Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12087 Modifiable risk factors for cardiovascular disease in Iraqi Kurdistan population: a large epidemiological study Nawzad Sulaiman Murad,1 Shawkat Salih Miro,2 Vazheen Abdul Hameed Ismael,3 Deldar Morad Abdulah4 1Adult and Fundamentals of Nursing Unit, College of Nursing, University of Duhok, Iraqi Kurdistan; 2Internal Medicine Department, College of Medicine, University of Duhok, Iraqi Kurdistan; 3Duhok Cardiac Center, Azadi Teaching Hospital, Duhok General Directorate of Health, Iraqi Kurdistan; 4Community and Maternity Health Nursing Unit, College of Nursing, University of Duhok, Iraqi Abstract Cardiovascular diseases (CVDs) are considered the leading factor of morbidity and mortality across the world. This study aimed to identify the modifiable risk factors of CVDs in the Kurdistan Region. In this retrospective cross-sectional study, the patients who visited and were diagnosed with any type of CVDs and treated in a main private cardiac center in Duhok governorate in Kurdistan Region were included between the years 2018 and 2023. The study found a similar percentage of male and female patients. The percentage of old patients was significantly increased from 18-19 to ≥70. The most preventable modifiable risk factors among cardiac patients were hypertension (86.17%), physical inactivity (60.59%), diabetes (40.15%), and dyslipidemia (56.31%). The less preventable modifiable risk factors were alco- hol (4.01%) and cigarette smoking (14.43%). Males had a higher prevalence of cigarette smoking (24.63% vs 4.38%; P<0.0001) and female patients had a higher prevalence of hypertension (91.25% vs 81.02%; p<0.000), diabetes (44.43% vs 35.80 %; p=0.0007) and dyslipidemia (59.15% vs 53.43%; p=0.0257). In terms of family history of heart disease, the middle age group had a higher prevalence compared to younger and older age groups. Diabetes and cigarette smoking was more prevalent among older age groups, while dyslipidemia was more prevalent among younger and older age groups. Alcohol, physical inactivity, and hypertension were similar among age groups. Hypertension, dia- betes, dyslipidemia, and physical inactivity were the most preva- lent risk factors for CVDs in this region. The older patients had significantly higher rates of some of these risk factors. Introduction Cardiovascular diseases (CVDs), including conditions such as coronary heart disease and stroke, are widely recognized as the pri- mary cause of illness and death worldwide.1 Over the past 30 years, there has been a significant increase in the number of cases of CVDs, with the total rising from 271 million in 1990 to 523 million in 2019. Similarly, mortality associated with CVDs has also increased, with the number of deaths rising from 12.1 million to 18.6 million during the same period. This trend is expected to continue due to the aging population, resulting in an increased burden of CVD-related deaths.2 It is projected that 55 million deaths occurred in the workplace in 2017, and 17.7 million of these deaths were due to CVD.3 It is cru- cial to collect and record information about the modifiable risk fac- tors associated with CVDs on a global and country-specific level. This data serves as a foundation for creating strategies for prevention that are tailored to the global and local contexts. Currently, there is limited data on modifiable risk factors in low and middle-income countries. The most comprehensive global estimates of the relation- ship between risk factors, adult deaths, and CVDs are provided by the Global Burden of Disease (GBD) study. Keeping this data up-to- date is vital for understanding the impact of risk factors on CVDs and developing effective preventive measures.1,4 The available cross- sectional studies conducted in this region reported that hypertension (55.3%), followed by dyslipidemia (42.7%), type 2 diabetes mellitus (T2DM, 29%), smoking (11%), and ex-smoking (9.3%) are the most prevalent risk factors for coronary artery disease.5,6 These studies have a small size and did not focus on risk factors specifically. Therefore, we need large and more robust studies to identify the modifiable risk factors of CVDs in this region for preventive purpos- es. In this regard, we aim to explore the modifiable risk factors of CVDs in a large study in Iraqi Kurdistan. Correspondence: Deldar Morad Abdulah, Community and Maternity Health Nursing Unit, College of Nursing, University of Duhok, Iraqi Kurdistan. E-mail: deldarmorad@uod.ac Key words: risk factor; modification; prevention; cardiovascular disease. Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics approval: the Ethics Committee of Duhok General Directorate of Health approved this study (registered as 08032023-2-24 on 8 March 2023). The study is conformed with the Helsinki Declaration of 1964, as revised in 2013, concerning human and animal rights. Informed consent: the written consent forms were not applicable in this study because we collected the data of this study from the medical records of the patients. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient infor- mation to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article (the raw data file was sent to the publisher). The raw data is available through the following link as wel l :h t tps : / /dr ive .google .com/f i le /d /1UYSfP3g6JfzuFAm- nf58GkvWZSUHKga0/view?usp=sharing Received: 14 November 2023. Accepted: 27 November 2023. Early access: 19 December 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12087 doi:10.4081/hls.2023.12087 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 258] [Healthcare in Low-resource Settings 2024;12:12087] Non -co mmerc ial us e o nly Materials and Methods Study design and sampling In this retrospective cross-sectional study, the patients who vis- ited and were diagnosed with any type of CVDs and treated in a main private cardiac center were included. In this regard, we recruited the medical records of the CVDs patients who were doc- umented in the center between the years 2018 and 2023. The men- tioned cardiac clinic is located inside the Shilan Private Hospital in Duhok City. The ethical approval of this study was obtained from the local health ethic committee registered as 08032023-2-24 on 8 March 2023. Sampling Between 5000 and 5500 patients have visited the cardiac cen- ter since 2018. The center has the papers of the medical records of the patients in some cabinets. The medical records have not been documented in a computer data system yet. To obtain a representa- tive and the most practical and suitable sample of the target popu- lation, we selected one medical record of fifth papers saved in the cabinets. We selected the sixth paper in the case of having too much missing information in the fifth medical record. This process was continued until all medical records were completed. Finally, we included 1497 patients in this study. Setting of the study The Kurdistan Region of Iraq is comprised of four gover- norates, which are officially recognized as Erbil, Sulaymaniyah, Halabja, and Duhok (Figure 1). The study was conducted among cardiac patients in the Duhok governorate. The Duhok governorate is in the North part of the Kurdistan Region and has a border with Turkey, Syria, and Iraq. Based on the latest statistics of the Kurdistan Regional Statistics Office Duhok governorate has 1,557,020 persons.7 Inclusion and exclusion criteria We included patients of both genders without applying any restriction of age and other socio-demographic aspects such as reli- gion, residency, etc. The patients who lived in the Duhok gover- norate and visited the center were eligible for this study. However, we excluded the patients with too much missing information and pregnant women to avoid possible bias. Measurements The flowing modifiable risk factors were drawn from the med- ical records of the clinic. The factors were alcohol, hypertension, diabetes, dyslipidemia, cigarette smoking, and physical inactivity. In addition, we included the following non-modifiable risk factors from the medical records of the patients; included past cardiac vas- cular history and family history of heart disease. We included gen- der and age groups to explore the risk factors by gender and age groups. We could not include more risk factors since only these factors have been documented in the medical records of the patients. The data were entered into a pre-designed Excel sheet between 25 June 2022 and 21 February 2023. Statistical methods Descriptive statistics were used for determining the prevalence of modifiable risk factors among CVD patients. The risk factors by gender and age groups were examined in Pearson chi-squared test. The statistical calculations are performed in JMP Pro 14.3.0. Results The study found a similar percentage of male (49.63%) and female (50.37%) patients. The most prevalent modifiable risk fac- tors among cardiac patients were hypertension (86.17%), physical inactivity (60.59%), dyslipidemia (56.31%), diabetes (40.15%), and the less prevalent modifiable risk factors were alcohol (4.01%) and cigarette smoking (14.43%). The non-modifiable risk factors were past cardiac vascular history (63.73%) and family history of heart disease (6.15%). The study showed that male and female patients did not have a statistically significant difference in the prevalence of alcohol, family history of heart disease, and physical inactivity. However, male patients had a significantly higher preva- lence of cigarette smoking (24.63% vs 4.38%; p<0.0001). Female patients had a significantly higher prevalence of hypertension (91.25% vs 81.02%; p<0.000), diabetes (44.43% vs 35.80%; p=0.0007, and dyslipidemia (59.15% vs 53.43%; p=0.0257). In terms of non-modifiable risk factors, the study showed that male patients had a significantly higher prevalence of past cardiac vas- cular history (74.16% vs 53.45%; P<0.0001). Most of the patients had multiple modifiable risk factors (82.43%) followed by mono risk factors (14.56%). We found that a small percentage of patients had only non-modifiable risk factors (3.01%). Both male and female patients mostly had multiple risk factors, but the males had significantly higher rates of mono risk factor (16.96%) compared to females (12.20%; P=0.0029; see Table 1 and Figure 1). Article Figure 1. Map of Kurdistan region.7 [Healthcare in Low-resource Settings 2024;12:12087] [page 259] Non -co mmerc ial us e o nly The study also found that patients with cardiac disease were more likely to be elderly. The prevalence of alcohol, cigarette smoking, and physical inactivity was not statistically significant among age groups. The modifiable risk factors of diabetes and cig- arette smoking were more prevalent among older age groups, while dyslipidemia was more prevalent among younger and older age groups. Alcohol, physical inactivity, and hypertension were similar among age groups. The multiple risk factors were increased with increasing age groups in contrast with mono risk factor (p<0.0001). In terms of non-modifiable risk factors, the study found that prevalence of past cardiac vascular history was higher among younger age groups, decreased by 40-49 years old, and increased from 40-49 years to ≥70 years old. In terms of family history of heart disease, the middle age group had a higher preva- lence compared to younger and older age groups. (Table 2; Figure 2). Additionally, the study found that the most commonly occur- ring types of cardiovascular diseases were ischemic heart ailments, hypertension, myocardial infarction, cerebrovascular accidents, heart failure, and angina (as depicted in Figures 3 and 4). Discussion In this study, we found that the most prevalent modifiable risk factors among cardiac patients were hypertension, diabetes, dys- lipidemia, and physical inactivity. Article Table 1. Prevalence of modifiable risk factors among all patients and by gender. Risk factors (N=1497) All patients Gender no (%) Male (743, 49.63%) Female (754, 50.37%) p(two-sided) Modifiable risk factors Hypertension No 207 (13.83) 141 (18.98) 66 (8.75) <0.0001 Yes 1290 (86.17) 602 (81.02) 688 (91.25) Physical inactivity 0.1086 No 590 (39.41) 308 (41.45) 282 (37.40) Yes 907 (60.59) 435 (58.55) 472 (62.60) Dyslipidemia 0.0257 No 654 (43.69) 346 (46.57) 308 (40.85) Yes 843 (56.31) 397 (53.43) 446 (59.15) Diabetes 0.0007 No 896 (59.85) 477 (64.20) 419 (55.57) Yes 601 (40.15) 266 (35.80) 335 (44.43) Cigarette smoking <0.0001 No 1281 (85.57) 560 (75.37) 721 (95.62) Yes 216 (14.43) 183 (24.63) 33 (4.38) Alcohol 0.3960 No 1437 (95.99) 710 (95.56) 727 (96.42) Yes 60 (4.01) 33 (4.44) 27 (3.58) Risk factors 0.0029 Mono risk factor 218 (14.56) 126 (16.96) 92 (12.20) Multiple risk factors 1234 (82.43) 588 (79.14) 646 (85.68) Non modifiable risk factors 45 (3.01) 29 (3.90) 16 (2.12) Non-modifiable risk factors <0.0001 Past cardiac vascular history No 543 (36.27) 192 (25.84) 351 (46.55) Yes 954 (63.73) 551 (74.16) 403 (53.45) Family history of heart disease 0.7734 No 1405 (93.85) 696 (93.67) 709 (94.03) Yes 92 (6.15) 47 (6.33) 45 (5.97) Pearson chi-squared tests were performed for statistical analyses. The bold numbers show the significant differences between male and female CVD patients. Figure 2. Overall and between gender modifiable risk factors among patients with CVDs. [page 260] [Healthcare in Low-resource Settings 2024;12:12087] Non -co mmerc ial us e o nly Hypertension According to the local health system, hypotension is diagnosed when systolic blood pressure (SBP) is equal to or greater than 130 mmHg, or diastolic blood pressure (DBP) is equal to or greater than 80 mmHg. Hypertension, characterized by elevated blood pressure, has been strongly linked to the development of CVD with robust evidence found globally.8,9 The Global Burden of Disease (GBD) study conducted a comprehensive and comparative assess- ment of the burden of CVDs attributable to hypertension from 1990 to 2019. The study reported that the number of deaths and years lived with disability (YLD) caused by CVDs related to hypertension in young adults were 640,239 and 2,717,474, respec- tively. These numbers represented a significant increase of 43.0% in deaths and 86.6% in YLDs compared to 1990. Interestingly, middle-income countries had the highest burden of hypertension- related CVDs, while high-income countries had the lowest burden.8,9 Our study found that hypertension was prevalent in both genders, but the prevalence was higher in females (91.25% vs 81.02%), and the rate of hypertension increased with age. However, in the GBD review, men had higher mortality rates from hypertension-related CVDs compared to women. Ischemic heart disease (IHD) and stroke were the leading causes of death and years lived with YLD burden, respectively, in the GBD review, which is consistent with our findings where IHD was also one of the most common types of CVDs. Another study on pre-hyperten- sive patients with 30,258 participants showed that for every 10 mmHg increase in systolic blood pressure, there was a 12% increase in mortality associated with CVDs.10 A prospective study conducted among 10,558 persons aged ≥30 years showed that liv- ing with blood pressure ≥180/105 mmHg increases the risk of CVD mortality by 37% among men and 18% among women com- pared to those persons with blood pressure <120/80 mmHg.11 Controlling hypertension is the most effective way to prevent CVDs development.8,12 A prospective study conducted on 13,383 participants aged 60-80 years who were free from CVD at baseline and had SBP within the range of 110 to <150 mm Hg, followed them up for a median of 13.01 years. The study observed 1,727 cases of CVD and 3,742 deaths. The analysis revealed that normal- ized SBP was associated with a decreased risk of CVD, with a haz- ard ratio (HR) of 0.81 (95% confidence interval [CI], 0.76-0.87), as well as a decreased risk of all-cause mortality, with an HR of 0.89 (95% CI, 0.85-0.93).13 Dyslipidemia According to an updated systematic review, the overall preva- lence of hypercholesterolemia, defined as total cholesterol (TC) levels ≥5.1 mmol/L (200 mg/dL), was found to be between 17% to 54.9% in males and 9% to 53.2% in females during the period from 1990 to 2014.14 Dyslipidemia is one of the main risk factors for developing CVD worldwide.15 The higher prevalence of dyslipi- demia has been shown to associate with the Western diet. The Western diet is characterized by high consumption of red and processed meat, high-fat milk and dairy products, fried and salty foods, refined grain products, and sugar-laden desserts and soft drinks.16,17 Various dietary patterns have been linked to decreased rates of dyslipidemia and CVDs. Examples of such eating patterns include vegetarian and near-vegetarian diets, Mediterranean-style diets, the Dietary Approaches to Stop Hypertension (DASH) diet, and the Prudent Heart Healthy Diet recommended by the American Heart Association (AHA), the Adult Treatment Panel III (ATP III), and the US Departments of Agriculture and Health and Human Services (DHHS) in their Guidelines for Americans 2005. These dietary patterns emphasize whole, plant-based foods and healthy fats, while limiting or avoiding animal products, added sugars, sodium, and saturated fats. Along with other healthy lifestyle choices, such as regular physical activity, maintaining a healthy weight, avoiding smoking, and managing stress, these dietary pat- terns can contribute to a lower risk of dyslipidemia and CVDs.18 Physical inactivity The World Health Organization advises individuals to partici- pate in regular physical activity, which can include moderate- intensity activity for a minimum of 150 minutes per week or vig- orous-intensity activity for at least 75 minutes per week. This rec- ommendation promotes the importance of incorporating physical activity into one’s lifestyle for maintaining overall health and well- Article Figure 3. Modifiable risk factors of CVDs among patients with different age groups. Figure 4. Age groups and current diagnoses of patients with CVD. [Healthcare in Low-resource Settings 2024;12:12087] [page 261] Non -co mmerc ial us e o nly being.19 Physical activity has been shown to associate with a reduc- tion in CVDs morbidity and mortality.20 In a retrospective national study carried out in Korea involving 131,558 adults, it was observed that an increase of 500 metabolic equivalent task-minutes per week in physical activity was associ- ated with a 14% decrease in the risk of mortality due to CVDs. This finding highlights the potential benefits of regular physical activity in reducing the risk of CVD-related mortality.21 A multi- centered, randomized, controlled community intervention involv- ing 364 patients in four primary care centers was aimed to evaluate the short and medium-term effects of 9 months of a supervised physical activity program. The study reported that there was a sig- nificant difference in physical activity in the intervention commu- nity compared to the control community. They reported a signifi- cant decline in the SBP, total cholesterol, and LDL-cholesterol even after adjustments for the confounders. The incidence of adverse cardiovascular events was substantially lower (2.5% vs 10.5%) compared to the control community, respectively.22 Habitual physical activity has been reported to associate with a lower predicted risk of CVD.23 We suggest that the Kurdistan Region encourages individuals for physical activity through suit- able health promotion programs. A healthy city is an active city.24 Smoking Cigarette smoking is a global public health issue. The age and gender-adjusted proportion of smoking is 31.2% ([95% CI: 30.9 31.6%] in the Middle East countries with a higher rate among men compared to women (48.0% vs 13.8%).25 The Global Youth Tobacco Survey conducted in Kurdistan Region revealed that the overall prevalence of current cigarette smoking among adolescents was 15.3%. Specifically, the preva- lence was 25.1% among boys and 2.7% among girls. Several fac- tors were found to be associated with smoking among adolescents, including parents’ smoking, smoking among closest friends, male gender, having pocket money, and perceptions that boys or girls who smoked were attractive. These findings shed light on the fac- tors that contribute to smoking behavior among adolescents in the Kurdistan Region.26 Smoking is the second main modifiable risk factor for CVD worldwide.27 A prospective study performed on 19,782 men and 21,500 women (40-59 years) showed that current smokers have a significantly higher risk of coronary heart disease incidence: 315% in men and 307% in women, compared to non- smokers. In addition, the study showed that smoking cessation was associated with a rapid risk reduction of coronary heart disease within 2 years.28 There is strong evidence that a range of pharma- cologic and behavioral interventions, both individually and in Article [page 262] [Healthcare in Low-resource Settings 2024;12:12087] Table 2. Prevalence of modifiable risk factors by gender among cardiac patients. Risk factors (n= 1497) Age groups no (%) p 18-19 20-29 30-39 40-49 50-59 60-69 ≥70 (5, 0.33%) (57, 3.81%) (91, 6.08%) (247, 16.5%) (385, 25.72%) (398, 26.59%) (314, 20.98%) Modifiable risk factors Hypertension 0.0239 No 0 (0.00) 11 (19.30) 15 (16.48) 35 (14.17) 67 (17.40) 36 (9.05) 43 (13.69) Yes 5 (100) 46 (80.70) 76 (83.52) 212 (85.83) 318 (82.60) 362 (90.95) 271 (86.31) Physical inactivity 0.3682 No 2 (40.00) 17 (31.48) 37 (41.57) 86 (35.68) 144 (37.89) 168 (43.19) 124 (39.87) Yes 3 (60.00) 37 (68.52) 52 (58.43) 155 (64.32) 236 (62.11) 221 (56.81) 187 (60.13) Dyslipidemia <0.0001 No 3 (60.00) 31 (54.39) 67 (73.63) 149 (60.32) 173 (44.94) 112 (28.14) 119 (37.90) Yes 2 (40.00) 26 (45.61) 24 (26.37) 98 (39.68) 212 (55.06) 286 (71.86) 195 (62.10) Diabetes <0.0001 No 4 (80.00) 37 (64.91) 64 (70.33) 174 (70.45) 223 (57.92) 199 (50.00) 195 (62.10) Yes 1 (20.00) 20 (35.09) 27 (29.67) 73 (29.55) 162 (42.08) 199 (50.00) 119 (37.90) Cigarette smoking 0.1119 No 5 (100) 54 (94.74) 84 (92.31) 205 (83.00) 323 (83.90) 340 (85.43) 270 (85.99) Yes 0 (0.00) 3 (5.26) 7 (7.69) 42 (17.00) 62 (16.10) 58 (14.57) 44 (14.01) Alcohol 0.8284 No 5 (100) 55 (96.49) 88 (96.70) 240 (97.17) 366 (95.06) 384 (96.48) 299 (95.22) Yes 0 (0.00) 2 (3.51) 3 (3.30) 7 (2.83) 19 (4.94) 14 (3.52) 15 (4.78) Risk factor categories <0.0001 Mono risk factor 0 (0.00) 18 (31.58) 23 (25.27) 49 (19.84) 52 (13.51) 26 (6.53) 50 (15.92) Multiple risk factors 5 (100) 37 (64.91) 64 (70.33) 192 (77.73) 315 (81.82) 364 (91.46) 257 (81.85) Non-modifiable risk factors0 (0.00) 2 (3.51) 4 (4.40) 6 (2.43) 18 (4.68) 8 (2.01) 7 (2.23) Non-modifiable Past cardiac vascular <0.0001 No 1 (20.00) 25 (43.86) 45 (49.45) 123 (49.80) 141 (36.62) 135 (33.92) 73 (23.25) Yes 4 (80.00) 32 (56.14) 46 (50.55) 124 (50.20) 244 (63.38) 263 (66.08) 241 (76.75) History of heart disease <0.0001 No 5 (100) 53 (92.98) 81 (89.01) 215 (87.04) 368 (95.58) 377 (94.72) 306 (97.45) Yes 0 (0.00) 4 (7.02) 10 (10.99) 32 (12.96) 17 (4.42) 21 (5.28) 8 (2.55) Non -co mmerc ial us e o nly combination are effective in rising smoking cessation in non-preg- nant adults.29 Diabetes mellitus The pooled prevalence rate of T2DM is about 14.6% (95% CI: 11.6-17.5) which varied from 2.6% (95% CI: 2.5-2.6) to 21.9 (95% CI: 16.8-17.5) amongst countries. It is estimated that a total of 46 million individuals are now suffering from diabetes in the Middle East.30 Diabetes is the main significant risk factor for the develop- ment of CVD.31 A Korean study induced 76,434 from the Health Screening and Promotion Center and showed that diabetes is asso- ciated with risks of total CVD by 70%, coronary heart disease by 67%, and stroke by 58%.32 It is crucial to focus on cardiovascular threat factors to decrease the illness’s lasting cardiovascular com- plications. Strengths and limitations The main strong point of this study is that we tried to include as much as possible the medical records in this study. But the study was not exempt from the limitations. Firstly, the study was per- formed retrospectively, therefore, we could not include obesity and diet factors in this study. In addition, the data repository of other private clinics was not accessible to the researchers. 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