Ahmed Bendary (Benha University, Benha, Egypt) details the CardioRisk project, an initiative to stratify the prevalence of atherosclerotic risk factors in Egyptian patients presenting with acute coronary syndromes.
Egypt is the most populous country in the Middle East and North Africa (MENA) and has more than 15% of the cardiovascular (CV) deaths in the region. Moreover, it is an official country member of the European Society of Cardiology (ESC). Until recently, very little was known about the prevalence of atherosclerotic risk factors (RFs) in Egyptian patients presenting with acute coronary syndromes (ACS). These data would be of particular interest from a CV preventive standpoint, considering the fact that Egypt has a relatively low per-capita health expenditure and hence, the cost of treatment of CV disease once manifested becomes unacceptably high.
Our group in Egypt set out to address this knowledge gap by conducting a nationwide, cross-sectional study called the ‘CardioRisk project’. We included 3,224 patients with ACS (STEMI and NSTE-ACS), from 31 coronary care units covering all regions in Egypt, in the time period from 2015 to 2018. The group aimed primarily to estimate the prevalence of RFs in those patients, with focus on the gender-specific differences and premature presentation. The final results have been recently published in the Journal of Public Health in Africa (JPHiA).1
“Many unanswered questions motivated us to start this project, including the age of onset of ACS in Egypt and the treatment strategies followed,” Ashraf Reda, professor of cardiology at Menofia University, Egypt and the lead author on the report, said. “These needed to be highlighted” stressed Reda, who is also the president of the Egyptian Association of Vascular Biology and Atherosclerosis (AEVA).
Alarming numbers, experts react
Investigators found that the vast majority were males (74%) and the most prevalent age group was (56‒65 years) representing 37% of whole study population. Among female patients, 92% were post-menopausal. The prevalence of premature ACS (defined as onset of ACS below age of 55 years in males and below 65 years in females) was 51%, which simply means that one in every two patients with ACS in Egypt presents prematurely. Forty five percent of total males and 69.6% of total females with ACS had premature ACS (p<0.001). Abdominal obesity was the most prevalent risk factor (66%) followed by hypertension (56%). Nearly half of the entire study patients were current smokers (48%). There was a high prevalence of documented dyslipidemia as well (48%). Importantly, all traditional RFs (apart from smoking) were significantly more prevalent in women compared to men.
Salim Yusuf, professor of medicine at McMaster University, Hamilton, Canada, and a global expert in the field of cardiovascular epidemiology called the project “an important” one. “It is useful as a starting point but hardly surprising,” he said. “One should focus on the rates of smoking, obesity, hypertension, and diabetes especially in women. These are very high rates to me,” added Yusuf, who is also the current director of the Population Health Research Institute (PHRI), Ontario, Canada.
Andreas Zirlik, professor of cardiology at University Heart Center Graz, Graz, Austria, and the current president of the German Society of Atherosclerosis Research (DGAF) agreed. He called the findings “alarming”. “Estimations of premature ACS in Europe or the US suggest a prevalence of approximately 25%, which would be half the prevalence observed in Egypt,” he said. Zirlik pointed out to the high rates of obesity ranging from 60 to 63% in western Europe and the US in the INTERHEART study that was led by Salim Ysusf and published in The Lancet back in 2004.
Good in-hospital management
The group reported that early invasive management strategy was employed in 65% of patients with no significant gender disparity noticed. Vascular access for coronary angiography was most commonly femoral (80% of time). Emergent percutaneous coronary intervention (PCI) was attempted in 53% of patients. Thrombolytic therapy (using Streptokinase) was used in only 24% of included STEMI participants. They also observed a very good adherence to evidence-based medical therapies for hospitalised ACS patients (again, with modest gender disparity).
“Treatments seem excellent once people get to hospital, but we don’t know how many dies before getting to hospital and whether any had been diagnosed with other manifestations of CV diseases, usually an opportunity to intervene a little earlier,” said Salim Yusuf.
“These results could be the basis for a health care policy for CV protection among the Egyptians,” answered Reda when asked about the implications for the findings. Other experts called for an action as well. “The results of this study strongly suggest that population-wide strategies for prevention and management of CV risk factors need to be implemented,” Zirlik added. Salim Yusuf referred to the importance of statins and blood pressure lowering medications for primary prevention. He pointed out to the HOPE-3 trial and the International Polycap Study-3 published in the New England Journal of Medicine (NEJM), for each Yusuf was a first author. “So, where do you go from here? You have to act,” he said. “You need to strengthen tobacco control more vigorously and to have a hypertension detection program. This [will] yield benefits within three to five years,” Yusuf promised. In line with this, the Egyptian government has recently completed a nationwide campaign called [100 Millions’ Wellness] covering all the 27 Egyptian governorates along a period of 14 months (from October 2018 to December 2019) for screening and detection of hypertension, diabetes, obesity, and Hepatitis C virus. We believe that this is a good move to mitigate CV prevention failures in Egypt.
- Reda A, Bendary A, Elbahry A, et al. Prevalence of atherosclerosis risk factors in Egyptian patients with acute coronary syndrome: final data of the nationwide cross-sectional ‘CardioRisk’project. Journal of Public Health in Africa. 2020;11(2).