Prevalence and Risk Factors for Angina Pectoris and Coronary Heart Disease in the Dhulikhel Heart Study, Nepal.

Abstract

Introduction: Cardiovascular diseases (CVDs) account for approximately one-third of global mortality, with an estimated 20.5 million deaths in 2021. Coronary heart disease (CHD) onset was higher in South Asians. According to 2019 data, the leading cause of death in Nepal was cardiometabolic disease. Physiologically, atherosclerosis-related reduced oxygen-rich blood flow to the heart can result in angina and the age range in which angina is most likely to occur is between 45 and 65 years. Behavioral and lifestyle interventions, such as regular exercise, quitting smoking, and reducing alcohol consumption, can help prevent and manage patients with CHD and angina. Methods: We conducted a cross-sectional study using secondary data from the Dhulikhel Heart Study (DHS) Wave 2, Nepal from June 2022 through July 2023. The total study sample size was 1608, in which adults (age 18 or older) residing in Dhulikhel Municipality, Kavre, Nepal, for more than 6 months of settlement were enrolled. Data were collected in household interviews by trained research assistants including demographics, medical history, lifestyle behaviors, and selected health metrics (e.g. blood pressure, height, and weight, etc.). The primary outcomes of this study were angina pectoris and CHD, which were defined through self-reported variables using the Rose Angina Questionnaire. Angina was defined through a series of questions on chest pain occurrence and location of the pain. CHD was defined if either self-reported angina pectoris or myocardial infarction had been identified. Multivariable logistic regression was used to determine factors associated with angina and CHD in unadjusted and adjusted models which included age, gender (male/female), ethnicity (Brahmin, Chettri/ Newar/ others), religious status (non-Hindu/ Hindu), education (high school or more/ less than high school/no formal education), body mass index(normal/ underweight/overweight/obese), smoking behavior (never smoker/ former smoker/ current smoker). physical activity (low/moderate/ high), alcohol intake, (non-drinker/ current drinker), diet (healthy/ unhealthy), diabetes (yes/no), and hypertension (yes/no). We tested for effect modification of both outcomes using interactions of gender and ethnicity by the following covariates: age, education, BMI, smoking, and hypertension. Results: Angina Pectoris: In this sample, only 55 individuals, with a prevalence of 3.4%, were identified as having angina pectoris. In the full multivariable logistic regression model, angina was significantly associated with age, BMI, former smoking, alcohol intake, and hypertension. The odds of having angina were 1.05 times per year higher in participants with greater age (95% CI: 1.02–1.07, p <0.001). Individuals who were overweight were three times more likely to have angina (OR: 3.05, 95% CI: 1.48–6.29, p < 0.002), and obese were almost five times more likely to have angina (OR: 4.92, 95% CI: 1.06–74.75, p 0.04) when compared to normal weight participants. The odds of having angina were 4.17 times higher among former smokers (95% CI: 1.98–8.76, p <0.001) in comparison to those who never smoked. The association between hypertension and angina was impacted by the effect modification of gender. CHD: CHD was self-reported in 123 individuals resulting in a prevalence of 7.6%. CHD was significantly associated with gender, education, BMI, smoking behavior, and dietary intake in fully adjusted multivariable logistic regression. In this sample, males had a lower risk of CHD than females, i.e. (males OR: 0.53, 95% CI: 0.32- 0.86, p < 0.01), and those with education below high school level also had a reduced risk of CHD (OR: 0.39, 95% CI: 0.18- 0.81, p 0.01) than those who had more education. The odds of CHD were 1.69 times greater among overweight participants (95% CI: 1.07- 2.65, p-value 0.02), and 1.90 times higher among obese participants (95% CI: 1.09-3.28, p 0.02) compared to normal weight participants. Former smokers were twice as likely to have reported CHD (OR: 2.35, 95% CI: 1.30–4.25, p 0.004) in comparison to those who never smoked. Those eating unhealthier diets had 1.90 times greater odds (95% CI: 1.20–3.00, p 0.006) of CHD compared with those who ate healthy diets. Effect Modification: Only one significant interaction (p<0.008) was found in the tests conducted to identify effect modification between gender and hypertension in the angina model. Among males, the likelihood of reporting angina pectoris was higher if they had hypertension (OR: 4.66, 95% CI: 1.50-14.4, p - 0.008) compared to those who did not have hypertension. In contrast, no such association was found among females. No, effect modification was observed in CHD models. Conclusion: Our study found that angina pectoris was prevalent in 3.42% of our sample, and CHD had a prevalence of 7.65% generated from self-reported data in an urban population in Central Nepal. Angina was significantly associated with greater age, a higher BMI, former smoking, and drinking alcohol. Similarly, CHD was associated with age, male gender, unhealthy diet, being obese and overweight, former smoking, and lower education. The prevalence of hypertension was found to increase the risk of angina only in male participants. These results document demographic and lifestyle factors related to these specific CVDs in the Nepalese population using household survey data. Interventions to address these cardiometabolic risk factors are needed to help reduce CVD and mortality due to heart disease in Nepal.