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Coronary artery disease (CAD) is the leading cause of mortality and morbidity worldwide. The Middle Eastern (ME) countries bear a heavy burden from CAD. The presentation of CAD occurs at much lower age among patients in the ME, in comparison to other regions. A substantial number of these patients with CAD are expatriates commonly from South East Asia, including Bangladesh. A good number of Bangladeshi workers from ME countries present to Ibrahim Cardiac Hospital and Research Institute (ICHRI) each year with symptoms related to CAD at relatively younger age. Many of them have risk factors for CAD. However, the health issues and risk factors contributing to early onset of CAD among Bangladeshi expatriates in ME have not been specifically studied.
This study was designed to investigate the angiographic profiles, demographic, lifestyle habits and risk factors for premature CAD among Bangladeshi expatriates in the ME, and if they are prone to an unhealthy lifestyle promoting CAD risk while living in the region.
This cross-sectional study was conducted on 79 male Bangladeshi expatriates living in the ME, who presented to ICHRI with signs and symptoms of CAD over the period extending from 1st January to 31st December 2015. All patients underwent coronary angiography (CAG) and were subsequently managed as per guideline recommendations. The study was approved by the ethical review committee of the hospital. Informed written consent was taken from all patients. Variables comprising of demographics, presenting symptoms, physical signs, biochemical tests, ECG changes, echocardiography and the coronary angiographic profiles were recorded for all subjects in a pre-designed structured data collection form. Data were analyzed using SPSS (statistical package for social science), version 17 (SPSS Inc., Chicago, IL, USA). The test statistics used to analysis data were Chi-square (x2) test and Student's t-Test. Data presented on the categorical scale were compared between two groups using Chi-square (x2) Test, while the data presented on the continuous scale were compared between groups using student’s T-test.
For all analytic tests, the level of significance was set at 0.05 and a p-value of <0.05 was considered statistically significant.
The mean age of the sampled male population was 47.8 ± 8.2 years. Over half (53%) of them belonged to low-income families, and 73.4% were with education levels of secondary or below. 63.3% of all subjects were diabetic, 58.2% were hypertensive, 59.9% were dyslipidemic, 34.2% current smoker and 54.4% had body mass index (BMI) above the normal range. In approximately 90% of cases, diabetes, hypertension, and dyslipidemia were detected after migrating overseas, which may reflect either a delayed detection or consequence of lifestyle changes in the Middle Eastern environment. Over 40% reported a habit of frequent intake of fast food from restaurants substituting for daily meals, while 35% failed to take meals at regular hours. 27% of these expatriates reported an excessive intake of carbohydrates and 30% had excessive fatty food intake, including the traditional fatty meal 'Kapsa'. The entire study population was married but living alone, with the majority reporting stressful lifestyles related to work, and deprivation of family life. More than half of the patients (50.7%) presented for CAG with a history of myocardial infarction, while 8.9% presented with unstable angina and 40.5% presented with stable angina. Coronary angiographic profiles revealed that most of the patients (43.03%) had single vessel disease, while 27.85% had double vessel disease and 29.12% had triple vessel disease (TVD).
TVD was significantly higher among diabetics (p=0.007), smokers (p=0.043) and those accustomed to fast food (p=0.048).
Bangladeshi expatriates living in the ME present with CAD at a relatively early age, with clustering of risk factors for CAD, particularly diabetes, hypertension, dyslipidemia, and smoking. Furthermore, poor dietary habits and stressful lifestyles with deprivation of healthy family lives could be additional contributing factors to this early onset and increased severity of CAD. This is evident by the finding of significantly greater incidence of TVD among diabetics, smokers and those with the high-calorie intake. Although it is difficult to draw conclusions as to whether this subset of the population was more prone to risk due to their work in the ME, the detection of risk factors such as diabetes and hypertension only after their migration to the ME suggest that unhealthy lifestyle changes might influence the early onset of CAD. Interventions to control hypertension and dyslipidemia, and to reduce the risk of developing diabetes is a primary clinical priority in this population. Dietary and lifestyle improvements are effective at reducing the number of cardiovascular risk factors simultaneously, however, cultural and environmental barriers, including lower socioeconomic conditions and poor educational status might render this difficult.
There is also a need for more detailed data on the epidemiology of CAD among Bangladeshis workers in the ME, particularly related to risk factor status prior to their migration.