INTRODUCTION: Schizophrenia is really one of the most perplexing but disabling of all brain diseases, with its severity and persistency of psychotic manifestations accompanied by means of variable cognitive dysfunction and profound psychosocial impairment. The onset of disease, at least of the psychotic manifestations, happens two in late adolescence/ early adulthood. Symptomatology is regularly undetectable in early life, are at their worst at some stage in child-bearing years, and often improve, to a degree, with aging. People with psychosis, go through notably for the duration of existence and medical requirement globally continues to be very high.[1] In 1959, a period when tobacco use was at its highest level, Abraham published “Cardiovascular Disease in Psychotics,” which showed an increased prevalence of atherosclerotic and hypertensive CVD in hospitalized patients with schizophrenia. He rejected the popular view of the time that “the protective life of people with schizophrenia seems to guard them from early onset of degenerative diseases of the heart.” By the late 1970s, accumulating mortality data from psychiatric patients showed a consistent pattern of increased mortality rates relative to the general population. However, despite such reports there were only a few controlled studies in that period that aimed to understand the causes and contributions to this excess mortality.[2] CVD is also the leading cause of mortality in individuals with schizophrenia, who are even more likely to experience premature cardiovascular mortality than individuals in the general population. The prevalence of CVD in people with schizophrenia is approximately two- to threefold increased, particularly in younger individuals. In a retrospective cohort study conducted by Curkendall and colleagues, 3,022 individuals with schizophrenia were compared to a general population cohort. The overall prevalence of CVD was increased in the patients with schizophrenia (10.6 vs. 8.7 percent), as was with the incidence of ventricular arrhythmia (odds ratio [OR] = 2.3; 95 percent condence interval [CI], 1.2 to 4.3), stroke (OR = 1.5; 95 percent CI, 1.2 to 2.0), diabetes (OR = 1.8; 95 percent CI, 1.2 to 2.6), and heart failure (OR = 1.6; 95 percent CI, 1.2 to 2.0). Cardiovascular mortality in schizophrenia has also been evaluated in large population- based samples using long periods of observation. Patients with schizophrenia were evaluated for mortality risk over a period of 19 years in a Swedish registry study, analyzed by Osby and colleagues. Between 1976 and 1991, death rates due to CVD increased 4.7-fold in men and 2.7-fold in women.[2] Correll et al. reported a 10-year CHD risk of 6.5% for inpatients with schizophrenia (n = 111). They also reported that 23.4% of patients with schizophrenia had a CHD risk more than equal to 10%.[4] In the Clinical Antipsychotic Trials of Intervention Effectiveness study, it was observed that patients with schizophrenia had signicantly higher 10-year risk of CHD than the general population (9.4% vs. 6.3% in males and 7% vs. 4.2% in females).[5] These ndings were replicated in a later study too.[3] Other studies reported 10-year CHD risk of 6 . 5 - 7 . 2 % a n d C M R t o b e 0 . 9 % i n p a t i e n t w i t h schizophrenia[4,6] with high/very high risk of CHD (≥10%) in 22-23% patients with schizophrenia[4,6] and high CMR risk (≥5%) in 6.5-8% patients with schizophrenia. MATERIALS AND METHODS: The study was approved by the Ethics Review Committee of the Institute .The patient was incompetent on account of the severity of illness to provide informed consent, then informed consent from the LAR of the patient was taken. The study was conducted by including patients above age 20years at the OPD of department of psychiatry MGM medical college Indore. The participants were screened for the following predened inclusion and exclusion criteria. Patients were diagnosed for schizophrenia according to the International Classication of Diseases - Classication of Mental and Behavioral Disorders - Clinical Descriptions and Diagnostic criteria for research 10th revision[18] were invited to participate in the study. Sociodemographic and clinical details of all subjects were recorded in structured formats. The Study design was the cross sectional study in which study sample was the 100 patients. Who were divided into two groups- 1) 50 Chronic Schizophrenic patients whose illness is more than 2 years and who are taking the treatment for the illness. 2) 50 Chronic Schizophrenic patients whose illness is more than 2 years and who are not taking the treatment for the illness. The study was conducted at department of psychiatry MGMMC Indore for one year from date of ethics committee approval. TO STUDY THE CARDIOVASCULAR RISK FACTORS IN PATIENTS WITH CHRONIC SCHIZOPHRENIA WHO ARE RECEIVING TREATMENT AND NOT RECEIVING TREATMENT Original Research Paper Krishna Kumar Carpenter M.D. Redsident, M.G.M. Medical College Indore Psychiatry To assess the cardiovascular risk in chronic schizophrenia(duration >2 yrs) patients with OBJECTIVE: and without treatment. MATERIALS AND METHODS: 100 OPD patients (aged 20 or above,both male or female), who were diagnosed with chronic schizophrenia(duration >2yrs) with and without treatment according to the International Classication of Diseases Classication of Mental and Behavioral Disorders Diagnostic criteria for research 10th revision. Those patients were evaluated for the coronary heart disease (CHD) risk as per Framingham (10 year all CHD events) function/risk equation. RESULTS: Intermediate cardiovascular risk was found in 2% without treatment patients and 5.73% in with treatment patients. Compared to females, males had higher Framingham score (4.08± 4.51 vs. 1.07± 0.26, likelihood ratio= 622.19, P value < 0.05 in with treatment patients and 1.63± 1.67 vs. 1.11± 0.48,likelihood ratio= 6.444, P value > 0.05 in without treatment patients) CONCLUSION: Patients of schizophrenia have a high prevalence of cardiovascular risk factors. Hence, there is a need to screen the patient of schizophrenia for the cardiovascular risk and manage it as early as possible. ABSTRACT KEYWORDS : Cardiovascular Risk, Mortality, Schizophrenia VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Ujwal Sardesai* M.D. Associate Professor, M.G.M. Medical College Indore *Corresponding Author Ram Ghulam Razdan M.D. Professor, M.G.M. Medical College Indore 38 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS ASSESSMENTS: By using standard mercury manometer systolic and diastolic blood pressure was measured. Fasting venous blood sample was collected under aseptic condition to estimate cholesterol, triglycerides (TGA) and high-density lipoprotein (HDL). ANALYSIS OF CARDIOVASCULAR RISK WITH THE FRA MI NGHAM/ATP III CRITERIA The Framingham/ATP III criteria had been used to estimate CHD risk in the USA. Data from 11,611 patients from a very large study, the NHANES III, have been used. [275] High risk used to be most many times found in patients with advanced age, and used to be more frequent in men than women. High risk patients are once in a while emerge as unknown with clinical features of cardiac failure Scoring. FRAMINGHAM RISK SCORE FOR WOMEN AGE: 20–34 years: Minus 7 points. 35–39 years: Minus three points. 40–44 years: zero points. 45–49 years: three points. 50–54 years: 6 points. 55–59 years: 8 points. 60–64 years: 10 points. 65–69 years: 12 points. 70–74 years: 14 points. 75–79 years: sixteen points. Total cholesterol, mg/dL: Age 20–39 years: Under 160: zero points. 160-199: four points. 200-239: eight points. 240-279: eleven points. 280 or higher: thirteen points. Age 40–49 years: Under 160: zero points. 160-199: 3 points. 200-239: 6 points. 240-279: 8 points. 280 or higher: 10 points. Age 50–59 years: Under 160: zero points. 160-199: 2 points. 200-239: four points. 240-279: 5 points. 280 or higher: 7 points. Age 60–69 years: Under 160: zero points. 160-199: 1 point. 200-239: 2 points. 240- 279: 3 points. 280 or higher: four points. Age 70–79 years: Under 160: zero points. 160-199: 1 point. 200-239: 1 point. 240- 279: 2 points. 280 or higher: 2 points. IF CIGARETTE SMOKER: Age 20–39 years: 9 points. Age 40–49 years: 7 points. Age 50–59 years: four points. Age 60–69 years: 2 points. Age 70–79 years: 1 point. ALL NON SMOKERS: zero points. HDL CHOLESTEROL, MG/DL: 60 or higher: Minus 1 point. 50- 59: 0 points. 40-49: 1 point. Under 40: 2 points. Systolic blood pressure, mm Hg: Untreated: Under 120: zero points. 120-129: 1 point. 130-139: 2 points. 140-159: three points. one hundred sixty or higher: four points. Treated: Under 120: zero points. 120-129: 3 points. 130-139: four points. 140-159: 5 points. a hundred and sixty or higher: 6 points. 10- year risk in %: Points total: Under 9 points: <1%. 9-12 points: 1%. 13-14 points: 2%. 15 points: 3%. sixteen points: 4%. 17 points: 5%. 18 points: 6%. 19 points: 8%. 20 points: 11%. 21=14%, 22=17%, 23=22%, 24=27%, >25= Over 30% FRAMINGHAM RISK SCORE FOR MEN AGE: 20–34 years: Minus 9 points. 35–39 years: Minus 4 points. 40–44 years: zero points. 45–49 years: three points. 50–54 years: 6 points. 55–59 years: eight points. 60–64 years: 10 points. 65–69 years: 11 points. 70–74 years: 12 points. 75–79 years: thirteen points. Total cholesterol, mg/dL: Age 20–39 years: Under 160: zero points. 160-199: four points. 200-239: 7 points. 240-279: 9 points. 280 or higher: eleven points. Age 40–49 years: Under 160: zero points. 160-199: three points. 200-239: 5 points. 240- 279: 6 points. 280 or higher: eight points. Age 50–59 years: Under 160: zero points. 160-199: 2 points. 200-239: 3 points. 240-279: four points. 280 or higher: 5 points. Age 60–69 years: Under 160: zero points. 160-199: 1 point. 200-239: 1 point. 240- 279: 2 points. 280 or higher: three points. Age 70–79 years: Under 160: zero points. 160-199: zero points. 200-239: 0 points. 240-279: 1 point. 280 or higher: 1 point. IF CIGARETTE SMOKER: Age 20–39 years: eight points. Age 40–49 years: 5 points. Age 50–59 years: 3 points. Age 60–69 years: 1 point. Age 70–79 years: 1 point. ALL NON SMOKERS: zero points. HDL CHOLESTEROL, MG/DL: 60 or higher: Minus 1 point. 50-59: 0 points. 40-49: 1 point. Under 40: 2 points. SYSTOLIC BLOOD PRESSURE, MM HG: Untreated: Under 120: zero points. 120-129: 0 points. 130-139: 1 point. 140-159: 1 point. 160 or higher: 2 points. Treated: Under 120: zero points. 120-129: 1 point. 130-139: 2 points. 140-159: 2 points. 160 or higher: 3 points. 10-YEAR RISK IN %: Points total: 0 point: <1%. 1-4 points: 1%. 5-6 points: 2%. 7 points: 3%. 8 points: 4%. 9 points: 5%. 10 points: 6%. 11 points: 8%. 12 points: 10%. 13 points: 12%. 14 points: 16%. 15 points: 20%. sixteen points: 25%. 17 factors or more: Over 30%.[7] STATISTICAL ANALYSIS The SPSS version 14.0 for Windows (Chicago, Illinois, USA) was used for analysis. Frequencies with percentages were calculated for nominal and ordinal variables and mean, and standard deviation were calculated for continuous variables. Chi-Square test and t-test were used for comparisons. For variables with a skewed distribution, nonparametric tests like Mann–Whitney U-test, test for proportion and Fisher exact test were used for comparison. RESULTS: During the study period of 1 year (2018 to 2019), 100 patients were assessed on the OPD basis. 50 of them were without treatment and 50 of them were with treatment chronic schizophrenia patients. All of them/their caregivers provided informed consent to participate in the study. SOCIODEMOGRAPHIC AND CLINICAL PROFILE OF THE SAMPLE Average age of without treatment schizophrenic patients was 32.16 yrs and with treatment schizophrenic patients was 39.17 yrs.Mean age of onset was 26.53 yrs in without treatment schizophrenic patients and 25.70yrs in with treatment schizophrenic patients. Mean duration of illness was 6.21 yrs in without treatment schizophrenic patients and 13.74 yrs with treatment schizophrenic patients.male patients were 33 and female patients were 17 in both with and without treatment. majority of the patienuts were hindu. Most of the patients were from low socioeconomic status (74% in without treatment and 76% in with treatment patients).most of the patients wer unemployed ( 84% in without treatment and 78% in with treatment patients. Most of the patients were urban (67.5% in with treatment and 56% in without treatment patients) Intermediate cardiovascular risk was found in 2% without treatment patients and 5.73% in with treatment patients. Compared to females, males had higher Framingham score (4.08± 4.51 vs. 1.07± 0.26, likelihood ratio= 622.19, P value < 0.05 in with treatment patients and 1.63± 1.67 vs. 1.11± 0.48,likelihood ratio= 6.444, P value > 0.05 in with treatment patients). There is no statistically signicant difference in the systolic and diastolic blood pressure of with treatment and without treatment schizophrenic patients. There is no statistically signicant difference in the blood parameters( HDL,TG and serum cholesterol) of with treatment and without treatment schizophrenic patients. VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra X 39GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Comparison of socio demographic prole between with treatment schizophrenic patients and without treatment schizophrenic patients Variables Without treatment schizophrenia patients With treatment schizophrenia patients Age M:F 32.16 1.9 : 1 (M= 33,F=17) 39.47 1.9 : 1 (M= 33,F=17) Marital status in %: Married Unmarried Divorced Widowed separated 38% ( n=19) 48%( n=24) 4%( n=2) 0%( n=0) 10%( n=5) 35.3%( n=18) 28.7%( n=14) 17.5%( n=9) 4.7%( n=2) 13.9%( n=7) Religion in %: Hindu Muslim 90%( n=45) 10% ( n=5) 91.4%( n=46) 8.6% ( n=4) Education in %: Illiterate thPrimary(5 ) thMiddle(8 ) High School Inter/Diploma Graduate Post graduate Professional 14%( n=7) 20%( n=10) 26%( n=13) 10%( n=5) 18%( n=9) 8% ( n=4) 4%(n=2) 17.6%( n=9) 10.9%( n=5) 23.5%( n=12) 25.8%( n=13) 12.5%( n=6) 7.7% ( n=4) 2%(n=1) Socioeconomic – Low Middle High 74%( n=37) 24%( n=12) 2% ( n=1) 76%( n=38) 22%( n=11) 2% ( n=1) Occupation- Employed unemployed 16%( n=8) 84% ( n=42) 22%( n=11) 78% ( n=49) Family type Nuclear Extended/ Joint. 58%( n=29) 42% ( n=21) 41.9%( n=21) 58.1% ( n=29) Locality Urban Rural 56%( n=28) 44% ( n=22) 67.5%( n=34) 32.5% ( n=16) Age of onset in years.(mean) 26.53 25.70 Total duration of illness in years.(mean) 6.21 13.74 Cardio vascular risk ( intermediate risk ) 2%( n=1) 5.73%( n=3) Cardio vascular risk ( low risk ) 98%(n=49) 94.24% ( n=47) Smoking 24%( n=12) 24.01%( n=12) Tobacco chewing 30%( n=15) 40%( n=20) Tests for proportion for “with treatment schizophrenic patient” Tests for proportion for “without treatment schizophrenic patient” Comparison of parameters of physical examination between with treatment and without treatment schizophrenic patients Comparison of blood parameters between with treatment and without treatment schizophrenic patients Correlations N Mean ± SD in males Mean ± SD in females Pearson value P value Likelihood ratio Exact sig sex Percentage CVD risk 50 4.08±4.51 1.07± 0.26 464.21 0.00 622.19 -- Correlations N Mean ± SD in males Mean ±SD in females Pearson value P value Likelihood ratio Exact sig sex Percentage CVD risk 50 1.63± 1.67 1.11± 0.48 4.248 0.373 6.444 --- Variables Patients Without treatment (mean±SD) Patients With treatment (mean±SD) correlation Sig ( 2 tailed) SBP (mm Hg) 124.80±18.89 124.12±15.26 0.07 0.842 DBP(mm Hg) 79.06± 13.49 77.57± 11.64 0.16 0.536 Variables Patients Without treatment (mean±SD) Patients With treatment (mean±SD) correlation Sig ( 2 tailed) Triglyceride (mg/dl) 124.14±67.34 135.65±72.43 0.25 0.362 Cholesterol (mg/dl) 170.25±41.55 179.78±37.65 -0.01 0.254 HDL (mg/dl) 44.93±13.28 45.06±12.66 -0.05 0.963 40 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS DISCUSSION: Findings with respect to coronary heart disease risk (Framingham score) for patients with schizophrenia in the present study is similar to Sandeep grover et al study however it is less than that reported from the West (6.5-11.3%).[8,9,10] The major reason for this difference could be a lower age and lower prevalence rate of smoking in Sandeep grover's study compared to those evaluated in studies from the West,[9,11] in which the mean age of the study groups was 40.7 years[9,11] and the percentage of smokers varied from 53.7[9] to 58.[11] This ndings also suggest that age is an important variable which inuences the Framingham risk score.[12] This suggests that possibly with age and treatment the coronary heart disease risk increases in patients with schizophrenia. Studies from different ethnic groups and that from India have reported prevalence rate of metabolic syndrome to be 9-68% in patients with schizophrenia.[10] In our study cardiovascular risk was higher in male patients than female patients in with treatment schizophrenia patients, which was statistically signicant and metabolic syndrome was present more in female patients than male patients in with treatment schizophrenia patients, which was also statistically signicant. but cardiovascular risk was higher in male patients than female patients in without treatment schizophrenia patients. As per Denial bressington et al exposure to endogenous oestrogens during the fertile period of life delays the manifestation of atherosclerotic disease in women. Before menopause the coronary heart disease event rate in women is low and predominantly attributed to smoking.3 Women with an early menopause (<40 years) have a two-year lower life expectancy compared with women with a normal or late menopause. [13,14,15] CONCLUSION: On the basis of available literature and results of index study , which substantiate the earlier ndings, it can be concluded that: Cardiovascular risk causes signicant morb idity and mortality in schizophrenic patients .There is no signicant difference in the physical and blood parameters of with treatment and without treatment schizophrenia patients. Age , duration of the treatment, duration of illness, smoking and severity of illness affect cardiovascular risk and metabolic syndrome in schizophrenia patients. Male patients had more risk for cardiovascular disease than female patients. LIMITATIONS AND FUTURE DIRECTIONS: The limitations of the present study are cross-sectional design, inclusion of out patients only, which had lack of healthy control group. We also did not assess the effect of lifestyle factors, physical activity, dietary factors and family history of diabetes, all of which can confound the prevalence of cardiovascular risk in schizophrenia patients. the study was also constrained by the lack of validation of the cardio vascular risk scores used for 10year risk projection in the Indian population (the framingham risk score is based on data from white people, whereas score was developed for European populations). In future studies with the longitudinal design should try to overcome the limitations of this study. Only selecting patients visited in out patient care, involved a selection bias, as the sample was not representative of the entire population. However, examining this sub-population could be interesting for the development of preventive strategies that are focused on primary care. The study was conducted at a single center and was conned to out patients with chronic disease. It may not, therefore, reect the true cardiovascular risk of all patients with schizophrenia in community. REFERENCES: 1. Carlsson A, Lindquist L. Effect of chlorpromazine or haloperidol on formation of 3- methoxytyramine and normetanephrine in mouse brain. Acta Pharmacologica etToxicologica. 1963;20:140–145. Clementz BA, Sweeney JA, Hamm JP, et al. Identication of distinct psychosis biotypes using brain-based biomarkers. Am J Psychiatry. 2016;173:373–384. Hyman SE. Revolution stalled. Sci Transl Med. 2012;4(155):155cm11. 2. Brown S, Kim M, Mitchell C, Inskip H. Twenty-ve year mortality of a community cohort with schizophrenia. Br J Psychiatry. 2010;196(2):116–121. *Charlson FJ, Baxter AJ, Dua T, Degenhardt L, Whiteford HA, Vos T. Excess mortality from mental, neurological, and substance use disorders in the Global Burden of Disease Study 2010. In: Patel V, Chisholm D, Dua T, Laxminarayan R, Medina-Mora ME, eds. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities. 3rd ed (Volume 4). Washington (DC): The International Bank for Reconstruction 3. Bolíbar B, Fina Avilés F, Morros R, et al.; SIDIAP Group. [SIDIAP database: electronic clinical records in primary care as a source of information for epidemiologic research]. Med Clin (Barc) 2012;138(14):61721. Spanish. 4. Correll CU, Frederickson AM, Kane JM, Manu P. Equally increased risk for metabolic syndrome in patients with bipolar disorder and schizophrenia treated with second generation antipsychotics. Bipolar Disord 2008;10:788 97. 5. Goff DC, Sullivan LM, McEvoy JP, Meyer JM, Nasrallah HA, Daumit GL, et al. A comparison of ten year cardiac risk estimates in schizophrenia patients from the CATIE study and matched controls. Schizophr Res 2005;80:45 53. 6. Bobes J, Arango C, Aranda P, Carmena R, Garcia Garcia M, Rejas J, et al. Cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: Results of the CLAMORS Study. Schizophr Res 2007;90:162 73. 7. "NHLBI, Estimate of 10-Year Risk for CHD". Nhlbi.nih.gov. Retrieved 2013-09- 14. 8. Goff DC, Sullivan LM, McEvoy JP, Meyer JM, Nasrallah HA, Daumit GL, et al. A comparison of ten-year cardiac risk estimates in schizophrenia patients from the CATIE study and matched controls. Schizophr Res 2005;80:45-53. 9. Bobes J, Arango C, Aranda P, Carmena R, Garcia-Garcia M, Rejas J, et al. Cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: Results of the CLAMORS Study. Schizophr Res 2007;90:162-73. 10. Malhotra N, Grover S, Chakrabarti S, Kulhara P. Metabolic syndrome in schizophrenia. Indian J Psychol Med 2013;35:227-40 11. Daumit GL, Goff DC, Meyer JM, Davis VG, Nasrallah HA, McEvoy JP, et al. Antipsychotic effects on estimated 10-year coronary heart disease risk in the CATIE schizophrenia study. Schizophr Res 2008;105:175-87. 12. Phutane VH, Tek C, Chwastiak L, Ratliff JC, Ozyuksel B, Woods SW, et al. Cardiovascular risk in a rst-episode psychosis sample: A 'critical period' 13. https://www.ncbi.nlm.nih.gov/pubmed/27863522 14. Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ. 1998; 316:1043-7. [PMC free article] [PubMed] [Google Scholar] 15. Ossewaarde ME, Bots ML, Verbeek AL, et al. Age at menopause, cause- specic mortality and total life expectancy. Epidemiology. 2005;16:556-62. [PubMed] [Google Scholar] VOLUME-9, ISSUE-2, FEBRUARY-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra X 41GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS