Table of Contents  

Razzak, Harbi, Shelpai, and Qawas: Prevalence and risk factors of cardiovascular disease in the United Arab Emirates

Introduction

Cardiovascular disease (CVD) and the associated burden are increasing in developing countries, particularly in the United Arab Emirates (UAE), and represent a key challenge in health care. The World Health Organization (WHO) reports that CVD is the primary cause of death worldwide, accounting for 17.5 million deaths (31% of all deaths) in 2012, of which 80% occurred in low- and middle-income countries.1 Globally, 85% of disability is attributable to CVD.2 CVD includes stroke, coronary heart disease (CHD) and peripheral vascular disease. CVD also accounts for a significant proportion of global deaths caused by non-communicable diseases among individuals aged under 70 years (37%). If intervention is not improved, global annual CVD deaths will increase from 17.5 million in 2012 to 22.2 million by the year 2030.3

A Ministry of Health and Prevention report4 has revealed that CVD is a leading cause of mortality in the UAE. Of CVD deaths, 22% were attributable to acute myocardial infarction (AMI), 16% to cerebrovascular disease, 6% to ischaemic heart disease and 5% to hypertension. WHO has reported5 on the most effective interventions, which include drug therapy, the regulation of alcohol and tobacco, health counselling and public awareness programmes that promote regular physical activity and a healthy diet. Greater understanding of the epidemiology, prevalence and risk factors of CVD is understood to be the basis for designing, implementing and monitoring effective prevention strategies. A Framingham heart study6 found an association between CHD mortality and congestive heart failure (HF), high blood pressure (BP), metabolic disorders, abdominal adiposity and diabetes mellitus (DM).

According to Assmann et al.7 and Hense et al.,8 both prevalence and prognosis are important in the development of risk prediction scores for CHD. Yusuf et al.9 and Rosengren et al.10 have reported on the INTERHEART study and the nine risk factors (excessive alcohol intake, lack of exercise, psychosocial index, abdominal obesity, hypertension, DM, smoking, apolipoprotein A-I and apolipoprotein B) associated with AMI, suggesting that risk of AMI is the same for both sexes and is consistent throughout all ethnic groups and regions across the globe. Teo et al.11 and Yusuf et al.12 describe the low prevalence of healthy lifestyle behaviours across countries of all income levels, with particularly low prevalence – along with a lower rate of use of cardioprotective drugs during secondary prevention – in low-income countries. The MONICA (MONItoring trends and determinants in CArdiovascular disease) project13,14 found that smoking rates had decreased in men and increased in women after a 10-year period, whereas cholesterol levels and systolic BP rates had decreased in both sexes. Furthermore, body mass index (BMI) had significantly increased in about half of the studied population. The project demonstrated the important relationship between CHD and serum cholesterol.

Bearing this trend in mind – increasing CVD-related mortality in the UAE – there is an evident need to further investigate CVD prevalence and risk factors across the UAE. This systematic review is intended to offer a comprehensive understanding of CVD in the UAE and highlight gaps in existing knowledge, summarizing previous research with UAE participants on CVD prevalence and risk factors.

Methodology

A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for reviewing epidemiological studies. Relevant articles were identified by searching data sources such as PubMed, Scopus, ScienceDirect and local journals. Search terms, including keywords and medical subject headings, were related to CVD (cerebrovascular disease; stenosis; peripheral arterial disease; myocardial infarction; stroke; vascular; cardiovascular event; cardiovascular risk; CVD; angiography; coronary artery disease; CHD; atherosclerosis) and the UAE (Dubai; Ajman; Al-Ain; Abu Dhabi; Fujairah; Sharjah; Ras al-Khaimah; Umm al-Quwain). A standardized approach was adopted by the authors and the literature search and data extraction were undertaken independently. Research articles were similarly searched for in local journals and cross-reference lists to ensure that a thorough search had been conducted.

Inclusion and exclusion criteria

We included studies that directly concerned potential risk factors of CVD. Extracted articles were limited to original research conducted in English and published in peer-reviewed journals between 2007 and 2016. The articles focused predominantly on the prevalence and risk factors of CVD in the UAE. Studies with insufficient information on risk factors and studies that did not address the high-risk UAE population were excluded.

Selection and data extraction

Overall, 177 records were identified, of which 40 remained after the removal of duplicates. Abstracts and titles were then reviewed in order to exclude non-relevant articles. The full text of each of the remaining 21 articles was retrieved for evaluation. Data were extracted into Excel 2013 (Microsoft Corporation, Redmond, WA, USA), including the names of the first author, publication year, sample, location and specific outcomes. A research strategy flow chart is presented in Figure 1.

FIGURE 1

Schematic representation of the selection of studies for the systematic literature review.

HMJ-755-fig1.jpg

Results

Following a systematic search to identify epidemiological studies on the prevalence and risk factors of CVD in the UAE, 21 studies met the inclusion criteria, including cross-sectional studies (n = 11), population-based studies (n = 3), literature reviews (n = 2) and a case–control study (n = 1). Of these, 16 studies1530 reported on CVD risk factors and five studies20,21,24,30,31 reported on CVD prevalence.

Prevalence of cardiovascular disease

All five studies reporting on CVD prevalence were conducted in the UAE. One study was conducted at a national level,24 two were multicentre studies20,31 and two were conducted in Abu Dhabi.21,30 All were cross-sectional with the exception of one review21 (Table 1). Two studies20,24 focused on HF and demonstrated that HF is significantly associated with inpatient mortality: the first involved a multivariate logistic regression analysis, which found that DM, heart rate, hyperlipidaemia and age were associated with higher inpatient HF;20 the second reported that the prevalence of HF was higher in women than in men.24 Almahmeed et al.21 focused on the lack of detailed, nationally representative epidemiological data and the need for registry development to reveal the nature of coronary disease. Shah et al.30 evaluated the association between CVD risk factors, acculturation and obesity among men; hypertension was found in 30.5% (419) of the sample along with DM in 9.0% (9) of the subsample. Another prospective multicentre study31 offered detailed information on post-discharge GRACE (Gulf Registry of Acute Coronary Events) risk scores in patients from the Arabian Gulf with acute coronary syndrome (ACS). The results demonstrated that this score can be used to stratify 1-year mortality risk among the Arab population; it does not need additional calibration and often has great discriminatory aptitude.

TABLE 1

Papers published between 2007 and 2016 on the prevalence of CVD in the UAE

Study Year Study design Study population Key findings
Shehab et al.20 2012 Prospective multinational multicentre registry, GRACE Patients with ACS Results indicate that HF is significantly linked with inpatient mortality. In multivariate logistic regression, DM, heart rate, hyperlipidaemia and age were associated with higher in-hospital HF
Almahmeed et al.21 2012 Literature review Patients with CHD Lack of current, detailed, nationally representative epidemiological data in the majority of countries. Development of national registries is required to reveal the nature of CHD. Beta-blockers are important for prevention
Shehab et al.24 2013 GRACE 18 UAE hospitals; patients with ACS Prevalence of HF is higher in women than in men
Shah et al.30 2015 Cross-sectional Random sampling from health screening centre, Abu Dhabi Overall prevalence of BMI-derived obesity and overweight and ‘waist-to-hip-derived central obesity’ was calculated to be 44.7% in women and 66.7% in men. Hypertension was reported in 30.5% (419) of the sample and DM in 9.0% (9) of the subsample
Thalib et al.31 2016 Prospective multicentre study, GRACE Six Gulf countries (Bahrain, Saudi Arabia, Qatar, Oman, UAE and Yemen); 65 hospitals Results suggest that discrimination, goodness of fit and calibration were excellent. Post-discharge GRACE risk scores can be utilized for stratifying the 1-year mortality risk across the Arabian Gulf population; it does not need additional calibration and has great discriminatory aptitude

ACS, acute coronary syndrome; GRACE, Gulf Registry of Acute Coronary Events.

Risk factors of cardiovascular disease

All 21 studies present data on risk factors. Ten studies were cross-sectional,15,19,20,2430 one was a case–control study,23 two were literature reviews18,21 and three were population-based studies16,17,22 (Table 2). Five studies were multicentre studies;19,2629 seven were conducted in Al-Ain1518,20,24,25 and three were conducted in Abu Dhabi.21,22,30 CVD is largely caused by risk factors that can be modified, treated or controlled, for example obesity and overweight,15,22,30 high BP,15,16,2023,28,30 DM,1517,19,22,26,28 lack of physical activity21,22 and smoking.16,17,19,23,26

TABLE 2

Papers published between 2007 and 2016 on CVD risk factors in the UAE

Study Year Study design Study population Key findings
Baynouna et al.15 2008 Cross-sectional, community-based Al-Ain, UAE (February 2004 – February 2005) Risk factor prevalence rates: obesity, 37.3%; hypertension, 20.8%; DM, 23.3%; metabolic syndrome, 22.7%; Framingham risk assessment score > 20%, 28.4%; smoking, 19.6% in men. Abnormal lipid profile was observed in 53.9% of women and 64% of men, mainly owing to high triglyceride levels and low high-density lipoproteins
Abdulle et al.16 2008 Health survey stratified by self-reported hypertension Al-Ain, UAE; included 641 normotensive subjects of various ethnicities Smoking prevalence was similar in two groups (normotensives 14.2%, hypertensives 13.2%). Prevalence rates of obesity and overweight, dyslipidaemia and DM, and thus the 10-year Framingham risk assessment score, were significantly higher in hypertensives
Baynouna et al.17 2009 Community-based; conventional CVD risk factors Al-Ain, UAE; 817 national residents Smoking was associated with DM. Few metabolic syndrome adjustments were reduced, while numerous others remained
Binbrek et al.18 2010 Six-study meta-analysis Six studies conducted in the UAE (1995 – 2009); 1262 patients with MI Patients admitted and treated after acute ST-segment elevation MI onset at an early age; recanalization induced via thrombolysis was a useful therapeutic approach. Patients’ characteristics in the six studies were very similar
Yusufali et al.19 2010 Prospective registry Four tertiary care hospitals; three major UAE cities (December 2003 – December 2006) Prevalence rates: smoking, 46.4%; DM, 38.9%; inpatient mortality, 1.68%. In-hospital complications were not common
Shehab et al.20 2012 Prospective multinational multicentre registry, GRACE Patients with ACS Results indicate that HF is significantly linked with inpatient mortality. In multivariate logistic regression, DM, heart rate, hyperlipidaemia and age were associated with higher in-hospital HF
Almahmeed et al.21 2012 Literature review Patients with CHD Beta-blockers are effective, as are numerous other therapies; issues related to the use of beta-blockers in CVD and hypertension are overstated
Hajat et al.22 2012 Population-wide cardiovascular screening programme using self-reported indicators, blood tests and anthropometric measures Abu Dhabi, UAE; 138 adults aged ≥ 18 years ‘The mean age of the participants was 36.82 years (SD = 14.3); 43% were men. Risk factor prevalence rates were: obesity, 35%; overweight, 32%; central obesity, 55%; DM, 18%; preDM, 27%; dyslipidaemia, 44%; and hypertension, 23.1%. In addition, 26% of men were smokers, compared with 0.8% of women.’
Jamil et al.23 2013 Case–control study UAE government hospital (2011–2012); patients with MI ‘The relationship among variables were examined followed by recommendation, discussion, and analysis for the treatment and prevention of CAD in UAE. The findings demonstrated higher incidence of Type A personality in the MI group. Additionally, these individuals were much more likely to suffer from hypertension and a history smoking, when compared to controls.’
Shehab et al.24 2013 GRACE 18 UAE hospitals; patients with ACS Women were significantly older, suffered more often from cardiac risk factors and were treated with reperfusion and beta-blockers significantly less often. Prevalence of HF was higher in women than in men (24.6% vs. 12.5%; P < 0.001)
Sulaiman et al.25 2014 Prospective multinational multicentre registry, GRACE 47 hospitals in seven Gulf countries (Saudi Arabia, Oman, UAE, Yemen, Kuwait, Qatar and Bahrain) (14 February 2012 to 13 November 2012); 5005 patients > 18 years of age admitted with acute HF The majority of hospitals were community hospitals (46%, 22/47), including university (17%, 8/47) and non-university (32%, 15/47). The majority of hospitals had coronary and intensive care unit facilities (93%, 44/47) and 59% (28/47) had laboratory facilities for catheterization. Few hospitals (29%, 14/47) had clinical facilities for HF. The majority of patients were cared for by a cardiologist (71%)
Kumar et al.26 2014 Cross-sectional multicentre study 64 centres in the UAE, Kuwait and Qatar (October 2008 – December 2010); patients with asymptomatic peripheral arterial disease with prior cerebrovascular or coronary event Multivariate logistic model shows old age as a significant peripheral arterial disease predictor. DM (OR 1.49; 95% CI 1.14–1.94; P = 0.004); smoking (OR 1.70; 95% CI 1.22–2.37: P = 0.002); ethnicity (OR 0.39; 95% CI 0.19–0.79; P = 0.009); female (OR 1.56; 95% CI 1.06–2.29; P = 0.024); adjusted OR (OR 1.04; 95% CI 1.02–1.05; P < 0.001)
Saheb et al.27 2014 Prospective analysis Two UAE government hospitals (1 December 2011 to 30 November 2012); patients with decompensated HF Patients with HFPEF less likely to be prescribed medication for HF and utilized fewer antiplatelet medications and more anticoagulants
Yusufali et al.28 2015 Voluntary point-of-care CVDRF screening was conducted in follow-up for newly diagnosed DM, hypertension and dyslipidaemia Nine health care facilities, four shopping malls and three labour camps in five cities of the UAE At follow-up of those with CVDRF, positive lifestyle changes were reported in 60%, and 33% had consulted a doctor; of the latter, the following diagnoses were confirmed: DM, 63%; hypertension, 93%; dyslipidaemia, 87%. A new diagnosis of DM, hypertension or dyslipidaemia was uncovered in 61.5%, with the highest yield (74.0%) in labour camps
Ong et al.29 2015 Prospective international multicentre cohort study of out-of-hospital cardiac arrests January 2009 – December 2012 0.5–8.5%, survival to hospital discharge; 1.6%–3%, survival with good neurological function
Shah et al.30 2015 Cross-sectional Random sampling from health screening centre, Abu Dhabi Overall prevalence of BMI-derived obesity and overweight and ‘waist-to-hip-derived central obesity’ was calculated to be 44.7% in women and 66.7% in men. Hypertension was reported in 30.5% (419) of the sample and DM in 9.0% (9) of the subsample

CAD, coronary artery disease; CVDRF, cardiovascular disease risk factor; HFPEF, heart failure with preserved ejection fraction; MI, myocardial infarction; OR, odds ratio; SD, standard deviation.

The findings suggest that a high prevalence of overweight, in addition to obesity, further increases CVD risk. A population-wide study reported the following risk factor prevalence rates: obesity, 35%; central obesity, 55%; overweight, 32%; DM, 18%; preDM, 27%; dyslipidaemia, 44%; and hypertension, 23.1%.22 On the other hand, Baynouna et al.15 found that 37.3% were obese, and an abnormal lipid profile was found in 53.9% of women and 64.0% of men, largely owing to high triglyceride levels and low high-density lipoproteins. Hypertension is the most significant risk factor for premature CVD and is more common than other major risk factors such as DM, dyslipidaemia and smoking.15,16,2023,28,30 As evidenced by a Framingham heart study, stroke in women and coronary disease in men are the principal primary cardiovascular events subsequent to the onset of hypertension.6 The risk of both stroke and coronary disease rises gradually with incremental escalation in BP above 115/75 mmHg, as demonstrated in several epidemiological studies.23,30 Smoking is a major cause of heart disease and is thought to increase the risk of stroke: nicotine, the addictive component of tobacco, raises BP and increases heart rate. Furthermore, smoking is also associated with DM.17 The rate of smoking was found to be 46.4% and DM was present in 38.9% of the population.19

Discussion

The results demonstrate that CVD is a cause for great concern in the UAE. CVD prevalence is precipitated by risk factors such as DM, high cholesterol, obesity and BP, all of which may be controlled or prevented through the avoidance of smoking, regular exercise and healthy eating. The literature review concerned epidemiological studies on CVD prevalence and risk factors in the UAE that were published between 2007 and 2016. All 21 studies present data on risk factors and five studies present data on prevalence.

The literature revealed that CHD prevalence in Middle Eastern regions is high, with a high prevalence of CVD risk factors, particularly sedentary lifestyles, DM, dyslipidaemia, hypertension and smoking.21 A research study performed in Abu Dhabi within a mandatory residency visa health screening centre reported an overall hypertension prevalence of 30.5%,30 while another prospective multicentre multinational registry of individuals hospitalized with ACS reported HF in about one in five patients in the UAE. HF is often related to a substantial rise in other hospital mortality and adverse outcomes.20

In the UAE, a 3-year prospective registry of ACS patients found that patients were relatively young and had risk factors such as smoking and DM.19 On the other hand, a GRACE analysis from 18 hospitals in the UAE estimated adjusted mortality rates of 4.6% in women and 1.2% in men; also, HF was recognized to be more common in women than in men.24 In contrast, another GRACE study validated the utilization of the post-discharge GRACE risk score among Arabian Gulf patients and found that the score can be utilized for stratifying 1-year mortality risk across the population of the Arabian Gulf.31

In Al-Ain, a cross-sectional CVD risk assessment study15 demonstrated the need for targeted interventions. From the population screened, around 28.4% had a Framingham risk assessment score > 20%, 19.6% of men smoked, 22.7% had metabolic syndrome, 37.3% were obese, 20.8% had hypertension and 23.3% had DM. CHD was reported in 2.4%. In 53.9% of women and 64% of men, lipid profiles were abnormal, largely owing to high triglyceride levels and low high-density lipoproteins. Another study30 carried out in a mandatory residency visa health screening centre in Abu-Dhabi reported an overall prevalence of BMI-derived obesity and overweight and ‘waist-to-hip-derived central obesity’ of 44.7% in women and 66.7% in men. A health survey16 that elicited ‘self-reported hypertension’ reported that high-density lipoprotein-cholesterol, triglycerides, obesity/overweight, dyslipidaemia and DM prevalence, and thus 10-year Framingham risk scores, were considerably higher among hypertensive respondents than in normotensive respondents.

A prospective analysis27 of patients with decompensated HF at two government hospitals in the UAE found that the prevalence of respiratory diseases and AF among women and older patients was higher than in developed countries. In a community-based survey,17 DM, increased waist circumference and smoking were associated with hypertension. A case–control study23 involving 90 patients with myocardial infarction (MI) admitted to a government hospital in the UAE showed a higher rate of incidence of Type A personality in the MI group.

Four other studies on the management of CVD and the evaluation of public health programmes were identified. A meta-analysis18 was carried out of six studies conducted in the UAE (1995–2009) among individuals with ST-segment elevation MT who were treated with thrombolytic drugs < 6 hours after onset of MI. The mean age of the selected population was 47 years, and, overall, 9% had suffered MI, 20% were hyperlipidaemic, 25% were hypertensive, 28% had DM and 98% were men. Among young men in the UAE who were admitted shortly after MI onset, thrombolysis-induced recanalization was found to be an effective treatment strategy.

A population-wide cardiovascular screening programme22 in Abu Dhabi (with a smaller sample), entitled Weqaya, revealed a large CVD burden. A study25 conducted in 47 hospitals in seven Gulf states examined the suitability of facilities for the management of CVD. Most hospitals had coronary care and intensive unit facilities and the majority of the patients were cared for by a cardiologist. However, only 29% of facilities had a dedicated HF service. In a study28 conducted in four shopping malls, nine health care facilities and three labour camps across five cities in the UAE, voluntary point-of-care screening was performed involving participants newly diagnosed with DM, hypertension and dyslipidaemia. Positive lifestyle alterations were reported in 60%, but only 33% had consulted a health professional; of the latter, 63% were diagnosed with DM, 93% with hypertension and 87% with dyslipidaemia.

An international, multicentre and prospective cohort study29 of out-of-hospital cardiac arrests showed that rates of survival to hospital discharge vary widely and can be improved via interventions, for instance through improved emergency medical services, public access to defibrillators and bystander cardiopulmonary resuscitation (CPR). The large burden of CVD demonstrated in the review is consistent with findings from global reports conducted by WHO. According to the Global Health Observatory, the UAE has the second highest cardiovascular mortality rate, after Saudi Arabia, higher even than the rate found in Gulf Cooperation Council countries and high-income countries such as Germany, the USA and Sweden.3 The results are also consistent with a Ministry of Health and Prevention report published in 2015, which revealed that CVD is the leading cause of death in the UAE, responsible for 29.89% of all deaths.4

This study is the first of its kind investigating the prevalence and risk factors of CVD in the UAE. However, the study had some limitations: Arabic papers were not included; findings from cross-sectional studies do not necessarily indicate causality; and publication bias may have been a factor. Nevertheless, we attempted to minimize bias by searching local and governmental reports, and the full texts of articles were examined. This review should be a very useful resource document for public health professionals and researchers concerned with CVD prevention and control, and those who seek better understanding of the priorities for future research. Though no previous studies have been conducted at a national level, studies from numerous geographical regions of the UAE were included in this review. Local journals were reviewed to identify all studies related to the UAE. Cross-reference of all included evidence was carried out.

Conclusion

Although prevalence studies were relatively rare in comparison with risk factor studies, it is evident that the significant burden of CVD requires further research and improved intervention. CVD is the leading cause of death worldwide, and risk factors include elevated cholesterol levels, obesity, physical inactivity, high blood glucose, smoking and hypertension. Risk factor identification offers new opportunities to form effective strategies for treating and preventing CVD. Further evidence-based research is needed on the association between CVD and Type A personality. Our findings support the implementation of opportunistic screening for CVD during visits to health care professionals, increasing the likelihood of early identification and management, including lifestyle interventions. Urgent commitment to CVD prevention from health care professionals, policy-makers, government and other stakeholders, and the promotion of healthy lifestyles, is warranted.

Some of the included studies, while investigating preventative measures, revealed areas where further research is needed, for example where treatment is concerned, bystander CPR, public access to defibrillators and improved emergency medical services; and, where prevention is concerned, the quality of health care facilities for the management of CVD, and promising public health programmes such as Weqaya. At the level of the individual, positive changes to lifestyle and diet, including regular physical activity and healthy eating, can delay or prevent the onset of risk factors associated with CVD.

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