Journal of Applied Pharmaceutical Science 02 (03); 2012: 80-84

ISSN: 2231-3354
Received on: 25-02-2012
Revised on: 15-03-2012
Accepted on: 23-03-2012

Cardiovascular disease prevalence and prescription

patterns at a tertiary level hospital in Bangladesh
Md. Abdul Muhit, Md. Obaidur Rahman, Sheikh Zahir Raihan, Muhammad
Asaduzzaman, Mohammad Ahasanul Akbar, Nahid Sharmin and A. B. M.
Faroque

Md. Abdul Muhit,

Sheikh Zahir Raihan,
Muhammad Asaduzzaman,
Mohammad Ahasanul Akbar
Department of Clinical Pharmacy
& Pharmacology, University of
Dhaka, Dhaka-1000, Bangladesh

Md. Obaidur Rahman

Department of Pharmaceutical
Chemistry, University of Dhaka,
Dhaka 1000, Bangladesh

Nahid Sharmin, A.B.M. Faroque

Department of Pharmaceutical
Technology, University of Dhaka,
Dhaka-1000, Bangladesh

ABSTRACT
Demographic study of cardiovascular diseases (CVDs) and drug utilization in
population is the basis for assessment of cardiovascular disease management. Aim of this study
was to analyze the prevalence of CVDs with drug utilization and current trends in Bangladesh.
A cross-sectional type of descriptive study was carried out at the outdoor of National Institute
of Cardiovascular Diseases (NICVD), Dhaka from July09 to August09. A total of 780
patients, who acquiesce with the inclusion and exclusion criteria, were interviewed with
structured questionnaire and followed up by prescription monitoring. Out of the total patients
with a male, female ratio of 5.3: 4.7, 45.90% patients were over 55 years and 69.62% patients
had come from urban area. The patients had lipid level disorder (47.05%), hypertension
(28.05%), heart failure (27.25%), ischaemic heart disease (21.55%) and 40.39% were
associated with diabetes. Individual patient got 6.35 1.56 no. of drug of different class of
which most frequently prescribed drugs were antiatherogenic (97.67%), lipid lowering agents
(95.35%), antianginal (79.07%), beta-blockers (51.16%), ACE inhibitors (30.23%), diuretics
(37.21%), anxiolytics (81.4%) etc. This data may be propitious for the general physicians for
optimizing rational use of cardiovascular drugs and also accessible in formulating strategy for
effective cardiovascular disease management.

Keywords: Prevalence, NICVD, prescription, ischemic heart disease

INTRODUCTION

For Correspondence
Md. Abdul Muhit
Department of Clinical Pharmacy &
Pharmacology, Faculty of Pharmacy,
University of Dhaka, Dhaka-1000,
Bangladesh. Tel: +88-02-9661920-73
(Ext-8156), Fax: +88-02-8615583,

Cardiovascular disease (CVD) is a major health problem throughout the world and a
common cause of premature morbidity and mortality. According to World Health Organization
(WHO), CVDs are the number one cause of death globally. An estimated 17.5 million people died
from CVDs in 2008, epitomizing 30% of all global deaths (WHO, 2009). Over 80% of CVD
deaths take place each year in low- and middle-income countries like Bangladesh (BBS, 2009). By
2015, almost 20 million people may endure from death due to CVDs, mainly heart disease and
stroke and they will remain the single leading causes of death (WHO, 2009).

Journal of Applied Pharmaceutical Science 02 (03); 2012: 80-84

CVD is a general category of diseases that affects the

heart and the circulatory system. CVD is caused by disorders of the
heart and blood vessels, and includes coronary heart disease
(CHD), congestive heart failure (CHF), stroke, hypertension,
peripheral artery disease, and rheumatic heart disease. CHD alludes
to a reduction of blood flow due to thickening and hardening of the
arteries that supply the heart muscle. A complete cut off of the
blood supply results in the death of heart cells, and a heart attack
(MI) occurs. CHF is a disorder where the heart loses its ability to
pump blood efficiently. Finally stroke occurs when a blood vessel
bringing oxygen and nutrients to the brain bursts or is clogged by a
blood clot (Badiuzzaman et al., 2009).
Important modifiable risk factors of CVDs are unhealthy
diet, physical inactivity, tobacco use and the effects insinuate
abnormal blood lipid profile and obesity. Less physical activity and
excess fat rich diet are two major health concerns in affluent
society. A study in Bangladesh revealed that 27.93%, 21.08% and
13.41% stroke patients with lipid disorder had high cholesterol,
low density lipoprotein (LDL) and triglycerides (TG) level
respectively. 42.67% patients had low high density lipoprotein
(HDL) level showed in the same study (Comeau et al., 1998).
The possible treatment options for the management of
CVDs are lipid lowering agents, vasodilators, beta-blockers, ACE
inhibitors, diuretics, calcium channel blockers etc. This study
examines prevalence and trends of drug using pattern indicated for
the treatment of CVDs among the outpatient visited at NICVD.
Population-based trends in drug use have important implications
for patient health outcomes, drug treatment and other health
services (Psaty et al., 1993). Several population-based studies have
probed the trends in the drug use; however few of these studies
have pondered the appropriateness of trends (Shaila et al., 2007).
To do so requires sufficient information on patient level
characteristics that are expedient for determining appropriateness
of treatment.

non-cooperative for the follow up monitoring of his/her

prescription were excluded from the study.
A total of 780 patients were enquired with the selfdeveloped questionnaire and their prescriptions were monitored to
explore the diagnosis of clinical examinations like lipid profile,
echocardiogram, blood pressure, blood glucose level,
electrocardiogram (ECG), other blood profiles etc. All the data
were fed to the computer and were analyzed by modified Wald
method in GraphPad prism software package in the computer for
statistical significance.
RESULTS
Socio-demographic characteristics
Out of 780 patients who came to visit the NICVD outdoor
unit, 52.95% (95%CI: 49.44 to 56.43%) patients were male and
47.05% (95%CI: 43.57 to 50.56%) were female. Approximately 66
% the patients (95%CI: 62.50 to 69.14%) were from the
demographically developed area whereas 34.10% (95%CI: 30.86
to 37.50%) patients came from rural area and the difference was
found to be statically significant (p<0.05). The patients were
divided in different age groups: between 13-34 yrs (18.97%), 3554 yrs (35.13%), and above 55 yrs (45.9%). (Table 1)
Table. 1: Age, sex and demographic distribution of the cardiac disorder patients
(n=780).
Age
13-34 years
35-54 years
>55 years
Sex
Male
Female
Demography
Rural
Urban

No. of
patients
148
274
358

Percentages
(%)
18.97
35.13
45.9

CI* (%)
16.37 to 21.88
31.86 to 38.54
42.43 to 49.41

413
367

52.95
47.05

49.44 to 56.43
43.57 to 50.56

266
514

34.10
65.90

30.86 to 37.50
62.50 to 69.14

Male

Female

76
148
189

72
126
169

Fishers exact test

P<0.05

CI*= Confidence interval calculated by modified Wald method at 95% confidence

level

METHOD
Objective of the study was to find out the prevalence of
cardiovascular diseases and prescribing patterns of the physicians
among the patient who attended the outdoor of NICVD, a tertiary
hospital in Dhaka, Bangladesh. The present study aimed at come
up with the prevalence of CVD among the patients who came to
seek treatment at a tertiary level hospital and usual trend of the
molecule of different therapeutic group of drugs prescribed to
them. This center receives a mixture of affluent and low-middle
income patients and serves the entire country as a referral center
for patients requiring high-intensity tertiary care. Other objective
was to disclose the variation of prevalence of CVD among
different age groups, between rural and urban populations and also
to get an assumption about the prescribing pattern & behavior of
the physicians. This cross sectional type of descriptive study was
carried out in the medicine outdoor of NICVD during the whole
month of July 2009 to August 2009. The first twenty patients
attending outdoor of NICVD each day were included in the study.
Patients who denied facing the questionnaire or those who were

Different medical disorders

Extensive diagnosis made by the physicians revealed
different clinical conditions prevailing among the patients. Above
47% (95%CI: 43.57 to 50.56%) patients were reported to have
disordered lipid profile whereas 28.05% (95%CI: 25.03 to 31.33%)
patients were diagnosed with hypertension and the difference was
statistically significant (p<0.05). Almost 16% (95%CI: 13.26 to
18.36%) CVD patients were reported with stroke. Ischaemic heart
diseases (IHDs) were reported in 21.55% patients, heart failure in
27.25%, and myocardial infarction in 23.78% patients. (Table 2)
Table 2: Different medical conditions among the cardiac disorder patients (n=780).
Medical conditions
No. of patients Percentages (%)
CI* (%)
Hypertension
219
28.05
25.03 to 31.33
Ischaemic heart disease
168
21.55
18.79 to 24.56
Heart failure
212
27.25
24.17 to 30.41
Myocardial infarction
185
23.78
20.86 to 26.83
Stroke
122
15.60
13.26 to 18.36
Lipid level disorder
367
47.05
43.57 to 50.56
Angina
97
12.47
10.30 to 14.94
CI*= Confidence interval calculated by modified Wald method at 95% confidence
level

Journal of Applied Pharmaceutical Science 02 (03); 2012: 80-84

Other associated conditions

The physicians also diagnosed several different medical
conditions in the patients. For example, 24.11% (95%CI: 21.23 to
27.23%) CVD patients were diabetic and type-I diabetes was more
prevalent (16.67%). Above 14% (95%CI: 12.18 to 17.14%)
patients were suffering from night-time anxiety with various
symptoms such as sweating, palpitation, nightmare, chest pain etc.
Other associated medical conditions included gastric disorder
(9.74%), eye disease (2.56%) and bronchial asthma (3.33%).
(Table 3)
Table 3: Associated other medical conditions among the cardiac disorder patients
(n=780).
Medical conditions
Diabetes type-I
Diabetes type-II
Anxiety
Gastric disorder
Eye disease
Bronchial asthma
None

No. of patients Percentages (%)

130
16.67
58
7.44
113
14.49
76
9.74
20
2.56
26
3.33
357
45.77

CI* (%)
14.21 to 19.45
5.78 to 9.50
12.18 to 17.14
7.85 to 12.04
1.64 to 3.95
2.26 to 4.86
42.30 to 49.28

CI*= Confidence interval calculated by modified Wald method at 95% confidence

level

Drugs prescribed in different conditions

Total 6.351.56 drugs per prescription were prescribed by
the physicians, which belong to different pharmacological
therapeutics class. We have categorized all the drugs prescribed to
the patients in different groups. Most of the patients got advice to
take lipid lowering agent (95.35%, 95%CI: 93.36 to 96.66%) and
antiatherogenic drugs (97.6%, 95%CI: 96.20 to 98.46%). Several
antihypertensive drugs were prescribed to the patients such as beta
adrenoreceptor blockers (51.16%, 95%CI: 47.65 to 54.65%), ACE
inhibitors (30.23%, 95%CI: 27.31 to 33.57%), angiotensin receptor
blockers (13.95%, 95%CI: 11.71 to 16.59%), and diuretics
(37.21%, 95%CI: 33.86 to 40.63%). The physicians prescribed
81.41% (95%CI: 78.52 to 83.99%) anxiolytic drugs for the patients
with or without anxiety. (Table 4, Figure 1)

Prescribing pattern of physicians

120
100

95.35 97.67

97.67
81. 4

79.07

)
80
%
(
et
ra 60
n
iot
ipr 40
cs
er
P 20

51.16
37.21

30. 23
11.63

13.95

F
Drugs

Drugs

No. of
prescriptions
744
761
617
399
91
236
109

Prescription
rate (%)
95.35
97.6
79.07
51.16
11.63
30.23
13.95

Lipid lowering agents

Antiatherogenic
Antianginal
Beta-blockers
Calcium channel blockers
ACE inhibitors
Angiotensin
receptor
blocker
Diuretics
290
37.21
Anxiolytics
635
81.41
Others
762
97.67
CI*= Confidence interval calculated by modified Wald method
level

CI* (%)
93.66 to 96.66
96.20 to 98.46
76.11 to 81.81
47.65 to 54.65
09.59 to 14.12
27.13 to 33.57
11.71 to 16.59
33.86 to 40.63
78.52 to 83.99
96.36 to 98.56
at 95% confidence

Lipid lowering agents

Among the lipid lowering agents, atorvastatin was given
to most of the patients (75.4%, 95%CI: 72.18 to 78.36%) whereas
the second choice was rosuvastatin (19.62%) (Table 5).
Clopidogrel and aspirin combination was given to 48.36% (95%CI:
44.82 to 51.91%) patients for reducing clotting for obtaining
synergistic antiplatelet effect of the both compounds whereas
37.21% (95%CI: 33.83 to 40.68%) patients were treated with only
clopidogrel. Aspirin and warfarin were prescribed to only 10.12%
and 4.33% patients, respectively. (Table 5)
Table 5: Different classes of drugs prescribed among the cardiac disorder patients
(n=780).
Drugs
Lipid lowering agents
Atorvastatin
Rosuvastatin
Simvastatin
Antiatherogenic
Clopidogrel
Clopidogrel + Aspirin
Aspirin
Warfarin
Antianginal
Nitroglycerine
Isosorbide mononitrate
Nitroglycerine +
Isosorbide
Beta-blockers
Metoprolol
Carvedilol
Ramipril + Carvedilol
Diuretics
Frusemide
+
Spironolactone
Indapamide
Anxiolytics
Bromazepam
Clonazepam
Diazepam
Clobazam

No. of
prescriptions

Prescription
rate (%)

CI* (%)

561
146
37

75.4
19.62
4.97

72.18 to 78.36
16.92 to 22.63
3.61 to 6.80

283
368
77
33

37.21
48.36
10.12
4.33

33.83 to 40.68
44.82 to 51.91
8.16 to 12.47
3.09 to 6.05

485
25
107

78.61
4.05
17.34

75.19 to 81.66
2.73 to 5.94
14.55 to 20.54

181
179
39

45.36
44.86
9.77

40.55 to 50.27
40.07 to 49.77
7.21 to 13.11

272

93.79

90.35 to 96.09

18

6.21

3.91 to 9.65

397
157
66
15

62.52
24.72
10.39
2.36

58.69 to 66.20
21.52 to 28.23
8.24 to 13.02
1.40 to 3.89

CI*= Confidence interval calculated by modified Wald method at 95% confidence

level

0
A

Table. 4: Drugs prescribed among the cardiac disorder patients (n=780).

Fig. 1: Prescribing pattern of the physicians among the cardiac disorder patients
(n=780). A = Lipid lowering agents, B = Antiatherogenic agents, C = Antianginal
drugs, D = Beta-blockers, E = Calcium channel blockers, F = ACE inhibitors, G =
Angiotensin receptor blockers, H = Diuretics, I = Anxiolytics, J = Others

Antianginal agents
Antianginal agents such as direct vasodilators were used
commonly. Nitroglycerine was prescribed in 78.61% (95%CI:
75.19 to 81.66%) patients whereas combination of isosorbide
mononitrate with nitroglycerine was prescribed in 17.34% patients.
(Table 5).

Journal of Applied Pharmaceutical Science 02 (03); 2012: 80-84

Antihypertensive agents
Antihypertensive agents were predominantly used among
the patients. The most preferred options were beta-blockers,
diuretics, and ACE inhibitors. Adrenergic receptor blockers such as
beta-blockers are given to the patients with hypertension. Most of
the physicians opted to prescribe single product rather than
combinations. Metoprolol (45.36%, 95%CI: 40.55 to 50.27%) and
carvedilol (44.86, 95%CI: 40.07 to 49.77%) were the preferred
options for the patients. On the other hand combination of ramipril
and carvedilol was given to the minority (9.77%) of the patients.
(Table 5).

Use of different antihypertensive agents

37.21

Diuretics
Calcium channel
blockers

11.63

ACE inhibitors

30.23

Angiotensin receptor
blocker

13.95

Beta-blockers

51.16
0

10

20

30

40

50

60

Fig. 2: Use of different antihypertensive agents among the CVD patients (n=780).

Anxiolytic drugs
Most common anxiolytic drugs reported in our study was
benzodiazepine groups. Bromazepam (62.52, 95%CI: 58.69 to
66.20%) was preferred by most of the physicians. Clonazepam
(24.72%) and diazepam (10.39%) were also prescribed to the
patients. (Table 5)
DISCUSSION
This cross sectional study was conducted in a tertiary
level hospital situated at the capital of the country. Clinical studies
on the cardiovascular disease patients are quite unknown in this
country. It allowed in-depth exploration of the health problems
related with cardiovascular diseases, different patterns of diagnosis
with treatment choice of the specialists.
No. of male patients attended the outdoor at NICVD was
slightly higher than the female patients as the male patients usually
get privileges for the treatment in the social structure of our
country. Moreover significant number of patients came to visit the
physicians from urban area. That is complied with the previous
report on daily habitual fact of urbanization that raises the risk of
cardiovascular disease (Kabiruzzaman et al., 2010). About half of
the population was suffering with the high cholesterol level, which
increases the risk of coronary heart diseases (CHDs). These may be

due to our food habit, less exercise, poor health hygiene and
urbanization. One Study revealed that hypertension is the second
leading cardiovascular disease, which is the major cause of other
diseases such as heart failure, stroke, myocardial infarction, and
angina pectoris etc. (Epstein and Sowers, 1992). Other population
based studies suggest that elevated insulin levels, which often
occurs in type II diabetes mellitus, is an independent risk factor and
co-exist with cardiovascular disease. Other cardiovascular risk
factors in diabetic individuals include abnormalities of lipid
metabolism, platelet function, and clotting factors (Science Daily,
2008). It was found in the present study that 14.49% patients
suffered from anxiety related disorders. Previously published work
revealed that anxiety co-existed with 26% patients with
cardiovascular disease (Bloomfield et al., 2006).
With a view to manage various complications of
cardiovascular disease, the patients were prescribed 6.35 drugs on
an average. Most of them were advised to take a little exercise on
daily basis in the morning with blood pressure monitoring. The
drugs that were mostly prescribed by the specialist doctors
(cardiologists and heart specialists) will add value for the general
practitioners. The study reveals that most of the patients with lipid
profile disorder should to take lipid lowering agent. To circumvent
this, physicians prescribed worlds mostly prescribed and mostly
vended drug, namely atorvastatin. It decreases blood LDL
cholesterol level effectively with increasing the HDL level. It also
reduces the risk of coronary heart diseases, myocardial infarction
and stroke effectively with fewer side effects (Esposti et al., 2004).
The patients with coronary heart diseases were treated with antiatherogenic agents to prevent clotting at the coronary vessels that
may be fatal for them ultimately. This type of narrowing of the
blood vessels may cause of sudden myocardial infarction or stroke.
In order to prevent this, physician preferred clopidogrel and aspirin
combination rather than individual agent. Nitroglycerine sustained
release (SR) dosage form was the preferred option for the relief of
stable and unstable angina. It dilates the blood vessels and supply
adequate oxygen to the heart muscle within few minutes. Nitrates
were the second choice for this purpose.
Beta-adrenergic receptor blockers include a class of
cardiovascular drugs, which are used mostly to treat hypertension.
Cardio-protective and antihypertensive effects of this class of drugs
justify much larger use as observed in our study. Beta-blockers
reduce mortality rate when used for primary and secondary
prevention of myocardial infarction and chronic heart insufficiency
(Heaton et al., 2004 and European Society of Hypertension, 2003).
Cardio-selective beta-blockers, metoprolol and carvedilol were the
mostly prescribed drugs in the population in our study, which was
a rational approach to the therapy. The outpatients took ACE
inhibitors and diuretics with same frequency. This could be
explained by widening of the indications for their use in
hypertension, diabetic nephropathy, heart failure, etc. In the last
decade ACE inhibitors became almost the most important drugs in
cardiology, taking into consideration their cardio-protective and
renoprotective effects. Many clinical studies confirmed reduction
in morbidity and mortality in patients with acute myocardial

Journal of Applied Pharmaceutical Science 02 (03); 2012: 80-84

infarction and congestive heart failure with use of ACE inhibitors

(European Society of Hypertension, 2003). Thiazide diuretics are
fundamentals of antihypertensive therapy whereas loop diuretics or
the high ceiling diuretics are used as potent antihypertensive agents
when used alone. Combination of frusemide ad spirinolactone was
mostly prescribed in order to overcome the side effects (viz. severe
hypotension) of the former one. Diuretics are recommended as
initial monotherapy in older patients with stage I or II of
hypertension, or in combination with other antihypertensives in
patients with severe hypertension (Esposti et al., 2004). Our study
showed the significant negative trends of using angiotensin
receptor blockers (ARBs) and calcium channel blockers (CCBs).
CONCLUSION
Analysis divulges that statins and antiatherogenic agents
are dominant cardiovascular drugs as compared to others. Betablockers, ACE inhibitors and diuretics are predominant in
antihypertensive group. The study has some restrains such as the
patient did not co-operate with the surveyors and some time it was
intricate to monitor prescription effectively. Besides the sample
size does not reflect the actual population and prescription pattern
in the whole country. Moreover, the study based on a tertiary level
hospital, may not accord with the data to other generalized
hospitals. Despite these, analysis of cardiovascular drugs use offers
insight into the actual prescribing practice in our country. Underuse of ARBs and CCBs should be changed by undertaking
educative interventions to change the prescribing practice. This
study will also ascertain the further evaluation of cardiovascular
drugs utilization in Bangladesh.
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