ORIGINAL�ARTICLE ABSTRACT Objective: To determine the frequency and association of waist-hip ratio with acute coronary syndrome in local population of Islamabad, Pakistan. Study Design: Analytical cross-sectional. Place and Duration of Study: The study was carried out in the department of Cardiology, Pakistan Institute of Medical Sciences, Islamabad for the duration of six months (December 2014-June 2015). Materials and Methods: A total of 388 patients presented with acute coronary syndrome which included patients with unstable angina, non-ST elevation and ST elevation MI. Non-probability purposive sampling was used for sample selection. After taking informed consent, a self-structured questionnaire was used to collect the data. Waist-hip ratio was assessed using tape measure. Waist circumference was measured between the last rib and iliac crest, whereas the measurement of hip circumference was done at the level of greater trochanters. A waist-hip ratio of >0.85 for females and >0.9 for males was taken as abnormal.Data was analyzed on SPSS Version 17.0. Chi square test was applied to find out the association between waist-hip ratio and other variables whereas p- value of < 0.05 was considered as significant. Results: Out of total 388 acute coronary syndrome patients, 70.9% patients were males and 29.1% were females. The mean age of these patients was 47.5±18.46 years. Out of the total study population, 59.5% patients of ACS had abnormal waist hip ratio (>0.9). Among the patients having abnormal waist hip ratio, 62.9% were males and 51.3% were females. 71.6% patients presented with STEMI, 18.8% with NSTEMI and 9.5% with unstable angina. Chi square test depicted non-significant association of waist-hip ratio with ACS (p>0.05). A significant association was found between WHR and gender (p<0.05). Conclusion: There is no significant association between waist-hip ratio and acute coronary syndrome. The frequency of acute coronary syndrome is highest among males, with maximum prevalence of STEMI, followed by NSTEMI and unstable angina. Key Words: Acute Coronary Syndrome, Coronary Artery Disease, Obesity, Waist-Hip Ratio. (ACS). ACS is associated with myocardial infarction (MI) and is usually symptomatic such as the presence 1 of unstable angina. A report by the Heart Disease and Stroke Statistics update of the American Heart Association in 2016 showed that CHD is prevalent in 15.5 million individuals aged > 20 years, and there was a proportional increase in prevalence with age in 2 both genders. One third of all the fatalities in 3 persons aged 35 years and above occurs due to CHD. In Pakistan, acute coronary syndrome is more 4 prevalent in males. Risk of heart diseases increases in the presence of risk factors. A most common modifiable risk factor is sedentary lifestyle or physical inactivity leading to 5 obesity. Globally, overweight and obesity are being considered as main public health issues due to their relation with various chronic diseases for instance type 2 diabetes, cardiovascular diseases and 6 cancers. There are multiple means of estimating the Introduction One of the highest reasons of mortality in developing countries is attributed to cardiovascular diseases, which refer to a group of cardiac conditions which include coronary heart disease (CHD), coronary artery disease (CAD) and acute coronary syndrome Association of Acute Coronary Syndrome with Waist Hip Ratio in Local Population of Islamabad Capital Territory, Pakistan 1 2 3 4 5 Hesham Naeem , Farrah Qayyum , Hina Qayyum , Saba Murad , Zara Khalid Correspondence: Dr. Zara Khalid Department of Rehabilitation Foundation University, Islamabad E-mail: zara_awan@hotmail.com 1 Department of Cardiology Rawalpindi Institute of Cardiology, Rawalpindi 2 Department of Medicine Yusra Medical and Dental College, Islamabad 3 Department of Paediatrics Bahria University Medical and Dental College, Karachi 4,5 Department of Rehabilitation Foundation University, Islamabad Funding Source: NIL; Conflict of Interest: NIL Received: January 01, 2019; Revised: March, 2019 Accepted: July 15, 2019 Association of ACS with Waist Hip RatioJIIMC 2019 Vol. 14, No.3 111 body size or excess body weight, of which the most commonly used method, is the traditional measurement of body mass index (BMI). However in the last few years, alternative measures of central adiposity, namely waist-height ratio, waist circumference and waist-hip ratio (WHR) have been found to be better for prediction of CVD risks as compared to BMI, due to their accurate depiction of 7,8 body fat distribution. It is also due to the fact that multiple metabolic abnormalities are associated with increased visceral adiposity. These include a decrease in glucose tolerance, reduction in insulin sensitivity and deranged lipid profile, all of which are 9 CVD and type 2 diabetes risk factors. There is found to be uncertainty and variation regarding the performance of these anthropometric measures across different ethnicities. Among the Asian population, central obesity is emerging as a problem, as these individuals have large waist circumference (WC), but a normal BMI. As per WHO 2 guidelines, BMI 25-29.9 kg/m which lies in overweight category, corresponds with a WC of 80.0- 87.9 cm in women and 94.0-101.9 cm in men and a WHR of 0.9 and 0.85 in males and females respectively. Yet these values are derivative of Caucasians, and might not be applicable for the non- Caucasian population. It is still unclear that which of the afore-mentioned measures has a strong a s s o c i a t i o n w i t h t h e r i s k o f d e v e l o p i n g 6 cardiovascular disease in various ethnicities. It is reported in literature that waist hip ratio is the most useful and favored method of measuring obesity for the purpose of identification or 10,11 prediction of CVD risk factors. Risk stratification is an essential part of initial diagnosis and management of acute coronary syndrome. Hence the value of assessment of waist-hip ratio as a quantifiable measure of obesity, during physical examination of at-risk patients still needs to be determined in our population. As per our knowledge, data regarding the relation of these measures with cardiac diseases in Pakistani population is still lacking. Therefore, this study was carried out to determine the frequency and association of waist-hip ratio with acute coronary syndrome (ACS) in local population of Islamabad. Materials and Methods An analytical cross-sectional study was conducted on 388 patients with acute coronary syndrome reporting to Cardiology department of Pakistan Institute of Medical Sciences, Islamabad. This study spanned over duration of six months (December 2014-June 2015). Sample calculation was done using Rao soft sample size calculator, while keeping 95% confidence interval and 5% margin of error. Non- probability purposive sampling technique was employed. The inclusion criteria comprised of 30-70 years aged male and female patients, presenting with coronary artery disease or acute coronary syndrome consisting of non-ST elevation myocardial infarction, ST elevation MI and unstable angina. The patients with chronic kidney disease, compensated or decompensated liver disease or with gestation were not included the study. Ethical approval was obtained from the ethics review committee of Pakistan Institute of Medical Sciences, Islamabad. Informed consent from all participants was taken after explaining the study procedure. Demographic data was recorded using a self-structured questionnaire. Waist-hip ratio was assessed by measuring the waist and hip circumference with a tape measure. The subjects were instructed to stand straight with feet closed together, arms at sides and even distribution of body weight. The measurement of waist circumference was done mid-way between the last rib and iliac crest, whereas hip circumference was measured at the level of greater trochanters, with legs close together. A waist-hip ratio of >0.85 for 12 females and >0.9 for males was taken as abnormal. Statistical analysis of data was done on SPSS (Version 17, SPSS Inc, and USA). Frequencies and percentages were used to express the categorical variables. Chi square test was applied to find out the association between waist-hip ratio and other variables whereas p- value of ≤ 0.05 was considered as significant. Results The sample comprised of 388 ACS patients including 275 (70.9%) males and 113 (29.1%) females. (Table I) The mean age of the sample was 47.5±18.46 years. In this study the patients were divided into three categories according to their diagnosis. The results showed 278 (71.6%) patients presenting with ST elevation myocardial infarction (STEMI), 73 (18.8%) with non-ST segment elevation myocardial infarction (NSTEMI) and 37 (9.5%) with unstable angina. Gender wise distribution of the 3 types of ACS Association of ACS with Waist Hip RatioJIIMC 2019 Vol. 14, No.3 112 presentation has been shown in Table I. Chi square test of association showed non-significant association of waist-hip ratio and acute coronary syndrome (p>0.05). (Table II) Out of total 388 patients, 231 (59.5%) had abnormal waist hip ratio. Among the patients having abnormal waist hip ratio, there were 173 (62.9%) males and 58 (51.3%) females. Chi square test of association depicted significant association of gender with waist- hip ratio (p<0.05). (Table III) hospital. We observed a majority of sample presenting with ST elevation myocardial infarction (STEMI) which was the most frequent type of ACS among both genders, followed by non ST elevation myocardial infarction (NSTEMI), and then unstable angina. These results are similar to the results of a study conducted in 2013 on the role of central obesity in risk stratification after an acute coronary event, in which total 285 patients were admitted wherein 96.1% reported myocardial infarction (STEMI and NSTEMI) and 13 3.9% had unstable angina. Regarding gender distribution, 71% of our sample comprised of male patients with ACS and only approximately 29% females. As per a review article on gender differences in coronary heart diseases, the development of cardiovascular diseases occurs 7-10 years later in women as compared to men. The risk of d e ve l o p i n g h e a r t d i s e a s e s i s q u i te o f te n underestimated in women and the resulting under- recognition along with different clinical presentation leads to a reduced representation of females in 14 studies and clinical trials. There are various measures to assess abdominal adiposity as a means of predicting CVD risk factors, of which waist-hip ratio (WHR) is the most favored. In the current study, more than half almost 60% of the sample had abnormal waist-hip ratio, higher than the normative standard. A study on central obesity and mortality risk in older adults with coronary artery disease concluded that higher values of waist 15 hip ratio are predictive of a greater risk of mortality. In our study, we found a non-significant association between waist hip ratio and acute coronary syndrome. Our results support the findings of a study on relationship of physical fitness v/s BMI with CAD and cardiovascular events in women which also showed that after adjusting for other risk factors, BMI and other abdominal obesity measures (WHR, waist circumference) were not significantly associated with coronary artery disease or its adverse effects (p=0.05-0.88). Rather physical fitness and functional capacity were more important and were significantly associated with cardiovascular 16 outcomes such as ACS. No significant association was found between abnormal waist-hip ratio and acute coronary syndrome possibly because acute coronary syndrome is multi-factorial and depends on Table I: Demographics and Presenta�on of ACS Subjects (N=388) Table II: Associa�on of Waist-Hip Ra�o with Different Types of ACS **Normal WHR (< 0.85 for Female, <0.9 for Male) ***Abnormal WHR (> 0.85 for Female & >0.9 for Male) Table III: Associa�on of Waist-Hip Ra�o with Gender (Males & Females) * Shows Significant Value p < 0.05 **Normal WHR (< 0.85 for Female, <0.9 for Male) ***Abnormal WHR (> 0.85 for Female & >0.9 for Male) Discussion This study was conducted to find out the frequency and association of waist-hip ratio with acute coronary syndrome (ACS) in local population of Islamabad. The patients were divided into three distinct categories according to the type of acute coronary syndrome with which they presented to Association of ACS with Waist Hip RatioJIIMC 2019 Vol. 14, No.3 113 other risk factors as well. Contrary to this, a study on impact of body mass index and WHR on clinical outcomes in patients with STEMI showed that highest WHR was one of the mortality risk factors due to ACS. Yet this study also recommended further observing these associations in larger population 17 cohort studies. The results of the current study also found that waist hip ratio was significantly associated with gender, wherein the proportion of males was higher in abnormal WHR category as compared to females. This is in contradiction to a study done on southern Chinese population which showed that abdominal obesity was more prevalent in females. Gender differences could be explained by the hormonal changes and varying physical activity levels in males 18 and females. Overweight and obesity, be it central or abdominal, poses many challenges for treatment of coronary heart diseases. The cornerstone of primary prevention is the assessment of atherosclerotic cardiovascular disease risk which includes estimation of multiple risk factors. Management of obesity along with associated increase in physical activity and cardiorespiratory fitness levels is currently being recommended for a subsequent reduction in cardiovascular morbidity and mortality 19,20 burden. The current study has been conducted in only one hospital of Islamabad limiting the generalization of the results to whole population. However, future studies on larger samples and in multiple settings are recommended to observe the association of ACS with other probable risk factors using objective measures. Conclusion Based on the results of statistical data analysis we conclude that there is no significant association between waist-hip ratio and acute coronary syndrome. 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