Risk Factors for Coronary Artery Disease Risk Factors for Coronary Artery Disease in Lebanese/Armenian Womenin Lebanese/Armenian Women

Authors: Authors:

Mary ArevianMary Arevian MPH, RN MPH, RN

Marina AdraMarina Adra MS, RN MS, RN

Loulou KoubessiLoulou Koubessi BS MPH BS MPH

Sponsored by the Sponsored by the

Armenian Relief Cross in Lebanon Armenian Relief Cross in Lebanon

SignificanceSignificance

- Coronary Artery disease (CAD) is the- Coronary Artery disease (CAD) is the leading cause of Death among women over leading cause of Death among women over 50 years (American Heart Association, 1997).50 years (American Heart Association, 1997).

- Women are 50% more likely to die during- Women are 50% more likely to die during hospitalization for a heart attack than menhospitalization for a heart attack than men (Hamilton, 1991; Stanhope, 2000).(Hamilton, 1991; Stanhope, 2000).

- Women may delay seeking treatment, - Women may delay seeking treatment, expecting that heart disease involves much expecting that heart disease involves much more pain than they experience.more pain than they experience.

- Their complaint may not be taken seriously - Their complaint may not be taken seriously by health providers, who may attribute by health providers, who may attribute symptoms to stress.symptoms to stress.

- Women undergo fewer procedures than men - Women undergo fewer procedures than men when hospitalized for CAD (Ayanian and when hospitalized for CAD (Ayanian and Epstein, 1991).Epstein, 1991).

- Women may be misdiagnosed until their - Women may be misdiagnosed until their condition warrants emergency surgery condition warrants emergency surgery (Hawthorne, 1994).(Hawthorne, 1994).

- Women on average are 10 years older than - Women on average are 10 years older than men when they initially present with men when they initially present with symptoms of cardiovascular disease (Lerner symptoms of cardiovascular disease (Lerner and Kannel, 1986) are 20 years older at the and Kannel, 1986) are 20 years older at the time of occurrence of a myocardial infarction time of occurrence of a myocardial infarction and they have more comorbid conditions and they have more comorbid conditions like diabetes and hypertension (Cannistra et like diabetes and hypertension (Cannistra et al., 1989).al., 1989).

- In Lebanon, though there are no accurate - In Lebanon, though there are no accurate statistics on the incidence of CAD, according statistics on the incidence of CAD, according to hospital records, there are approximately to hospital records, there are approximately 550-580 open heart surgeries of coronary 550-580 open heart surgeries of coronary artery bypass graft (CABG) performed each artery bypass graft (CABG) performed each year at the American University Medical year at the American University Medical Center. In addition there are eight other Center. In addition there are eight other hospitals that perform open-heart surgeries.hospitals that perform open-heart surgeries.

- Many patients are:- Many patients are: Heavy smokersHeavy smokers HypertensiveHypertensive DiabeticDiabetic HypercholestrolemicHypercholestrolemic ObeseObese

- Approximately 20% of patients undergoing - Approximately 20% of patients undergoing upon heart surgery for CABAG are upon heart surgery for CABAG are estimated to be women.estimated to be women.

- This rate may increase as more and more Lebanese women are adopting Western life style habits, such as smoking, use of oral contraceptives, sedentary life style, etc...

PurposePurpose

The purpose of this descriptive study was The purpose of this descriptive study was

to explore risk factors for CAD among to explore risk factors for CAD among

Lebanese/Armenian women.Lebanese/Armenian women.

The following questions were addressed:The following questions were addressed:

1. What is the prevalence of CAD risk factors 1. What is the prevalence of CAD risk factors in a sample of Lebanese/Armenian in a sample of Lebanese/Armenian women?women?

2. 2. What is the nature/type of risk factor What is the nature/type of risk factor (modifiable versus non-modifiable)?(modifiable versus non-modifiable)?

3. What is the association between 3. What is the association between hypertension and other CAD risk factors hypertension and other CAD risk factors in the sample?in the sample?

MethodMethodDesign and SampleDesign and Sample

This descriptive study explored risk factors for This descriptive study explored risk factors for coronary artery disease among Lebanese/coronary artery disease among Lebanese/

Armenian women. The setting was the Araxy Armenian women. The setting was the Araxy Boulghardjian socio-medical center (ABSM), Boulghardjian socio-medical center (ABSM), of Armenian Relief Cross in Lebanon (ARCL). of Armenian Relief Cross in Lebanon (ARCL). The ABSM is a primary health care center The ABSM is a primary health care center located in the densely populated area of located in the densely populated area of Bourj-Hammoud in the Great Beirut region. Bourj-Hammoud in the Great Beirut region.

The population consists of mostly Armenian The population consists of mostly Armenian ethnic minority group. This study was part of ethnic minority group. This study was part of a health promotive program targeting a health promotive program targeting Lebanese/Armenian women.Lebanese/Armenian women.

A convenience sample of 83 women were A convenience sample of 83 women were recruited for the study. The participants were recruited for the study. The participants were adult women who attended regularly, at least adult women who attended regularly, at least five of six panel discussions about risk five of six panel discussions about risk factors for CAD.factors for CAD.

InstrumentInstrument

Data was collected through a structured Data was collected through a structured questionnairequestionnaire followed by followed by clinical clinical examinationexamination..

The questionnaireThe questionnaire consisted of 18 items consisted of 18 items that addressed demographic data, lifestyle, that addressed demographic data, lifestyle, personal and family health history.personal and family health history.

Demographic data included age and birth Demographic data included age and birth date, educational level, occupation of women date, educational level, occupation of women and spouse.and spouse.

Lifestyle and personal health history included Lifestyle and personal health history included smoking, physical activity, history of hyper-smoking, physical activity, history of hyper-tension and current use of antihypertensives, tension and current use of antihypertensives, and for their use of oral contraceptive pills, and for their use of oral contraceptive pills, their menopausal status and use of HRT. their menopausal status and use of HRT. Participants were asked whether they got Participants were asked whether they got angry easily and how did they relieve their angry easily and how did they relieve their anger, and type of oil used for cooking. anger, and type of oil used for cooking. Participants were also asked if they had any Participants were also asked if they had any sudden deaths excluding accidents in their sudden deaths excluding accidents in their families and the relation of the deceased to families and the relation of the deceased to them. them.

It was assumed that sudden deaths were due It was assumed that sudden deaths were due mostly to coronary incidents, so their measure mostly to coronary incidents, so their measure was used as a proxy for family history of CADwas used as a proxy for family history of CAD

The second part of the instrument consisted of The second part of the instrument consisted of clinical findingsclinical findings. For each participant height . For each participant height in centimeters and weight in Kilograms were in centimeters and weight in Kilograms were taken and the BMI calculated. A BMI of 27.3 or taken and the BMI calculated. A BMI of 27.3 or greater classified the participants into greater classified the participants into overweight category (Kugmarski et al., 1994). overweight category (Kugmarski et al., 1994). Blood tests included fasting blood sugar Blood tests included fasting blood sugar (FBS), total cholesterol, HDL and LDL (FBS), total cholesterol, HDL and LDL cholesterol and triglyceride values expressed cholesterol and triglyceride values expressed in mg/dl. in mg/dl.

An FBS level of greater or equal to An FBS level of greater or equal to 138mg/dl, cholesterol level of greater or 138mg/dl, cholesterol level of greater or equal to 200mg/dl, LDL level of greater or equal to 200mg/dl, LDL level of greater or equal to 130mg/dl, HDL level of less than equal to 130mg/dl, HDL level of less than 40mg/dl and triglyceride level greater than 40mg/dl and triglyceride level greater than 230mg/dl classified the participants into 230mg/dl classified the participants into high risk group (Hudak, Gallo & Morton, high risk group (Hudak, Gallo & Morton, 1998).1998).

For each participant means of systolic and diastolic blood pressures were calculated from the readings. Participants whose mean systolic pressures were greater than or equal to 140mmHg and mean diastolic pressures greater than or equal to 90mmHg were classified as hypertensive (the VI Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, 1997).

ProcedureProcedure

During the first session of the panel discussions, the height, weight and blood pressure of the participants were taken and recorded.

On subsequent sessions, only blood pressures were taken.

When the panel discussions were over, those participants who attended regularly received free cards, as an incentive to do blood tests. In addition they answered the interview. the interview.

Blood tests were taken, analyzed and Blood tests were taken, analyzed and recorded by the same person for all recorded by the same person for all participants to enhance reliability.participants to enhance reliability.

A cardiologist was available for A cardiologist was available for consultations, physical exam, reporting of consultations, physical exam, reporting of laboratory findings and follow-up visits when laboratory findings and follow-up visits when advisable.advisable.

AnalysisAnalysis

Frequency distributions were used to present Frequency distributions were used to present the demographic characteristics, life style the demographic characteristics, life style and personal and family health histories. and personal and family health histories. Cross tabulations were conducted to test for Cross tabulations were conducted to test for the relationships of hypertension states and the relationships of hypertension states and age, lifestyle, personal and family histories age, lifestyle, personal and family histories and clinical findings.and clinical findings.

The Chi square was calculated and the The Chi square was calculated and the significance level was set up at P<0.05.significance level was set up at P<0.05.

Results and Tables Results and Tables

LimitationsLimitations

- Small sample size- Small sample size

- Convenience sample- Convenience sample

- Participants were seriously motivated - Participants were seriously motivated

women who attended a series of panel women who attended a series of panel

discussions to raise awareness about risk discussions to raise awareness about risk

factors of CAD.factors of CAD.

ConclusionConclusion

The findings of this study show a high The findings of this study show a high prevalence of CAD risk factors in this sample.prevalence of CAD risk factors in this sample.The majority of the women were:The majority of the women were:- 50 years and older- 50 years and older- menopaused and not taking HRT- menopaused and not taking HRT- overweight- overweight- hypertensive- hypertensive- hypercholestrolemic, high levels of LDL, low - hypercholestrolemic, high levels of LDL, low levels of HDL.levels of HDL.

Although generalizations from this study is Although generalizations from this study is limited, we can conclude that CAD is no more a limited, we can conclude that CAD is no more a men's health problem but women's as well.men's health problem but women's as well.

RecommendationsRecommendations

It is highly recommended that community It is highly recommended that community health nurses plan and implement.health nurses plan and implement.- Programs for awareness, detection and - Programs for awareness, detection and control of hypertensioncontrol of hypertension- Advise women to quit smoking- Advise women to quit smoking- Avoid obesity- Avoid obesity- Increase physical activity- Increase physical activity- Reduce the ratio of total cholesterol to HDL - Reduce the ratio of total cholesterol to HDL cholesterol.cholesterol.

Further studies with a larger and randomly Further studies with a larger and randomly selected group of women are warranted.selected group of women are warranted.