Unconventional Cardiovascular Risk Factors and Systematic Coronary Risk Estimation (SCORE) in the Lebanese Rural Population: The Forgotten Factors

Figures & data

Table 1 Classification of Cardiovascular Risk According to the SCORE

Risk of Fatal Cardiovascular Event Over 10 Years	Definition Criteria
Low	Calculated SCORE <1%
Moderate	Calculated SCORE ≥1% and <5%
High	Calculated SCORE ≥5% and <10% Patients with a history of Cardiovascular Event Patients known to have Diabetes and 2 to 3 other Cardiovascular Risk Factors
Very High	Calculated SCORE ≥10% Patients with uncontrolled risk factors (Total cholesterol levels ≥ 310mg/dL or Blood Pressure ≥ 180/110mmHg) Patients with uncomplicated Diabetes or with a Cardiovascular risk factor Patients taking lipid-lowering antidiabetic drugs Diabetic patients with a value of “HIGH” on hemoglucotest machine

Table 2 Criteria Used in This Study for Defining the Assessed Conventional and Unconventional Risk Factors

Risk Factors	Definition
Age and Sex	Men and Women aged between 40 and 70 years old
Systemic Hypertension	Known hypertensive patients Patients taking anti-hypertensive drugs Hypertension defined by the European Society of Cardiology (ESC): Systolic blood pressure (SBP) ≥ 140 mmHg and/or (DBP) diastolic blood pressure ≥ 90 mmHg.^Citation1
Diabetes	Known Diabetic patients Patients with at least one diagnostic criteria according to the American Diabetes Association (ADA) A fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT) A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis (polyuria, polydipsia, unexplained weight loss, drowsiness, coma) A hemoglobin A1c (HbA1c) level of 6.5% (48 mmol/mol) or higher Patients taking antidiabetic drugs^Citation2
Dyslipidemia	Known dyslipidemic patients Patients taking lipid-lowering drugs (statins or Ezetimibe) SCORE ≥10%^Citation3
Smoking	Any patient who has smoked a cigarette or a hookah (water pipe) during the last 12 months is considered a smoker. A former smoker is someone who quit smoking more than a year ago.^Citation4
Metabolic Syndrome	Combination of three or more of the following criteria:^Citation5 Waist circumference > 102cm in men or > 88cm in women Triglycerides levels ≥150 mg/dL Patients taking antihypertensive drugs and/or SBP ≥130 mmHg and/or (DBP) ≥85 mmHg Patients taking antidiabetics or Fasting Blood Glucose ≥ 110 mg/dL.
Socio-Economic Status	The markers of Socio-Economic status that we have retained are: the work status, the educational level and the number of inhabitants per room. The elements in favor of a high socio-economic status are: self-employment or work for an employer, a high school or University diploma, and a number of inhabitants per bedroom below the median (4). The socio-economic status classification is calculated by assigning one point to each item in favor of a high level and zero points to those denoting a low level (see Table 3). The correlations are established according to the final result ranging from 0 to 3.
Family History	Occurrence of a cardiovascular event in a first-degree relative at a young age: before the age of 55 for men and before the age of 65 for women.^Citation6 Family History includes Cardiovascular Risk Factors such as systemic hypertension, dyslipidemia and type 2 diabetes.^Citation7

Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; ADA, American Diabetes Association; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test.

Table 3 Classification of the Socio-Economic Status of the Studied Population

		Point Allocated
Work Status	Self Employed	1
	Employee	1
	Unemployed	0
	Retired	0
Educational level	Illiterate	0
	Primary: no high school diploma	0
	Secondary: high school diploma	1
	University Diploma	1
Number of inhabitants per bedroom	< 4	1
	≥ 4	0

Figure 1 Flowchart of the study population.

Table 4 Socio-Demographic Characteristics of the Studied Population

		Number of Patients	Mean	Standard Deviation
Age		433	55	8
		Number of Patients	Percentage	Lower Limit of CI^a	Higher Limit of CI^a
Region	Kfarhabou	88	20.3%	16.7%	24.3%
	Riyak	77	17.8%	14.4%	21.6%
	Mtole	78	18.0%	14.6%	21.8%
	Kfar-Dlaquous	94	21.7%	18.0%	25.8%
	Amaz	96	22.2%	18.5%	26.3%
Sex	Female	249	57.5%	52.8%	62.1%
	Male	184	42.5%	37.9%	47.2%
Marital Status	Single	58	13.4%	10.5%	16.9%
	Married	356	82.4%	78.6%	85.8%
	Divorced	3	0.7%	0.2%	1.8%
	Widowed	15	3.5%	2.0%	5.5%
Number of children	>4	41	15.7%	11.7%	20.5%
	3–4	134	51.3%	45.3%	57.4%
	1–2	52	19.9%	15.4%	25.1%
	0	34	13.0%	9.4%	17.5%
Work status	Self-Employed	89	21.9%	18.1%	26.1%
	Employee	131	32.3%	27.9%	36.9%
	Unemployed	157	38.7%	34.0%	43.5%
	Retired	29	7.1%	4.9%	10.0%
Education	Illiterate	29	8.4%	5.8%	11.7%
	Primary	131	38.1%	33.1%	43.3%
	Secondary	126	36.6%	31.7%	41.8%
	University	58	16.9%	13.2%	21.1%
Number of inhabitants per bedroom	Number of Patients	Mean	Standard Deviation	Median	Q1^b	Q3^c
	340	4	2	4	3	5

Abbreviations: ^aCI, confidence interval; ^bQ1, first quartile; ^cQ3, third quartile.

Table 5 Epidemiology of Conventional Risk Factors

		Total Number of Patients	Number of Patients	Percentage	Lower Limit of CI^a	Higher Limit of CI^a
Hypertension	Per protocol	423	279	66.0%	61.3%	70.4%
	Known	273	123	45.1%	39.2%	51.0%
	Known and treated	123	99	80.5%	72.8%	86.7%
	Unknown and treated	150	17	11.3%	7.0%	17.1%
	Treated	273	116	42.5%	36.7%	48.4%
	Treated and controlled	116	30	25.9%	18.6%	34.4%
	Controlled	273	37	13.6%	9.9%	18.0%
Diabetes	Per protocol	420	131	31.2%	26.9%	35.7%
	Known	128	96	75.0%	67.0%	81.9%
	Known and treated	96	74	77.1%	68.0%	84.6%
	Unknown and treated	32	1	3.1%	0.3%	13.7%
	Treated	128	75	58.6%	49.9%	66.9%
	Treated and controlled	75	5	6.7%	2.6%	14.0%
	Controlled	128	8	6.3%	3.0%	11.4%
Dyslipidemia	Per protocol	263	103	39.2%	33.4%	45.2%
	Known	417	112	26.9%	22.8%	31.3%
	Treated		97	23.3%	19.4%	27.5%
Smoking	None	418	190	45.5%	40.7%	50.2%
	Current smokers		209	50.0%	45.2%	54.8%
	Former smokers		19	4.5%	2.9%	6.9%

Abbreviation: ^aCI, confidence interval.

Table 6 Epidemiology of Unconventional Risk Factors

		Total Number of Patients	Number of Patients	Percentage	Lower Limit of CI^a	Higher Limit of CI^a
Metabolic Syndrome		268	115	42.9%	37.1%	48.9%
Socio-Economic Status Classification	0 point	433	89	20.6%	17.0%	24.5%
	1 point		182	42.0%	37.4%	46.7%
	2 points		125	28.9%	24.8%	33.3%
	3 points		37	8.5%	6.2%	11.5%
Family History	Father	417	185	44.4%	39.6%	49.2%
	Mother		232	55.6%	50.8%	60.4%
	Brother(s)		149	35.7%	31.2%	40.4%
	Sister(s)		102	24.5%	20.5%	28.8%
	Child(ren)		28	6.7%	4.6%	9.4%
	Parents’ or children’s cardiovascular events		364	87,3%	83,8%	90,2%
	Global familial cardiovascular events		365	87,5%	84,1%	90.4%

Abbreviation: ^aCI, confidence interval.

Table 7 Anthropometric Measurements

		Total Number of Patients	Mean	Standard Deviation	Median	Q1^a	Q3^b
BMI^c		419	28.04	4.78	27.41	24.69	30.63
Waist circumference	Female	171	96	12	95	87	104
	Male	125	104	12	104	96	111
Hip circumference	Female	170	98.9	14.2	100.0	89.0	109.0
	Male	125	105.0	10.8	106.0	98.0	111.0

Abbreviations: ^aQ1, first quartile; ^bQ3, third quartile; ^cBMI, body mass index.

Table 8 Cardiovascular Risk of the Rural Lebanese Population Studied

	Number of Patients	Percentage	Lower Limit of CI^a	Higher Limit of CI^a
Low	69	27.6%	22.3%	33.4%
Moderate	18	7.2%	4.5%	10.9%
High	107	42.8%	36.8%	49.0%
Very High	56	22.4%	17.6%	27.9%

Abbreviation: ^aIC, confidence interval.

Table 9 Correlations Between Risk Factors and SCORE^a

		p-value
Diabetes		0.000
Metabolic Syndrome		0.000
Familial History: parents and children		0.834
Familial History: Parents, children and siblings		0.975
Socio-Economic Status	CC^b	p-value
	−0.104	0.059
BMI^c	0.179	0.005

Abbreviations: ^aSCORE, Systematic Coronary Risk Estimation; ^bCC, correlation coefficient; ^cBMI, body mass index.

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