European Journal of Cardiovascular Medicine

Cardiovascular diseases (CVDs) are a significant global health issue because they cause a significant amount of morbidity and mortality in a variety of communities [1]. With its fast urbanisation, shifting dietary practises, and sedentary lifestyles, India has seen a major increase in the prevalence of cardiovascular risk factors and related disorders in recent decades [2]. As a result, comprehensive cardiovascular risk assessment is now more crucial than ever because it helps identify people who are more likely to develop CVDs and supports the implementation of focused preventative measures [3]. This article explores the crucial topic of adult cardiovascular risk assessment in India, looking at the various risk factor facets, current assessment techniques, and the consequences for public health policy.

As a result of several variables, including urbanisation, altered eating habits, cigarette use, physical inactivity, and an increase in the frequency of metabolic diseases, the burden of CVDs in India has significantly increased over time. According to recent estimates, CVDs are the main cause of death in the nation, accounting for about 25% of all fatalities [4].   The essential need for reliable cardiovascular risk assessment tools to properly target high-risk groups and efficiently allocate healthcare resources is highlighted by this worrying trend.

The early detection and treatment of people at risk for CVDs depend critically on the assessment of cardiovascular risk [5]. Healthcare practitioners can categorise people into distinct risk groups by looking at a variety of risk variables, including age, sex, blood pressure, lipid profiles, smoking status, and diabetes, among others [6]. These risk categories direct the beginning of preventative interventions, which might range from pharmacological therapies to changes in lifestyle. Additionally, thorough risk assessment enables interventions to be tailored to particular populations, ensuring that resources are allocated where they are most required. In India, a variety of risk assessment techniques have been used to estimate the likelihood that adults may develop a CVD. Notably, estimations of cardiovascular risk have been developed for the Indian setting using the Framingham Risk Score, Reynolds Risk Score, and SCORE (Systematic Coronary Risk Evaluation) methodology [7].   Due to the distinct risk factor profiles of the Indian population, these instruments frequently need to be modified and recalibrated.

The goal of this article is to give a thorough overview of adult cardiovascular risk assessment among the patients attending general OPD of a tertiary care hospital in Gujarat utilizing the WHO/ISH Risk prediction chart[8]. It will delve into the presence and importance of key risk variables, clarify how to use the tools currently available for risk assessment, and examine the opportunities and challenges associated with putting risk assessment techniques into practise in the Indian healthcare system. The essay aims to advance knowledge of CVD prevention and management in the developing setting by looking at these topics.

A cross-sectional study was conducted from September 2019 to November 2019. The study population consisted of adults over and above 40 years of age who were recruited from both urban and rural locations. Using formula Z2PQ/D2 where P was the prevalence of hypertension in India approximately 21.4%(WHO)[9]. Q was (1-P) and a relative allowable error of 5.5%. The sample calculated was 214 with 95% confidence interval. Purposive sampling technique was employed to select individuals from diverse socioeconomic backgrounds.

Data Collection

A combination of clinical examinations and structured interviews were used to gather data. The Institutional Review Board's ethical permission was acquired prior to data collection. Participants were interviewed after taking informed consent in a language which they understand. A predesigned and pretested questionnaire was used to obtain sociodemographic variables and risk factors such as smoking, tobacco chewing, family history of CVD, history of DM & HTN, physical activity, salt intake. Anthropometric variables such as weight(kg) and height(cm) will be measured using standard equipment and procedures. Three measurements of blood pressure 5minutes apart using a mercury sphygmomanometer and stethoscope will be taken after 15minutes of rest in sitting position and cuff will be placed on unclothed left arm above the elbow while putting the arm in the table facing palm up. Average reading of the blood pressure will be considered for diagnosing hypertension in the participants. Random blood sugar was done on participants who had no previous history of DM. The chart stratifies individual into low (<10%), moderate (10% to <20%), high (20% to <30%), and very high (>30%) risk groups.

Risk Assessment for CVD

WHO/ISH risk prediction charts by epidemiological sub-regions and the Member States were used to indicate 10-year risk of a fatal or non-fatal major cardiovascular event (myocardial infarction or stroke), according to age, sex, blood pressure, smoking status, total blood cholesterol and presence or absence of diabetes mellitus. South East Asia sub-region D (SEAR D) chart without blood cholesterol was used to stratify an individual into low (<10%), moderate (10% to <20%), high (20% to <30%), and very high (>30%) risk groups.

Data Analysis

Data entered into Microsoft excel 2007 and analysed by using SPSS. To determine how risk factors were distributed among sociodemographic traits, descriptive statistics were employed. And to compare categorical variables, the chi-square test was employed.

A total of 214 adults, with a mean age of 55±0.4 attending general OPD of tertiary care hospital took part in the study. There were 58% male participants and 42% female with most of them belongs to below primary education 89 (41%), followed by primary 44 (21%) and secondary education 35 (17%), while graduates were least among all participant 22 (10%) in this study. Participants with the moderate type of occupation were the highest in number 116 (54%) followed by sedentary type of occupation 81 (38%) and heavy duty were the minimum 17 (8%). In this study, upper lower class in socioeconomic status were the highest 172(81%), followed by lower middle class 72 (17%), and the upper middle class 12 (6%), while the minimum participant 10 (5%) were in lower socioeconomic class (Table 1).

Using the South East Asia sub-region D (SEAR D) WHO/ISH chart, 19.62% of participants had an expected 10–20% risk of coronary heart disease events. Following this, 7.94% and 2.33% of participants had an expected 20–30% and 30–40% risk of CVD events respectively. In contrast, 68.60% of participants have CVD risks <10%, while only 1.40% have a chance of more than 40% of CVD events in their anticipated 10 years of age as shown in Figure 1.

Assessment of CVD risks

Participants showed varied CVD risks i.e., low, moderate and high as per sociodemographic variables in Table 2. Distribution of CVD risks in different age-groups (40-49; 50-59; 60-70 years) showed that age-group (40-49 years) have significantly (64%) lower CVD risk than higher age groups (50-59; 60-70 years). Male were more susceptible (62%) to moderate and high CVD risk than the females (38%). Education categories (below primary, primary, secondary, high school and graduation) also showed varied CVD risks. Below primary educated participants were 50% more susceptible to high CVD risk compared to educated participants (Table 2). Likewise, sedentary participants belong to upper lower socioeconomic class have higher CVD risk as compared to moderate or heavy working category belong to lower or upper moderate socioeconomic class as shown in Table 1.

The participants with diabetes have more moderate and high CVD risks, whereas participants with hypertension have moderately high CVD events compared to hypertension free participants (Table 2). In contrast, smoker have 4.5% chance of high CVD events as compared to non-smoker i.e., 3.6%. likewise, overweight and obese have 3 and 4% high CVD risk, while patients with sufficient physical activity are susceptible to high CVD risk events as shown in Table 1.

Association of risk factors and CVD events

Analysis using chi-square test showed a substantial positive association between potential risk factors and CVD events (< 10% risk or ≥10% risk) as shown in Table 2.

Age is directly proportional to ≥ 10 % CVD risk and significantly associated, which mean older patients were more susceptible to CVD risk events. In the present study, male gender is also associated with ≥ 10% CVD risk and significantly (p < 0.001) higher in number than female. Illiteracy was also observed significantly (p = 0.005) associated with ≥ 10% CVD risk and found that participants who are under primary have 41% more ≥ 10% CVD risk than high school passed and graduated participants. Moreover, participants with upper lower income have significantly (p = 0.009) higher susceptibility to ≥ 10% CVD risk compared to other classes (Table 2).

Like socioeconomic, health factors such as diabetes, hypertension, smoking, physical activity, BMI as showed significant association with ≥ 10% CVD risk. Participants with diabetes have high ≥ 10% CVD risk as compared to participants without diabetes. Hypertension is also a significant factor that increase ≥ 10% CVD risk by 59% among the patients attending General OPD of Tertiary Care Hospital in Vadodara. Likewise, smoking and physical activity participant have significantly associated (p < 0.05) with ≥ 10% CVD risk as shown in Table 2.

The current study sheds light on the prevalence of risk factors, the computed risk scores, and the implications for public health measures. It also offers a thorough insight into the cardiovascular risk profile of individuals in India. The results highlight the need for swift action to combat the nation's rising CVD burden through targeted interventions and risk reduction programmes. The study's findings point to an alarmingly high incidence of significant cardiovascular risk factors among individuals in India.

Similar study conducted in Oman by Adhra Al-Mawal et al utilizing the WHO/ISH Risk Prediction Chart, the study categorized the prevalence of low, moderate, and high cardiovascular disease (CVD) risk as 68.0%, 19.1%, and 12.9%, respectively. Significant associations were found between elevated CVD risk and participant age (p < 0.001), education level (p < 0.001), and employment status (p < 0.001) which align with the current study [10].

According to earlier research conducted by Gupta et al shows the effects of urbanisation, changing lifestyles, and changing food patterns on the health of the Indian population the observed high rates of hypertension, diabetes, and smoking remain consistent. Furthermore, insufficient eating habits and insufficient physical activity levels also add to the burden of cardiovascular risk which supports the findings of current study [11]. These results highlight the necessity of behavioural interventions, policy initiatives, and health education efforts to encourage better lifestyles and lessen modifiable risk factors.

Another study conducted by K. Premanandh, R. Shanka et al in Salem shows quite similar finding  with respect to moderate and high CVD risk were 12.14% and 7.5% respectively and 2.5% had very high  risk  (>40%) but shows contrast findings like high  risk  (binge  drinking)  alcohol  drinkers  (p=0.04)  and  abdominal  obesity  (p=0.0001)  were significantly associated with higher CVD risk.[12] Both the study shows a unique contributions of lifestyle choices and physical health toward CVD risk with respect to different demographic population.

A study conducted by Dugee Otgontuya1et al found the prevalence of WHO/ISH “high CVD risk” (≥20% chance of developing a cardiovascular event over 10years) of 6%, 2.3% and 1.3% in Mongolia, Malaysia and Cambodia, respectively, aligns with the current study when charts alone are used and whereas revealed variations in risk levels when considering blood pressure measurements which support the finding of the current study.[13]

The results of the study conducted by Karwalayjtys et al convey important ramifications for Indian public health policy and practise. Prioritising preventative measures is necessary due to the frequency of cardiovascular risk factors and the elevated risk scores. Effective tactics can include neighbourhood-based awareness campaigns, early detection initiatives, and lifestyle-focused interventions.[14] By including a cardiovascular risk assessment in doctor visits, high-risk patients can receive resources and early interventions. Even if the study offers insightful information, some restrictions should be taken into account. Causal inferences are prohibited by the cross-sectional design, and the inclusion of self-reported data raises the possibility of recall bias and other CVD risk factors like Cholesterol and stress are not included. Additionally, longitudinal follow-ups to evaluate the efficacy of therapies and changes in risk profiles over time could be beneficial for the study's focus on risk assessment.

The study advances knowledge of the cardiovascular risk environment among adults in India. High risk factor prevalence and elevated risk scores highlight the urgent need for specialised interventions with a focus on illness prevention and risk reduction. The results highlight the critical significance of risk assessment in directing public health policies and tailored clinical therapy to reduce the rising burden of cardiovascular illnesses in India.

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