth decade as seen in the West but frequently seen at an earlier age in South Asians.3 The relative risk of developing CAD in Pakistani men is highest in early ages. A study conducted in an urban slum of Karachi, Pakistan of 545 individuals 35 years of age or older 119 or 22% had a stroke TIA or both. The average age of stroke was 50 years or 10 years or 10 years younger than in Western populations.23
  • Hameed et al have reported a Pakistani teenager, who suffered a heart attack, complicated cardiogenic shock, and pulmonary edema on two separate occasions. Except for low HDL and mildly raised homocysteine levels, the patient did not have other conventional or novel risk factors for CAD but lipoprotein(a), the strongest risk factor for very premature heart disease was not reported.4
  • The diameters of coronary arteries of Pakistani population are not significantly different from that of Caucasians and the cause of increased mortality in the people of South Asian origin seems to be other than the diameter of coronary arteries.5 
  • Pakistan is among the top 10 world nations for highest number of people with diabetes.6 The prevalence of diabetes ranges from 6% to 12% and is accompanied by high rates of microalbuminuria, nephropathy, and retinopathy.7-10 In one study, the prevalence of diabetes among Pakistanis in the UK was 33% and higher than all other ethnic groups.11
  • The prevalence of metabolic syndrome in Pakistan ranges from 18% to 49%, depending on different definitions. It is close to the latter when the unified consensus definition is used and as high as 80- 85% in people with diabetes.12-16
  • The prevalence of various components of metabolic syndrome is very high: abdominal obesity (46-68%), hypertriglyceridemia (27-54%), low HDL-C (68-81%), and high blood pressure (50%).12 Given that metabolic syndrome is a predictor and precursor of diabetes and heart disease, every effort should be made to prevent and control metabolic syndrome in the first place.

Risk Factors

  • The prevalence of risk factors is very high especially in urban centers like Karachi: high blood pressure (39%), obesity (52%), a sedentary life style (65%), diabetes (9%), high cholesterol (11%); 12% had two or more major risk factors of CAD.17 Overall, a third of Pakistanis aged more than 45 years have high blood pressure.6
  • Most of these risk factors are highly correlated to CAD in the Pakistani population: current smoking (4-fold risk), use of ghee or hydrogenated vegetable oil in cooking (4-fold risk), raised fasting blood glucose or pre-diabetes (4-fold risk), raised serum cholesterol (2-fold risk for each 40 mg/dl increase), low income (5-fold risk), paternal history of cardiovascular disease (5-fold risk), and parental consanguinity (4-fold risk), were all independent risk factors for heart attack in young adults.18
  • Pakistani people develop CAD at a much lower level of cholesterol.19 High levels of lipoprotein(a) are common and correlated with occurrence and severity of CAD and are found in Pakistanis with and without diabetes.2, 19-21
  • High homocysteine (15-25 micromol/l) is common and reflects very poor dietary habits such as not consuming fresh fruits and vegetable as well as overcooking and deep frying that destroys most of the nutrients.
  • Women in general have more risk factors than their male counterparts except for smoking.2 They also have higher saturated fat intake than men in Pakistan.2 Smoking is the most common risk factor amongst the male population.
  • Despite its high prevalence, awareness regarding CAD risk factors is very low.17 Knowledge about CAD and its risk factors is an important pre-requisite for an individual to implement behavioral changes for CAD prevention. There are striking gaps in knowledge about CAD, its risk factors, and symptoms in this population resulting in inadequate preventive behavior patterns. Educational programs are urgently required to improve the level of understanding of CAD in the Pakistani population.22

Sources

1.  www.heartstats.org. CHD Statistics. Mortality. 2011. Accessed July 15, 2011.

2. Jafar TH, Qadri Z, Chaturvedi N. Coronary artery disease epidemic in Pakistan: more electrocardiographic evidence of ischaemia in women than in men. Heart. Apr 2008;94(4):408-413.

3. Hughes LO, Raval U, Raftery E. First myocardial infarctions in Asian and White men. BMJ. 1989;298:1345-1350.

4. Hameed A, Quraishi AU. Acute myocardial infarction in a young patient. J Coll Physicians Surg Pak. Feb 2004;14(2):112-114.

5.  Kaimkhani Z, Ali M, Faruqui AM. Coronary artery diameter in a cohort of adult Pakistani population. J Pak Med Assoc. May 2004;54(5):258-261.

6. Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. Bmj. Apr 3 2004;328(7443):807-810.

7.  Mahar PS, Awan MZ, Manzar N, Memon MS. Prevalence of type-II diabetes mellitus and diabetic retinopathy: the Gaddap study. J Coll Physicians Surg Pak. Aug 2010;20(8):528-532.

8. AS. S, Basit A, Fawwad A, et al. Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in the Punjab Province of Pakistan. Prim Care Diabetes. Jul 2010;4(2):79-83.

9. Ahmadani MY, Fawwad A, Basit A, Hydrie ZI. Microalbuminuria prevalence study in hypertensive patients with type 2 diabetes in Pakistan. J Ayub Med Coll Abbottabad. Jul-Sep 2008;20(3):117-120.

10. Jamal u D, Qureshi MB, Khan AJ, Khan MD, Ahmad K. Prevalence of diabetic retinopathy among individuals screened positive for diabetes in five community-based eye camps in northern Karachi, Pakistan. J Ayub Med Coll Abbottabad. Jul-Sep 2006;18(3):40-43.

11. Riste L, Khan F, Cruickshank K. High prevalence of type 2 diabetes in all ethnic groups, including Europeans, in a British inner city: relative poverty, history, inactivity, or 21st century Europe? Diabetes Care. 2001;24(8):1377-1383.

12. Basit A, Shera AS. Prevalence of Metabolic Syndrome in Pakistan. Metab Syndr Relat Disord. Aug 12 2008.

13. Hydrie M Z, Shera AS, Fawwad A, Basit A, Hussain A. Prevalence of metabolic syndrome in urban Pakistan (Karachi): comparison of newly proposed International Diabetes Federation and modified Adult Treatment Panel III criteria. Metab Syndr Relat Disord. Apr 2009;7(2):119-124.

14. Imam SK, Shahid SK, Hassan A, Alvi Z. Frequency of the metabolic syndrome in type 2 diabetic subjects attending the diabetes clinic of a tertiary care hospital. J Pak Med Assoc. May 2007;57(5):239-242.

15. Mohsin A, Zafar J, Nisar YB, et al. Frequency of the metabolic syndrome in adult type 2 diabetics presenting to Pakistan Institute of Medical Sciences. J Pak Med Assoc. May 2007;57(5):235-239.

16. Ahmed N, Ahmad T, Hussain SJ, Javed M. Frequency of metabolic syndrome in patients with type-2 diabetes. J Ayub Med Coll Abbottabad. Jan-Mar 2010;22(1):139-142.

17. Dodani S, Mistry R, Khwaja A, Farooqi M, Qureshi R, Kazmi K. Prevalence and awareness of risk factors and behaviours of coronary heart disease in an urban population of Karachi, the largest city of Pakistan: a community survey. J Public Health (Oxf). Sep 2004;26(3):245-249.

18.  Ismail J, Jafar TH, Jafary FH, White F, Faruqui AM, Chaturvedi N. Risk factors for non-fatal myocardial infarction in young South Asian adults. Heart. Mar 2004;90(3):259-263.

19. Nishtar S, Wierzbicki AS, Lumb PJ, et al. Waist-hip ratio and low HDL predict the risk of coronary artery disease in Pakistanis. Curr Med Res Opin. Jan 2004;20(1):55-62.

20. Habib SS, Aslam M. High risk levels of lipoprotein(a) in Pakistani patients with type 2 diabetes mellitus. Saudi Med J. Jun 2003;24(6):647-651.

21. Habib SS, Aslam M. Lipids and lipoprotein(a) concentrations in Pakistani patients with type 2 diabetes mellitus. Diabetes Obes Metab. Sep 2004;6(5):338-343.

22. JafarTH., Jafary FH, Jessani S, Chaturvedi N. Heart disease epidemic in Pakistan: women and men at equal risk. Am Heart J. Aug 2005;150(2):221-226.

23. Kamal A K, Itrat A, Murtaza M, et al. The burden of stroke and transient ischemic attack in Pakistan: a community-based prevalence study. BMC Neurol. 2009;9:58.

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