International Journal of Community Medicine and Public Health

Mittal D et al. Int J Community Med Public Health. 2016 Jul;3(7):1894-1899

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20162061
Research Article

Study of cardiovascular risk factor profile among first-degree

relatives of patients with premature coronary artery disease
at Kota, Rajasthan, India
Deepika Mittal, Kirti Shekhawat*

Department of Preventive and Social Medicine, Government Medical College, Kota, Rajasthan, India

Received: 20 May 2016

Accepted: 10 June 2016

*Correspondence:
Dr. Kirti Shekhawat,
E-mail: dr.kirti.shekhawat@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Traditional cardiovascular risk factors are strong predictors of an increased likelihood for premature
CHD. Considering the benefits of risk factors᾿ management, it is imperative to find and treat them before looking for
more unknown and weak risk factors. The objectives of the study was to determine the distribution of cardiovascular
risk factors in first degree relatives of the patients with premature coronary artery disease.
Methods: The study was conducted under the department of Preventive and Social Medicine and patients were
enrolled from the Department of Cardiology of GMC Hospital, Kota to screen the first- degree relatives of the
patients suffering from premature CAD, for the presence of risk factors. For the purpose of study, 200 consecutive
patients admitted in the cardiac care units of GMC Hospital, Kota with the primary diagnosis of premature coronary
artery disease were enrolled. These patients‟ 643 first-degree relatives, who were in the coronary age group were
included in the study. Inclusion criteria were age (25 years and above), residence (residing within Jaipur city) were
enrolled for the purpose of the study.
Results: Out of total 643 study subjects approximately half were in middle age group (31-50 years). 66.9% of the
relatives of CAD patients were males and females represented 33.1% of the study population. 66% of the first-degree
relatives of the patients suffering from premature CAD were from Social class II, III and IV. approximately 50% of
first degree relatives of CAD patients were bearing 1 or more CAD risk factors. Hypertension was present in 29.7 %
of the relatives suffering from Premature CAD. Diabetes mellitus and high lipid levels affected 13.0 % and 10.1 %
relatives respectively. 47.5% of the relatives were either obese or leading a sedentary life style while 27.7% were
smokers.
Conclusions: Premature Coronary Heart Disease is a public health problem. However, there is lack of effective and
intensive treatments of well-defined traditional risk factors and prevention methods for the majority of the patients
experiencing premature CHD. In sum, there is still plenty of room for improvement of risk management in India.

Keywords: Atherosclerosis, Risk factors, Coronary heart disease, Coronary artery disease

INTRODUCTION India is now four fold higher than in the US. Although
the present high burden of cardiovascular disease deaths
Cardiovascular diseases have become a leading cause of is in itself an adequate reason for attention, a greater
morbidity and mortality in adult population of Indian cause for concern is the highly malignant form of CAD
subcontinent. The prevalence of coronary artery disease occurring at an early age in South East Asians. In contrast
(CAD) has doubled in both rural and urban Indians to the developed market economies where CAD mortality
during the last 20 years.1 The CAD prevalence in urban rates are declining, the mortality rates are accelerating in

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 Mittal D et al. Int J Community Med Public Health. 2016 Jul;3(7):1894-1899

most developing countries.2 It has been estimated that 5.3 Questionnaire administration
million deaths attributable to CAD occurred in
developing countries in 1990.3 The questionnaire consisted of the following parts-

The diversity of current CVD profile between and within Family census card: It recorded the general information
the developing countries reflects the different stages of about the family i. e (age, sex religion, caste, education,
epidemiological transition. Increased life expectancy occupation, income etc.) of the patient with premature
results in more proportion of elderly population surviving CAD. It also served as a source of information on
up to vulnerable age. Rising prosperity and urbanization prevailing health problems of all the members of the
leads to life style changes resulting in consumption of family. General questionnaire also recorded the
unhealthy diet, physical inactivity, addictions and information regarding living conditions, personal history,
stressful life situations. The transition occurs first in past and current medical history, psychological status of
“early adopter” segment of the society, usually the urban the patient and their first-degree relatives.
and affluent group with greater disposable incomes and
easier access to new life style. Clinical examination and investigations: Clinical
examination; anthropometry and biochemical
In view of the large ethnic population at risk of an investigations.
impending epidemic, high genetic susceptibility and
transitional life style with different risk factor profiles, Thorough general physical examination, a focused
there is an urgent need for focused approach to this systemic examination and complete cardiovascular
problem. There is a need to contain the epidemic as well examination of index cases were performed.
as combat its impact, minimize the morbidity and
mortality. Global regional and national strategies need to Blood pressure was measured using BHS A/A grading
be developed to fight this problem. In view of the "micro life" automated blood pressure monitoring and
differences in risk association, the interaction of various pulse arrhythmia detection device. A person was made to
risk factors may be different in this population. Hence the rest for 5 minutes before recording his or her blood
study has been conducted in this part of Rajasthan to pressure. Three consecutive readings of blood pressure
identify the risk factor profile of first degree relatives of were taken on the right arm in the sitting position with 5
the patients of premature CAD. minutes interval in between each reading. First reading
was discarded and the average of other two was taken. At
METHODS the time of recording blood pressure the person was
advised not to talk and the machine was kept at the level
The study was conducted under the department of of heart of the individual.
Preventive and Social Medicine and the Department of
Cardiology of GMC Hospital, Kota. The study was All anthropometric measurements were taken using the
conducted for the period of 3 months (October-December guidelines adopted by NIH sponsored Arlie conference
2015). Anthropometric standardization reference manual. These
included height, weight, waist circumference and hip
For the purpose of study, 200 consecutive patients circumference.
admitted in the cardiac care units of GMC Hospital, Kota
with the primary diagnosis of premature coronary artery Biochemical examination: Blood samples were analysed
disease were enrolled. These patients‟ 643 first-degree for complete lipid profile and glucose levels after 8 hours
relatives, who were in the coronary age group were fasting.
included in the study.4 Inclusion criteria were age (25
years and above), residence (residing within Kota city) The study was executed in the following way
were enrolled for the purpose of the study.
1st contact: During 1st visit, Cardiology Department of
Premature CAD is defined as “sudden death or definite GMC Hospital was visited and all the patients admitted
myocardial infarction in male before 55 years of age or in with the primary diagnosis of Premature CAD were noted
the female before 65 years of age”.5 down.

For all these subjects detailed information about family 2ndcontact: The patients and their relatives were
composition, dietary patterns, socioeconomic status and contacted at their homes and were briefed on the purpose
housing were obtained and complete screening for and benefits of the study. Their questionnaire was filled
conventional coronary heart disease risk factors was up with complete socio-demographic profile and family
carried out. census. They were instructed to go to the standardized
laboratory to give the blood samples for fasting sugar and
lipid profile, after fasting for 10 hours. At this stage
The study was divided into two parts (a) questionnaire
administration and; (b) clinical examination and clinical examination and anthropometric measurements
of the relatives of the patients were taken.
investigations.

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3rd contact: The study subjects were contacted again and Table 1: Sex wise distribution of study population
reports of various investigations were also handed over to according to demographic attributes.
them. In case any abnormality was detected in the first-
degree relatives they were referred for specialty Demographic Male Female Total
treatment. variable N % N % No %
Age (years)
Data analysis 25 12 1.9 3 0.4 15 2.3
26-30 33 5.0 11 1.6 44 6.9
The data generated was analysed using SPSS software for 31-35 42 6.3 14 2.1 56 8.7
detection of any association between socio-demographic 36-40 59 8.7 26 3.0 85 13.2
status and various risk factors. A comparative analysis of
41-45 62 9.3 21 3.1 83 13.0
risk factor profile of study subjects with that of the cases
46-50 74 11.1 30 4.5 104 16.2
was performed.
51-55 30 4.5 17 2.5 47 7.3
RESULTS 56-60 19 2.8 28 4.2 47 7.3
61-65 32 4.8 27 4.0 59 9.2
Out of total 643 study subjects approximately half were 66-70 31 4.7 20 3.0 51 7.9
in middle age group (31-50 years). 66.9% of the relatives >70 30 4.6 20 3.0 50 7.8
of CAD patients were males and females represented Religion
33.1% of the study population. 83.5% subjects were Hindu 356 55.0 181 28.1 537 83.5
Hindus. Scheduled caste and tribes represented small Muslim 58 9.0 32 4.9 90 13.9
number of relatives (20.1%). 31.0% of female, first- Sikh 8 1.2 4 0.6 12 1.86
degree relatives of patients suffering from premature Christian 4 0.6 0 0.0 4 0.6
CAD had received senior secondary, graduate & Caste
postgraduate level of education. Only 1/4th study General 188 29.2 69 10.7 257 39.9
population was educated up to or above senior secondary OBC 152 23.6 105 16.3 257 39.9
level. In males, the education level was almost equally ST 30 4.6 21 3.2 51 8.0
distributed in all the categories. 66% of the first-degree SC 56 8.7 22 3.4 78 12.1
relatives of the patients suffering from premature CAD Literacy status
were from Social class II, III and IV. Skilled labourers, Illiterate 110 16.5 108 16.2 218 32.7
farm owners, clerical class and shopkeepers represented Primary 59 8.8 22 3.3 81 12.1
84.9% of the first-degree relatives of patients suffering
Middle school 56 8.4 31 4.7 87 13.1
from premature CAD (Table 1).
Secondary 54 8.1 25 3.7 79 12.8
Table 2 shows approximately 50% of first degree Senior 43 6.4 11 1.7 54 8.1
relatives of CAD patients were bearing 1 or more CAD secondary
risk factors. Graduate 55 8.3 9 1.3 64 9.6
Post graduate 49 7.3 11 1.7 60 9.0
In 240 relatives with only 1 risk factor smoking was the Socio-economic status
most common risk factor (101 relatives). Hypertension Class I 46 6.9 21 3.1 67 10.0
was the next most common factor (89 relatives). Diabetes Class II 99 14.8 61 9.1 160 24.0
and high cholesterol levels were there in 34 and 16 Class III 93 13.9 33 4.9 126 18.9
relatives respectively. In 123 relatives with 2 risk factors Class IV 91 13.6 52 7.8 143 21.4
hypertension & smoking was the most common Class V 97 14.5 50 7.5 147 22.0
combination (46) followed by hypertension and diabetes Occupation
(32), hypertension & high cholesterol (19), smoking & Un-employed 13 2.0 13 2.0 21 3.3
high cholesterol (15), diabetes &high cholesterol (6) and Un-skilled 8 1.2 8 1.2 10 1.5
diabetes & smoking (5). In all the 12 relatives with 3 0r Semiskilled 34 5.2 34 5.2 37 5.7
more risk factors in addition to hypertension, 6 had Skilled/House 163 25.3 163 25.3 352 54.8
diabetes, smoking &high cholesterol,3 had diabetes & wife
smoking,2 had smoking 7 high cholesterol and 1 had Farm 156 24.3 156 24.3 165 25.6
diabetes & high cholesterol (Table 3). owner/clerk/sh
op
Hypertension was present in 29.7% of the relatives Semi-professional 25 3.8 25 3.8 30 4.6
suffering from premature CAD. Diabetes mellitus and Professional 27 4.1 27 4.1 28 4.4
high lipid levels affected 13.0% and 10.1% relatives Total 426 66.9 217 33.1 643 100.0
respectively. 47.5% of the relatives were either obese or
leading a sedentary life style while 27.7% were smokers.
(Table 4).

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Table 2: Frequency of major risk factors *amongst CAD patients’ first-degree-relatives.

No of risk factors Patients’ relatives

N %
0 268 41.6
1 240 27.3
2 123 19.2
3 or more 12 1.9
*(Major risk factors include hypertension, diabetes, smoking and high cholesterol).

Table 3: Frequency distribution of various risk factors in different categories of relatives of CAD patients.

Category (C) No of patients Total frequency

Hypertension Diabetes High cholesterol Smoking
risk factor (N) of risk factors
0 268 0 0 0 0 0
1 240 89 (37.08) 34 (14.16) 16 (6.67) 101 (42.08) 240 (100.0)
2 123 97 (39.43) 43 (17.47) 40 (16.26) 66 (26.82) 246 (100.0)
3 or more 12 12 (28.57) 10 (23.48) 9 (21.42) 11 (26.19) 42 (100.0)
Total 643 198 87 65 178 528*
*overlapping risk factor categories‟ cumulative frequency in 375 first degree relatives of CAD patients who have one or the other risk
factor.

Table 4: Distribution of risk factors among first-degree relatives of CAD patients.

Sex Total N=643

Risk Factor Male Female
No % No % No %
Hypertension 134 20.1 64 9.6 198 29.7
Diabetes 61 9.1 26 3.9 87 13.0
High cholesterol 45 6.7 20 3.0 65 10.1
High LDL 45 6.7 15 2.2 60 8.9
Low HDL 170 25.5 91 13.6 261 39.1
High triglyceride 113 16.9 44 6.6 157 23.5
Smoking 147 22.0 31 4.6 178 26.6
Obesity 52 7.8 9 1.3 61 9.1
Sedentary life style 203 31.5 44 6.8 247 38.4
Mental stress 57 8.5 44 6.6 101 15.1

DISCUSSION part of Rajasthan. Kutty et al in their study on prevalence

of CAD in rural population of Thiruvnantpuram also
During the past 30 years, a large decline in cardiovascular reported existence of CAD in poorest class of society
diseases has been experienced in the West and substantial (22%).6 The scenario has changed considerably from
increase has been experienced in developing countries. 1970‟s when low socioeconomic group of people in rural
These trends are expected to continue and the medical, and semi-urban India were engaged in lot of physical
social and economic consequences of CAD will be labour and hence the prevalence of CAD was reported to
enormous. Hence this study was undertaken under the be low in this group. In a study of premature CAD,
Department of PSM and information was gathered from Shaukat et al has reported high proportion of patients
the patients‟ relatives at the cardiac care units of GMC from lower and middle socio-economic class which they
Hospital for calculating the frequency of risk factors in have attributed to the clientele of the hospital which
the patients suffering from premature CAD and their first being a Government sponsored, free facility center,
degree relatives. An understanding of the risk factors that catering mainly to middle and lower class of the
lead to development of premature CAD is required to population of capital city of India, which is quite similar
develop strategy for prevention. to this study that has been undertaken in GMC Hospital,
Kota.7
This study reflects the existence of CAD in the lower
socioeconomic group (SE Class III-V constituting more In the present study risk factor profile of the first-degree
than 2/3rd proportion of total relatives) of people in this relatives residing within Kota City was analyzed. There
were 643 relatives (426 males and 217 females) with a

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male to female ratio of 1.9:1 Females were older to their some form of tobacco (35.0% smoking, 22.0% chewing
male counterparts (47 versus 43 years). The mean age and 8.0% multiple forms). Prevalence rate for smoking in
was 44.3 years. Most of them belonged to 41 to 55 years women is generally low (3%) but varies widely-from
age group (42.4%). In comparison with the CAD patients 15% in Bhavnagar to 67% in Andhra Pradesh (Prem Pais;
mean age was 5 years more but this mean age of relatives Smoking and CAD, The Indian scenario 1998).14 Use of
was still within the definition of premature CAD age tobacco chewing is similar in men and women in general
group hence reflecting the relevance of comparative population. Gupta R in his study on Prevalence of CAD
analysis. and CAD risk factors in an urban population of Rajasthan
published in indian heart journal reported a prevalence of
Proportion of hypertensive in male relatives were almost tobacco use in 39% of general population. Of the smokers
double (20.1%) than the females (9.6%). In the 62.0% smoked cigarettes, 21% smoked bidis and 17%
comparative age group from general population free from smoked both.15 Bidis consists of a small amount of
CAD Shankar Krishna Swami et al in the study “CAD in tobacco wrapped in temburni leaves. In spite of its small
Indians from CMC Vellore reported hypertension in size bidis deliver a higher content of tar and nicotine than
21.6% of male and 8.6% of females).8 Enas and Enas also conventional Indian cigarettes. This may explain the
reported 14% prevalence of hypertension in their study of similar risk of developing CAD in bidi and cigarette
CAD in Indians in the USA.9 Total cholesterol, LDL, smokers. 28.8% male & 10.0% female relatives were
HDL cholesterol and triglycerides were measured in all either overweight or obese, giving overall distribution of
cases. 29.0% of the relatives of CAD patients were abnormal BMI as 38.9%, (p<0.05). Obesity is associated
having high LDL levels. A large study of persons with increased prevalence of other CAD risk factors and
developing premature CAD Allen JK et al (Prevalence of increased morbidity and mortality from CAD. In most
Hypercholesterolemia among siblings of persons with affluent societies there is an inverse relationship between
premature CAD; Arch Int Med: 1996) showed that high socio-economic status and prevalence of overweight but
LDL cholesterol levels, more than 160 mg/dl were in societies where food is scarce, overweight may be seen
present in 38.0% asymptomatic siblings of the patients.10 as a visible indicator of wealth and status and the
Low HDL level was 40.5% in relatives of CAD patients transition period from poverty to affluence is
& significantly more males (26.4%) were having this low accompanied by overall increase in weight and
HDL levels than females (14.1%). Kaul U has reported abdominal obesity. 32.1% of the males and 14.4% of the
low HDL cholesterol in 38.7% population from urban female relatives were classified as having visceral obesity
Delhi.4 High triglyceride levels were present in 31.5% of according to waist hip ratio.
male and 12.9% of the female relatives and the difference
was statistically significant (p<0.05). High triglyceride Abdominal obesity is a marker of abnormal glucose
levels were observed in 24.3% of the relatives in our insulin metabolism, hypertension, low HDL cholesterol,
study. A 33.0% prevalence of high triglyceride levels has increased triglycerides and increased risk of CAD. Reddy
been reported from Haryana by Siwach et al.11 This KS, Puri SK and Bahl VK on a study of CAD risk factors
similarity has not been observed in the European athero- in an industrial population of North India published in
sclerosis research study, which investigated young adults Can J Card have reported 70.9% and 39.1% prevalence of
with a paternal history of premature CAD. In this study abdominal obesity in general population.16 In comparison
(EARS) serum triglyceride levels were higher in those to Europeans and Americans, Indians have a more central
with a positive family history of premature CAD than in distribution of body fat. In addition at any given level of
the general population.12 Diabetes was noted in 12.2% waist- hip ratio, prevalence of diabetes is twice in Indians
relatives of CAD patients. Comparative prevalence of as compared to Whites, and both WHR and diabetes
diabetes among general population in India has been mellitus are independently related to CAD. 31.5% of
reported to be between 8.0% (Enas and Enas; CADI male relatives were leading a sedentary life style
study-2002) to 12.0% (Mohan V et al. Chennai Urban prevalence of sedentary life style has been reported to be
Population Study 2000).9,13 A highly significant ranging from 20.0% (CADI 2002) to 33.3% (Sonia A et
association between diabetes and development of CAD al, SHARE Pilot study).17 Out of 643 relatives, 15.6%
has been reported and it has been observed that even pre- were either having anxiety or depression and it was
diabetic subjects have the same probability of developing slightly more in males (8.9%) than females (6.8%)
CAD as age and sex matched diabetic subjects, hence the (p>0.05). Psychosocial factors and individual life style
importance of screening the pre-diabetics for CAD risk have significant impact on health. Unhealthy habits
factors. In a case control study of 300 acute myocardial account for 54.0% of known contributions to CAD.
infarction cases and 300 hospital-based controls in India, Gupta et al in their observations on “psychosocial factors
Pais et al found that glucose elevations within the normal and coronary artery disease”, from Jaipur also observed
range demonstrated a continuous relationship with risk of that psychosocial factors associated with increased risk of
acute myocardial infarction.14 24.8% relatives of CAD were lack of joint family support, more number of
premature CAD patients were habitual smokers. Out of children, religious non-affiliations and lack of prayer
643 relatives, 25.6% smoked bidi, cigarette or hookka & habits.18 Varghese et al in their study titled „type A
the males were significantly more (21.7%) than females behaviour and CAD (JAPI: 1985)” and Chadha et al in
(3.8%) (p<0.05). It is estimated that 65.0% of all men use the study “Coronary prone behaviour and MI” (JAPI:

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 Mittal D et al. Int J Community Med Public Health. 2016 Jul;3(7):1894-1899

1920) have also reported a strong correlation of CAD with coronary artery disease reflect their parents'
with type A personality.19,20 risk factor patterns. BHJ. 1995;74:318-23.
8. Krishnaswamy S. Sethi KK edited. Conventional
CONCLUSION risk factors for CAD in Indians –A Global
Perspective. 1998:73.
Currently in actual family practice family screening for 9. Enas EA, Mehta J. Malignant atherosclerosis in
risk factors is undertaken in less than 20.0% of premature young Indians: Thoughts on pathogenesis,
CAD patients. Screening individuals with a family Prevention and Treatment. Clinical cardiology.
history of premature CAD is encouraged by all the 1995;18:131-5.
current guidelines. The potential yield from family 10. Allen JK, Young DR, Blumenthal RS, Moy TF,
screening in identifying high-risk individuals is Yanek LR, Wilder L, et al. Prevention of
considerable but increased resources are needed to carry hypercholesterolemia among siblings of persons
this out properly. with premature CAD. Arch Int Med.
1996;156(15):1654-60.
There should be Indian guidelines issued on the pattern of 11. Siwach SB, Singh H, Sharma D, Katyal VK. Profile
US health agencies. of young acute MI in Haryana. JAPI. 1998;46:424-
6.
 Eat a variety of foods 12. European Atherosclerosis Research Study (EARS).
 Avoid too much fat, saturated fat and cholesterol Study of Young adults with a parental history of
 Eat food with adequate starch and fiber, low in salt premature CAD. Circulation. 1994;89;1967.
content. 13. Rajmohan L, Deepa R, Mohan A, Mohan V.
 Avoid too much sugar. Association between isolated hypercholesterolemia,
 If you drink alcoholic beverages, do so in moderation isolated hypertriglycerideia and coronary artery
 Maintain desirable weight disease in South Indian type 2 diabetic patients.
Indian Heart J. 2000;52(4):400-6.
 Be physically active, walk 30-60 minutes, 3-4 times
14. Pais P, Pogue J, Gerstein H, Zachariah E, Savitha D,
a week.
Jayprakash S. Risk factors in acute myocardial
 Stop smoking
infarction in Indians- A case control study. Lancet.
1996;348(9024):358-63.
Funding: No funding sources
15. Gupta R, Gupta VP, Ahluwalia NS. Educational
Conflict of interest: None declared
status, coronary heart disease and coronary risk
Ethical approval: The study was approved by the
factor prevalence in a rural population of India.
Institutional Ethics Committee
BMJ. 1994;309:1332-6.
16. Reddy KS, Shah P, Shrivastava U, Prabhakaran D,
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