QJM Advance Access published online on July 4, 2008
QJM, doi:10.1093/qjmed/hcn076
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Prevalence trends for myocardial infarction and conventional risk factors among Greek adults (2002–06)
From the 1Department of General Practice, Health Centre of Kalivia, Kalivia-Lagonisi, Athens, Greece, 2Third Department of Internal Medicine, Diabetes Centre, ‘Saint Panteleimon’ General Hospital, Nikea-Pireaus, Greece, 3Department of Nutrition Science - Dietetics, Harokopio University, Athens, Greece and 4Health Centre of Salamis, Salamis, Greece
Address correspondence to A. Gikas, MD, 6 Gavriilidou Street, 11141, Ano Patisia, Athens, Greece. email: argikas{at}internet.gr
Received 16 April 2008 and in revised form 3 June 2008
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Summary |
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Aim: To examine trends in the prevalence of myocardial infarction (MI) and conventional risk factors in Greek adults between 2002 and 2006.
Design: Repeated cross-sectional study.
Methods: Self-reported data from surveys given in Salamis during two election days in 2002 and 2006 were analysed. The same sampling method and procedures were used on both surveys. The study sample included 2805 and 3478 subjects (
20 years) in 2002 and 2006, respectively, with similar age and sex distribution to the target population.
Results: The prevalence of MI increased from 4.1% (men, 6.3%; women, 1.9%) in 2002 to 4.8% (men, 7.3%; women, 2.2%) in 2006 (P = 0.18). At the same time, prevalence rates of major risk factors were as follows: diabetes increased from 8.7% to 10.3% (P = 0.037), hypertension from 20.1% to 25.7% (P < 0.001) and hypercholesterolemia (cholesterol >240 mg/dl or the use of cholesterol-lowering medication) increased from 17.5% to 22.3% (P < 0.001). Prevalence of current smokers in 2002 (defined as persons who smoked 5 cigarettes/day) was 37.0% and in 2006 (defined as those who smoked 1 cigarettes/day) was 40.1%. Logistic regression analysis showed that the aforementioned risk factors were significantly associated with MI in both surveys; the factor that showed the greatest magnitude of association with MI was hypercholesterolemia, followed by diabetes, hypertension and smoking.
Conclusions: These findings show that, in the Greek population, prevalence of MI continues to rise (at 
4% per year). This trend seems to be driven by a persistently high prevalence of smoking and the rapidly increasing burden of diabetes, hypertension and hypercholesterolemia.
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Introduction |
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Coronary heart disease (CHD) continues to be the leading cause of death in developed countries and is increasing rapidly in the developing world.1–3 It is well known that CHD is strongly associated with conventional risk factors, namely smoking, diabetes, hypertension and hypercholesterolemia.4–6 The most recent reports suggest that these risk factors are found in
75% of the occurrences of CHD within populations, and not 50%, as has been previously claimed.6–8 Changes in the prevalence rates of different forms of CHD have implications for prevention policy and health provision.9 Moreover, continued assessment of temporal trends regarding risk factors for CHD is needed to inform population strategies in order to reduce risk and predict the future burden of CHD.10 There is limited data about temporal trends of CHD and of major cardiovascular disease risk factors among different populations.11–14 For Greece, there is some evidence that indicates the current high prevalence of major risk factors in the general population.15–18 However, the morbidity information regarding CHD is scarce,19,20 a phenomenon which characterizes most European countries.21 In the 1960s, Greece, like other Mediterranean countries, was known to have low rates of CHD morbidity and mortality compared with northern European countries and United States.22 In the following decades, however, the increment of coronary risk factors that resulted in the increasing mortality from CHD was documented in Greek population. These trends were largely different from those recorded in the western populations, where a decrease of CHD incidence was noted after the 1970s.23 In this context, the information concerning recent evolution of CHD rates and risk factors in the Greek population would be of great interest. Thus, we sought to examine trends in the prevalence of self-reported myocardial infarction (MI), in combination with trends in the prevalence of classic risk factors between 2002 and 2006 in the same urban population.
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Methods |
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Study design and data collection
Two cross-sectional surveys were performed in the municipality of Salamis, which is part of greater Athens. The surveys took place during two election days: 13 October 2002 and 15 October 2006. The target population was composed of
23 000 adult residents. The survey methods have been described elsewhere.16,20,24 In brief, almost the same team of trained interviewers (10 in 2002 and 13 in 2006) performed face-to-face interviews, using the same anonymized questionnaire. All voting centers in the city of Salamis (n = 8) were included in the sampling procedure, and eligible participants were selected at random. The response rates were 91% in 2002 and 88% in 2006. Participants were unaware of the content of the questionnaire and there were no differences in the distribution either by sex, or by age group in the nonrespondents. The following information was initially collected: year of birth, sex, educational level and smoking status. Current smokers were defined in 2002 as persons who smoked at least five cigarettes daily and in 2006, as those who smoked at least one cigarette daily. Former smokers were defined as those who had quit smoking at least 1 year before the interview. The rest of the participants were defined as nonsmokers.
Participants were then asked to report if they have been diagnosed as having diabetes, the presence of which was confirmed by questions regarding the type of diabetes, year (or age) at diagnosis and current mode of treatment. Additionally, respondents were asked to state their height and weight, and were thus classified as overweight if their body mass index (BMI) was 25.0–29.9 kg/m2 and as obese if it was 30 kg/m2.
Data was collected regarding hypercholesterolemia. Respondents were defined as having hypercholesterolemia if they reported having total cholesterol levels >240 mg/dl (>6.21 mmol/l)25 on repeated measures or if they currently used cholesterol-lowering medication. They also were asked if a physician had told them that had hypertension, and the use of medication was noted. Finally, all participants were asked if they ever had a medical diagnosis of MI and if the answer to this question was ‘yes’, the year of its occurrence also was recorded.
Study population
After excluding respondents aged younger than 20 years, the total number of study participants in the two surveys in 2002 and 2006 was 2805 (1430 women and 1375 men) and 3478 (1747 women and 1731 men), respectively; the mean age of participants was 49.19 ± 17 (range 20–94) years and 49.24 ± 17 (range 20–93) (P = 0.90), respectively, indicating that the age and sex distribution between the populations of two surveys was similar. Also, there were only minor differences in the age and sex distributions between the two surveys and the target population.16 Probably, the high voter turnout (86% in 2002 and 82% in 2006) contributed considerably to obtain a representative sample.
Statistical analyses
The t- and Pearson's chi-squared tests were used to evaluate differences in mean values and percentages between the two time points (2002 and 2006). Total and sex prevalence estimates were age-adjusted by using the direct method, based on the 2001 standard population of Greece. The relationships between risk factors and prevalence of MI for the two time points (2002 and 2006) were assessed by logistic regression analysis. The same model was applied for each study sample, with history of MI (yes/no) as the dependent variable, and age, sex, educational level, obesity, diabetes, hypertension, hypercholesterolemia and smoking, as covariates. The level of significance for all analyses was P < 0.05. SPSS software (Statistical Package for Social Sciences, version 12.0 Inc., Chicago, IL, USA) was used for all statistical calculations.
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Results |
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Trends in the prevalence of MI
The crude prevalence of MI increased from 4.1% in 2002 to 4.8% in 2006, a rising tendency that does not reach statistical significance (P = 0.18). The mean age of subjects with history of MI was 65.7 ± 8.5 years in 2002 and 65.9 ± 9.3 years in 2006 (P = 0.81). The mean duration between the first episode of MI and the survey was 7.1 ± 5.7 and 7.7 ± 6.4 years (P = 0.44), respectively. As shown in Table 1, the prevalence rates of self-reported MI increased, in both sexes and in all age groups between 2002 and 2006. In particular, in women, the age-adjusted prevalence increased from 1.9% to 2.3% (an increase of 21%) and in men from 5.4% to 6.1% (an increase of 13%). In total, the age-adjusted prevalence of MI increased from 3.6% to 4.2% (an increase of 17%).
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Trends in the prevalence of major cardiovascular risk factors
The crude prevalence of known diabetes increased from 8.7% in 2002 to 10.3% in 2006 (P = 0.037); in women, it increased from 7.9% to 9.2% (P = 0.19) and in men, from 9.6% to 11.4% (P = 0.11). The total prevalence of diagnosed hypertension increased from 20.1% to 25.7% (P < 0.001); in women, it increased from 21.1% to 25.6% (P = 0.003) and in men, from 19.1% to 25.8% (P < 0.001). There was a modest significant increase in percentage of subjects taking antihypertensive medications, from 88.5% to 91.7% (P = 0.04). The prevalence of self-reported hypercholesterolemia increased from 17.5% in 2002 to 22.3% in 2006 (P < 0.001); in women, it increased from 17.3% to 22.2% (P = 0.001) and in men, from 17.6% to 22.4% (P = 0.001). Among subjects with hypercholesterolemia the percentage of those who were under cholesterol-lowering medication increased considerably from 38.6% to 56.7% (P < 0.001).
The percentage of current smokers in 2002 (defined as persons who smoked 5 cigarettes/day) was 37.0% (women, 27.3%; men, 47%) and in 2006 (defined as those who smoked 1 cigarettes/day) was 40.1% (women: 31.3%; men: 49%). The percentage of former smokers was increased from 11.3% to 13.3% (P = 0.017). Figure 1 shows the age-adjusted prevalence rates for the four major risk factors in two examination surveys. The prevalence of adults with none of the four major risk factors declined from 40.6% to 34.4% (P = 0.001), while the prevalence of those with two or more risk factors increased from 18.3% to 25% (P = 0.001). The latter proportion among persons aged 50 years and older increased from 28.2% to 41.9% (P = 0.001).
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Impact of risk factors on the prevalence of MI
Table 2 shows the multi-adjusted analysis revealing that the four major risk factors were significantly associated with history of MI in both surveys.
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Discussion |
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We report the results of two consecutive, cross-sectional surveys regarding the trends in the prevalence of self-reported MI and conventional cardiovascular risk factors in a representative sample of a Greek urban population. The results show that the prevalence of MI increased from 2002 to 2006. Specifically, the age-adjusted prevalence of MI rose from 3.6% to 4.2% (an increase of 4% per year), which corresponds to an increase of the population with nonfatal MI, in Greece, from 3 10 000 in 2002 to approximately 3 60 000 in 2006. It should be noted that, although the differences in prevalence of MI between the two time points were not statistically significant, it does not diminish the apparent rising tendency to MI. This result is probably due to the relatively short surveillance period; moreover, it is expected that the changes in frequency rates of major health problems, which presented with low rates (e.g. MI), to be less statistically evident than those of conditions presented in higher rates (e.g. hypertension).
The finding that the survival time after the first episode of MI remained stable between the two time points (2002–06) indicates that the increase in the number of patients with MI has been attributed mainly to the accumulation of new cases, and not to improved survival among those patients. Whether the increasing trend in prevalence of MI reflects increasing or stable trend in the incidence of MI we are unable to conclude. However, bearing in mind the aforementioned substantial increase of about 50 000 new cases with nonfatal MI, in whole Greek population, we assume that the decline in the incidence of MI during the 4-year study period is unlikely to happen.
A previous study carried out in a representative adult Greek population, in the early 1980s, showed that the prevalence of MI was 1.08%.26 Comparing that prevalence with ours (4.2% in 2006), we found a 3.9-fold increase during the last 25 years. This observed rise agrees with data reported by Chimonas,19 who reported that the number of hospitalized patients suffering an acute MI almost doubled during a 15-year period (from 1980 to 1995). Also, nationwide morbidity statistics show similar trends: the number of patients discharged with a diagnosis of acute MI (fatal plus nonfatal) increased from 14 458 in 1996 to 18 325 in 2004 (an increase of 3.5% per year).27 The question raised here is whether the new definition of MI,28,29 based on troponin values, had any impact in the increasing prevalence of MI. Given the fact that the two surveys were conducted after publication of the new definition is unlikely to have resulted in substantial short-term increase of MI prevalence in the general population. However, this issue should be taken into consideration when comparing current rates of MI with those of the early 1980s.
We examined the trends of four major modifiable risk factors. In particular, the age-adjusted prevalence of diabetes increased from 8.2% in 2002 to 9.5% in 2006, which correspond to a total increasing rate of 16%. Accordingly, in our recent report,24 we demonstrated that the prevalence of diabetes increased in parallel with obesity (from 17.9% to 21.1%, increase of 18%), which seems to be a usual worldwide phenomenon.30,31 At the same time, we found that the prevalence of diagnosed hypertension increased from 19.0% to 24.0% (giving an overall increase of 26%). Similarly, the prevalence of known hypercholesterolemia increased from 16.8% to 21.0% (an increase of 25%). Moreover, there was a rising tendency for the above risk factors for both sexes and all age groups (data not shown). Whether this upward trend is due, in part, to better detection of these conditions is difficult to derive from this study. However, the available data from Greece show that blood pressure and cholesterol levels have increased significantly during the last three decades.17,23 Of note, we found that in 2006 more people were taking cholesterol-lowering and blood pressure medications, suggesting that these risk factors were better controlled than in 2002. Regarding smoking the present work showed that its current prevalence remains high in the Greek population (40% in 2006). Unfortunately, the minor differences in definition of current and nonsmokers (in 2002 and 2006 survey) do not allow for direct and precise comparisons between the two time points. However, we may speculate that a slight decrease in the prevalence of smoking has occurred. This is based on the following observations: first, there was a significant increase in the percentage of persons who quit smoking, and, second, there was a slight decrease in the prevalence of smoking compared with previous studies conducted in Greek adults between 2001 and 2002, which showed that the prevalence of smoking was 45–46%.15,32
Compared with other countries, the prevalence of self-reported MI in Greece is close to that in the United States (4.0% in 2005).11 However, there are some differences regarding the evolution of CHD rates in the United States, where rates of self-reported MI decreased among white people from 1971 to 1994, but increased among people of other racial/ethnic groups.33 At the same time, upward trends were shown regarding known major risk factors for CHD (except smoking), with persistent disparities between blacks and whites, and between Hispanics and non-Hispanic whites.12 Also, the prevalence trends of MI and major risk factors (including obesity, diabetes, hypertension and hypercholesterolemia), in Greece, seems to be similar with those of other southern European countries such as Spain.14,34 In contrast with other developed countries where impressive results on declining of smoking consumption are noted—with smoking prevalence to be lower than 30% (available at http://www.who.int/infobase/), in Greece this rate is still very high.
Our results also show that modifiable risk factors tend to occur in combination, especially among persons aged 50 years and older. This tendency has important implications for health promotion because clustering of risk factors provides support for multiple-behaviour interventions as opposed to single-behaviour interventions.35 Moreover, given the fact that these subjects have a substantially higher risk for CHD,36 this clustering raises concerns about the future trends in the burden of CHD in the Greek population. Taking into account other parameters such as increasing ageing of the population, the near absence of strong encouragement from the state and general individuals’ failure to reduce risk factors significantly, the chances of decreases in the incidence of CHD appear remote.37
As expected, we found that smoking, diabetes, hypertension and hypercholesterolemia were strongly and consistently associated with the occurrence of MI. The factor that showed the greatest magnitude of association with MI was hypercholesterolemia (adjusted OR: 7.6 and 5.3, in 2002 and 2006, respectively). Of note, there was a decrease (from 2002 to 2006) in the strength of the association between hypercholesterolemia and prevalence of MI. Most likely, this decrease reflects the widespread availability of cholesterol-lowering agents in the last decade, which resulted in the significant increase in the use of these agents in our population; this translates to the evidence-based fact that people with hypercholesterolemia taking statins gain the benefit of having a lower risk of developing cardiovascular events.38 However, whether this decrease is, in part, attributable to misclassification bias (inclusion of persons who initiate statin therapy after MI occurrence) cannot be ruled out. Interestingly, a similar trend was seen regarding the impact of sex in the prevalence of MI (OR: 5.50–3.64), indicating that differences in the incidence of MI between men and women are narrowing over time.
Several epidemiologic studies indicate that trends in the incidence of MI have declined in most developed countries, especially in northern European countries,9,39,40 and this is thought to be attributable to reductions in major risk factors including smoking, cholesterol and blood pressure. Unfortunately, our study indicates that the opposite pattern is occurring in Greece, which is experiencing unfavourable changes in major risk factors that probably have affecting the incidence of MI. In the pioneering epidemiological project of the Seven Countries study, Greece was represented by two rural communities and was characterized by very low incidence of CHD compared to western populations, mainly due to the different lifestyle related behaviours. Specifically, the prevalence of MI was only 0.3% in men aged 40–59 years.22 However, after the 1970s the socioeconomic development that took place was associated with health-related changes: the traditional Mediterranean diet and high habitual physical activity gradually gave way to western-type diet, a more sedentary lifestyle, and an increase in smoking. These changes, as confirmed by our study, brought Greece in a position where it ranks among countries with high rates of CHD and among nations with the most unfavourable risk factor profile.15,17,19,41,42 In addition, our findings confirm that the conventional risk factors are strong predictors of CHD to a Mediterranean country as they are in other countries, and suggest that the north–south high-to-low gradient in Europe for CHD43 appears to diminishing. It is thus time to learn from the experience of northern European countries where a decrease in major risk factors that resulted in declining incidence of CHD has been observed due to energetic and comprehensive prevention policies over many decades.44,45 Furthermore, the adverse trends in Greek population regarding cardiovascular disease are of international interest, especially for future prediction of the burden of disease in developing countries and those in transition, which during 1990s began to experience the same consequences of rapid changes in lifestyle and diet that Greece saw during the early phases of the last 30-year evolution.2,46,47
This analysis of trends in MI and major risk factors has two main limitations. First, the self-reported data may underestimate the true prevalence of the conditions examined. The validity of self-reported data varies among different cardiovascular risk factors. Compared with medical records or measurements, recent studies report substantial to almost perfect agreement for diabetes, substantial to moderate for hypertension and moderate to low for hypercholesterolemia.48 Regarding MI, earlier studies showed relatively low validity,49 while a more recent study showed good positive predictive value (71.5%) and high sensitivity (98%), suggesting that even a postal questionnaire is a useful method to identify hospitalizations for nonfatal MI cases in epidemiologic cohort studies.50 Furthermore, considering that a history of cardiovascular disease is a strong predictor of the accuracy of self-reported data, we cannot exclude the possibility that misclassification or other confounding factors might affect the magnitude of the association of each risk factor with the prevalence of MI. However, because the survey was repeated on the same day of the year, in the same target population, using the same methodology, and because the data collection procedure was performed by almost the same team of health care professionals, we believe that the level of reliability of the self-reporting data did not change during the 4-year period. Thus, our findings regarding trends in the prevalence of MI and conventional risk factors are only slightly biased. Second, the present study focused on only nonfatal MI—a major coronary event, which means that it is difficult to create a complete picture of all forms of CHD. However, we have no reason to believe that the ratio between different forms of CHD has changed during the 4-year period, assuming that the upward trends in MI reflect the trends in overall CHD. Finally, although our study population is largely representative of age, sex and educational level, and moderately representative of geographic origin (because about 50% of the participants were born in different regions of Greece),16r generalization of our study's results to all Greek population should be made with caution.
In conclusion, these findings indicate that, in the Greek population, the prevalence of MI continues to rise. This trend seems to be driven by a persistently high prevalence of smoking and the rapidly increasing burden of diabetes, hypertension and hypercholesterolemia. Consequently, more effective clinical interventions are needed to prevent CHD in our population, focusing on smoking cessation, promotion of traditional Mediterranean diet and increased physical activity. Effective national strategies are urgently needed to halt the further increase in the burden of cardiovascular risk factors.
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This work was financially supported by the Hellenic Society of Primary Care Research and Continuing Education. We thank all the health professionals who participated in the interviewing process as well as the local authorities’ representatives who helped with the completion of this study.
Conflict of interest: None declared.
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References |
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