Abstract
Background: In Romania data on cardiovascular risk factors are sparse. Objective: To describe the prevalence and distribution of cardiovascular risk factors in a primary care setting in Romania. Methods: In a cross-sectional study, patients aged 25–65 years on the lists of four general practitioners in Iasi (Romania), selected by 1/5 systematic sampling, were invited for a cardiovascular risk evaluation (interview, physical examination, blood tests for cholesterol and glucose). Prevalence rates for coronary heart disease (CHD), diabetes (DM) and other risk factors were estimated, SCORE risk was determined, and treatment targets were evaluated. Results: The response rate was 79% (325 men, 476 women). Prevalence rates were: CHD 7.4%, DM 3.2%, hypercholesterolemia (>190 mg%) 47.2%, hypertension 23.7%, obesity 21.2%, and smoking 33.8%. In women, obesity and lack of physical exercise were more prevalent, whereas in men, higher rates were found for smoking and an unhealthy diet. The proportion of patients considered to be at high risk (CHD, DM or SCORE ≥ 5%) was 39.2%. Female patients failed to meet targets for systolic blood pressure, total cholesterol and glucose, whereas smoking cessation will be the greatest challenge for men. Conclusion: There were relevant gender differences in modifiable cardiovascular risk factors. Many patients failed to meet treatment targets.
Introduction
Background
Ten per cent of the global burden of disease, in terms of death and disability, is attributable to cardiovascular disease (CVD), and this is expected to increase to 15% by 2020. Despite pharmaceutical progress in this field, as well as a multitude of studies and many health policy programmes focusing on CVD prevention, cardiovascular diseases still remain a challenging health problem worldwide. Coronary heart disease (CHD) by itself is responsible for nearly 2 million deaths in Europe each year, with over one in five women and men (23% and 21%, respectively) dying from the disease. Whereas in most northern and western European countries, the trend is towards a decreasing CHD death rate, CHD mortality rates are rising rapidly in most central and eastern European countries Citation[1].
Romania has the highest cardiovascular mortality rates in Europe, and cardiovascular pathology forms a large part of the workload of Romanian general practitioners (GPs). According to the results of the Sentinel Network Project—in which 100 Romanian GPs recorded medical data over a 3-year period using the ICPC classification—every fourth adult patient seen by a GP is a cardiovascular patient. Cardiovascular diseases are among the most frequent reasons for encounter, diagnoses, prescriptions, and referrals Citation[2].
The most effective and cost-efficient way to decrease the incidence and prevalence of CVD is primary prevention, based on early detection of cardiovascular risk factors in the general population, and the subsequent correction of modifiable factors. Three lifestyle parameters—smoking, lack of physical exercise, and an unhealthy diet—are responsible for, or at least interfere with, all of the modifiable risk factors: obesity, hypertension, diabetes mellitus (DM), and hypercholesterolaemia Citation[3].
These risk factors could be controlled by managing lifestyle, which is the main target of most preventive actions against cardiovascular diseases. Given its holistic approach, the continuous care it offers and the option of tailored medical care, primary care seems to be the ideal setting for activities targeted at lifestyle modification. The recommendations of the European guidelines on CVD prevention 2003 can be used as a starting point for clinical practice Citation[4]. However, there are no data from Romanian primary care on which to base a preventive strategy.
Aim
The aim of this study was to estimate the prevalence of CHD and cardiovascular risk factors, including lifestyle parameters, as well as the distribution of cardiovascular risk factors in various categories of SCORE risk (the 10-year risk of dying from a cardiac event) in a primary care setting in Romania.
Methods
Design and setting
The study was initially designed as a practice-based screening project for hypercholesterolaemia, but developed into a cross-sectional study on CHD and cardiovascular risk factors. It was implemented in a group practice in Iasi, a city in northeast Romania. The four participating GPs collaborate in a capitation-funded practice group that covers a representative area of the city and offers services to approximately 9000 patients.
Patient selection
The target population consisted of all persons aged 25–65 years from the lists of the four participating GPs. Persons younger than 25 years were not included, given the absence of clear recommendations on cholesterol screening at that age Citation[5]. Persons over 65 were not included in view of the evidence that, above this age, cholesterol values are less relevant for primary prevention Citation[6]. Pregnant women, patients with dementia, patients in a terminal disease stage, and patients who had suffered a myocardial infarction in the last 3 months were also excluded. Since—according to the European guidelines on cardiovascular prevention in clinical practice Citation[4]—the optimal period between two cholesterol level assessments in non-symptomatic patients is 5 years, we selected 1/5 of all patients to be screened within the first year by systematic sampling. Patients were arranged in order of ascending age, and every fifth patient was selected.
Assessment
Data were collected using medical records, structured interviews, physical examination, and laboratory testing. The screening activities took place outside normal consultation hours. The selected patients were invited for an assessment of their cardiovascular risk. After having obtained informed consent, each person was evaluated by means of an interview, physical examination, and blood tests. The interview covered demographic data (age, gender), personal medical history (CHD, DM, hypertension, smoking habits, physical activity, diet, alcohol intake, and menopause in women), and a family history of cardiovascular events or hypercholesterolaemia. The physical examination consisted of measurements of height (in centimetres), weight (in kilograms, using a calibrated spring balance), waist and hip circumference (in centimetres, according to WHO guidelines), and blood pressure (using a standard mercury sphygmomanometer and the WHO protocol). Blood tests for fasting glucose and cholesterol were performed with capillary blood samples (finger prick) using point-of-care instruments (OneTouch glucometer and Accutrend lipidometer).
Variables and definitions
CHD was considered to be present in patients who had previously been diagnosed by a cardiologist as suffering from stable or unstable angina, and in patients who had had a cardiac revascularization procedure or survived a myocardial infarction.
Major risk factors
DM, obesity and overweight, hypercholesterolaemia, hypertension, and smoking were regarded as major risk factors. DM was considered to be present in patients already treated for the disease and in newly detected symptomatic persons with capillary blood glucose ≥200 mg/dl (11.1 mmol/l). Obesity was defined as a body-mass index (BMI) ≥30 kg/m2. Patients were classified as “overweight” when 25≤ BMI < 30 kg/m2. Originally, hypercholesterolaemia was considered to be present if the total serum cholesterol level (TC) was ≥240 mg%. In line with current European guidelines, the final analyses also used a cut-off value of 190 mg%. Hypertension was considered to be present in patients with documented hypertension (blood pressure (BP) ≥140/90 mmHg in patients without co-morbidity, BP ≥130/80 in patients with DM, congestive heart failure, or renal insufficiency, or BP ≥125/75 in patients with proteinuria > 1 g/24 hours) or those taking antihypertensive medication. Smoking was defined as a current smoking habit.
Other risk and lifestyle variables
Abnormal glucose was defined as capillary glucose ≥100 mg/dl (5.6 mmol/l). Abdominal obesity was defined as a waist circumference >88 cm in women and >102 cm in men. The waist/hip ratio was considered abnormal if >1 in men and >0.8 in women Citation[7]. When only a single blood pressure measurement was available for a person not diagnosed with hypertension, “high blood pressure” was defined as values ≥140 mmHg for systolic blood pressure or ≥90 mmHg for diastolic blood pressure (130 and 80 for patients with DM, congestive heart failure, or renal insufficiency, and 125 and 75 for patients with proteinuria). A positive family history of cardiovascular events was defined as the awareness of myocardial infarction, stroke, or sudden death in a first-degree relative before the age of 60. A positive family history of hypercholesterolaemia was defined as the awareness of hypercholesterolaemia in a first-degree relative. The cut-off value for early menopause was 42 years. Physical activity was assessed by asking about leisure-time activities (practising any sport or walking systematically for at least half an hour a day, at least three times a week), as well as about work-related physical activities (work requiring physical effort); a negative answer to both questions was coded as “low physical activity”. An unhealthy diet was defined as the habit of eating (or not paying attention to) fatty animal products and high-caloric foods. Alcohol intake was considered “high” in persons who said they usually drink more than seven standard drinks a week.
SCORE
A cardiovascular risk score was calculated for all subjects, according to the recommendations of the European guidelines on CVD prevention 2003 Citation[4], using the web-based version of the European SCORE risk charts for high-risk countries Citation[8]. Patients with a risk of a fatal cardiovascular event within 10 years of <5% and without known CVD or DM were considered to be at “low” risk.
Statistical analysis
Data were recorded in electronic format and processed using Epi Info 5 and SPSS 10 software Citation[9], Citation[10]. Prevalence rates are expressed as percentages of the study population. Each risk factor was assessed in four age strata: 25–34, 35–44, 45–54, and 55–65 years. Continuous variables are reported as mean and standard deviation (SD) or median values, and the t test was used to compare them. The association of each risk factor (independent variable) with CHD (dependent variable) was first analysed bivariately, using chi-square tests, and expressed as an odds ratio with 95% confidence intervals (CI). Multiple logistic regression analysis was then used to investigate the independent association of each cardiovascular risk factor with CHD, correcting for the other risk factors.
Results
Study population
The recruitment process is described in . compares the study population and the non-participants with regard to distribution of age, gender, and CHD. Statistically significant age differences between participants and non-participants were found for the youngest and oldest age groups. Interviews and physical examinations were performed in 801 persons, while blood tests for glucose and cholesterol were done in 773 (96.5%) and 798 (99.6%) persons, respectively. Mean age was 43.9 years (SD 11.1), 44.5 years for men and 43.5 years for women.
Figure 1. Patient recruitment and participation.
Table I. Comparison between study population and non-participants.
Cardiovascular risk factors
An outline of all cardiovascular risk factors and their (bivariate) association with CHD is shown in . Multivariate analysis of the relation between each major risk factor and CHD, adjusted for age and the other major risk factors, confirmed the independent association with CHD for all major risk factors (data not shown). There was an overlap of three or more major risk factors in 17.7% of the population.
Table II. Cardiovascular risk factors and their association with coronary heart disease (bivariate analysis).
Risk SCORE
Nine per cent of our sample was at high CV risk due to CHD or DM. Of the remaining patients with neither CHD nor DM, 10.2% were at high CV risk, as they had an estimated SCORE value of 5% (all of them were in the 45–65 years age group). Since the decision to intervene must be based on CV risk, either current or projected to age 60, we used the latter value in our estimations (incl. ) and discussion. Thus, 39.2% of all patients in our population met the European criteria for “priorities” in cardiovascular prevention (CHD, DM, or SCORE risk ≥5%), 70.1% of the men and 18.1% of the women (gender difference statistically different).
Table III. Prevalence of coronary heart disease, five major cardiovascular risk factors, and SCORE risk by gender and age group.
Age and gender differences
shows the distribution of CHD, major cardiovascular risk factors, and SCORE risk in more detail. CHD was present in 7.4% of the population included in the study. There was an age-associated increase in the prevalence of CHD in both sexes (Mantel-Haenzel chi-square test for trend, p < 0.05). CHD had the highest prevalence in women aged 55–65 years. The gender differences for DM were not statistically significant.
The relatively high prevalence rate for obesity in women (23.7% vs. 17.5% for men) reached a peak in women in the age groups 45–54 and 55–65 years (33.3% and 42.4% vs. 18.5% and 16.2% in men, respectively). These age groups also had the highest proportions of hypercholesterolaemia in both sexes, especially when the low cut-off value of 190 mg% was used. The distribution of hypertension showed a similar picture for the two highest age groups. Men had higher rates for smoking in all age categories.
The overall SCORE risk was also much higher for men in all age categories. However, when the SCORE for men was recalculated leaving out “gender”, the SCORE values for men resembled those for women shown in (in order of ascending age category): 4.2%, 13.8%, 26.7%, and 44.6%; overall 22.4%.
Cardiovascular risk factors in various SCORE risk categories
presents data on cardiovascular risk for three clinically relevant patient categories: low-risk patients (SCORE <5%; n = 484), patients for whom primary prevention has high priority (neither CHD nor DM, but with a SCORE ≥5%; n=240), and finally patients with known CHD or DM (n=74). Three patients without CHD or DM had missing cholesterol values, which meant that no SCORE value could be calculated.
Table IV. Prevalence of cardiovascular risk factors by SCORE risk categories and gender.
A total of 81.9% of all women belonged to the low-risk group, whereas only 28.9% of the men had a low cardiovascular risk. Risk factors most frequently found among the low-risk patients of both sexes were an unhealthy diet (around 60%), lack of physical exercise (almost 50%), and associated biological parameters such as obesity/overweight (around 50%), hypercholesterolaemia (40%), and an abnormal glucose value (around 20%). The mean BMI in the low-risk group was above 25 (the median BMI value was 25.7), implying that more than 50% of this subpopulation was at least overweight. A remarkable finding was the relatively high frequency of smoking women in this low-risk category (20.5%).
For both high-risk groups, the clinically most interesting figures are those indicating whether treatment targets have been met. In the “primary prevention” group (SCORE ≥5%), the target blood pressure was not met by 31.7%, with results for women being worse than those for men (68.6% vs. 25.4%); target cholesterol levels were not met by 56% of all persons, and again the results among women were worse (82.9% vs. 51.2% above 190 mg%); abnormal glucose levels were found in 24% of the subjects in this subgroup. It is evident that smoking contributed a great deal to the high risk score in this group (67.6% smoking men, 37.1% smoking women).
In the group of patients with CHD or DM (“secondary prevention”), almost 40% of the patients smoked, 22% of all patients failed to meet their target for systolic blood pressure (SBP), 68% had a cholesterol value above 190 mg%, and 42% had an abnormal glucose value. Glucose values were abnormal in 54% of the diabetic patients.
Discussion
This study intended to explore the burden of CVD in Romanian primary care. Three or more major risk factors were present in nearly a fifth of the population. The women had higher prevalence rates for obesity and lack of physical exercise, whereas the men had higher prevalence rates for smoking (all ages) and an unhealthy diet. The total proportion of patients considered to be at high risk according to the European guidelines on CVD prevention was nearly 40%. The proportions of patients who failed to meet targets for SBP, TC, glucose, or smoking were 55%, 56%, 24%, and 63%, respectively, in the primary prevention group (n=240) and 69%, 68%, 42%, and 39%, respectively, in the secondary prevention group (n=74). Female patients were less likely to meet the targets for SBP, TC, and glucose than men. In men, smoking cessation will be the greatest preventive challenge.
Strengths and limitations
The population in our study was representative of the 25–65-year age group of the population of Iasi, a city in northwest Romania. Although our results may not be representative for the whole of Romania, they represent the first attempt to report in detail on CVD risk as seen in Romanian primary care. We regard our high participation rate (79%) as a sign of validity. Another strong point of this study is that the screening was done in an unselected population from the GPs’ lists, including people who did not regularly visit their doctor. However, since patients from the youngest age category were underrepresented, whereas patients from the oldest age category were overrepresented, our study might have overestimated overall risk. On the other hand, our age-specific data provide a reliable picture of the occurrence of cardiovascular risk factors in the general population.
In Romania, fasting blood glucose is used as the main measure of DM control, instead of glycated haemoglobin, which is rarely accessible or affordable. The use of capillary blood samples could be considered a source of bias, although the reliability of this technique appears to be similar to that of venous samples if the proper technique is used and the devices are properly calibrated Citation[11]. We can thus consider half of our diabetic patients, whose fasting plasma glucose was above target, as being poorly controlled. Another limitation of this study is the fact that we did not use internationally standardized questionnaires to assess diet, drinking habits, and physical activity.
Romania compared to other countries
The prevalence rate for hypertension in our study is similar to figures from Greece and Germany Citation[12], Citation[13], but is lower than figures from neighbouring countries such as Hungary Citation[14] or Russia Citation[15]. Our figure may be underestimated, since we found abnormal blood pressure values in 8% of the patients classed as “normotensive”.
The prevalence rate for obesity we found is higher than that reported by a study in the European Union Citation[16]. Women tended to be obese, men overweight. Abdominal obesity (waist circumference) was more frequent than general obesity (BMI) in both sexes; the difference is even greater if one uses the ADA criteria for waist circumference instead of the WHO criteria we used. Though it was demonstrated that much of the risk of CHD associated with overweight is mediated by its association with hypertension and metabolic disorders Citation[17], our multiple regression analysis indicated that obesity and overweight are independent predictors of CHD. Consequently, intervention should be aimed at treatment of overweight and stimulating physical activity.
Whereas Western countries are showing a general trend towards decreasing smoking habits, the large proportion of smokers in Romania is remarkable. In all of the age groups we assessed, almost half of the adult men smoked, although not all of them were heavy smokers. Similar percentages of smokers have been found in a screening study in Hungary (32.2%) Citation[18] as well as in statistical reports on other eastern European countries (Croatia, Poland, Ukraine) Citation[19]. Cigarette smoking should be prioritized as the target of preventive strategies, especially for the male population in Romania.
Prevention of cardiovascular disease in Romanian primary care
The European guidelines on CVD prevention in clinical practice were used to obtain data on overall cardiovascular risk and a more reliable estimate of the CVD burden in terms of the size of risk groups. Based on the criteria of the European guidelines, 9% of our sample were at high risk due to CHD or DM. Application of the SCORE model to the non-CHD/DM group identified 10% as being currently at high risk (SCORE ≥5%), but this was three times more when projected to age 60. Consequently, 40% of the patients aged 25–65 years from our practices should be offered cardiovascular prevention with high priority. However, significant proportions of our high-risk patients had suboptimal control of blood pressure, cholesterol, or blood glucose and needed to have the interventions reconsidered. Since large proportions of both high-risk groups reported an unhealthy lifestyle (smoking 63% and 39%, lack of exercise 43% and 68%, unhealthy diet 80% and 50% for the primary and secondary prevention groups, respectively), prescribing medication alone is not enough, and the emphasis should be on education and counselling as well. According to our findings, smoking cessation should be the main objective in male patients, whereas in female patients weight reduction and physical exercise appear to be most important.
In the “low-risk” category of patients (SCORE risk <5%) we observed a high prevalence of unhealthy lifestyle parameters (unhealthy diet 60%, lack of physical exercise 46%) and intermediary biological parameters (overweight 31%, abnormal blood glucose 20%) that are not included in the SCORE risk calculation. Abnormal cholesterol levels (40% ≥190 mg%) and smoking (17% overall, 21% in women) were also rather prevalent in these low-risk subjects. In our view, counselling and monitoring are necessary to prevent these “low-risk” subjects from becoming cardiovascular patients within the next 10 years.
In conclusion, our study detected a large proportion of patients at risk of CVD, in whom preventive treatment targets were not met. It also revealed relevant gender differences with regard to modifiable cardiovascular risk factors. The large proportion of patients at high risk, the high prevalence of modifiable risk factors, and the high number of subjects who reported an unhealthy lifestyle clearly indicate that there is definitely a cardiovascular risk problem and that current cardiovascular risk-reduction practices are far from optimal in Iasi, and most probably also elsewhere in Romania. We consider the high participation rate in our project as a promising sign for further preventive actions. We regard our results as an important indication of the necessity of a well-designed cardiovascular prevention programme for Romanian primary care.
Acknowledgements
The authors wish to thank Anca Deleanu, Liviu Oprea, and Emil Alexandrescu, GPs working at the Centre for Family Medicine in Iasi, for their contribution to the data collection for this study. The authors also would like to thank Jan Klerkx for his language corrections.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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