|Year : 2018 | Volume
| Issue : 3 | Page : 105-111
Prevalence and risk factors of cardiovascular disease in the United Arab Emirates
Hira Abdul Razzak, Alya Harbi, Wael Shelpai, Ahmad Qawas
Statistics and Research Center, Ministry of Health and Prevention, Dubai, United Arab Emirates
|Date of Web Publication||24-Sep-2018|
Hira Abdul Razzak
Statistics and Research Center, Ministry of Health and Prevention, Dubai
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Noncommunicable diseases are a cause of great concern in developing countries, particularly cardiovascular disease (CVD). CVD is most commonly attributable to risk factors such as obesity, high-blood pressure (BP), lack of physical activity and smoking. This study aims to summarize previous research on the prevalence and risk factors of CVD in the United Arab Emirates (UAE). Search engines and databases such as PubMed, Scopus and Science Direct, as well as several local journals, were utilised to identify relevant literature. Inclusion was limited to studies published between 2007 and 2016 in the English language and conducted with UAE participants (citizens and/or expatriates). Twenty-one relevant studies were found, including cross-sectional studies (n = 11), population-based studies (n = 3), literature reviews (n = 2) and a case–control study (n = 1). Estimates of the prevalence of CVD are considerably high, although there is insufficient information available on prevalence in the UAE as a whole. Primary determinants of CVD include obesity, smoking and diabetes mellitus. The prevalence of risk factors associated with CVD has increased in the UAE and will continue to increase, as made clear by the reviewed studies and as predicted by projections and future estimates. Some risk factors can be controlled, treated and prevented. Further attention should be given to developing preventative and curative strategies in order to reduce BP, increase physical activity, improve dietary habits and reduce smoking.
Keywords: Cardiovascular diseases, prevalence, risk factors, United Arab Emirates
|How to cite this article:|
Razzak HA, Harbi A, Shelpai W, Qawas A. Prevalence and risk factors of cardiovascular disease in the United Arab Emirates. Hamdan Med J 2018;11:105-11
| Introduction|| |
Cardiovascular disease (CVD) and the associated burden are increasing in developing countries and represent a key challenge in health care. The World Health Organisation (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-income and middle-income countries. Globally, 85% of disability is attributable to CVD. 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.
A Ministry of Health and Prevention report  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. The WHO has reported  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 study  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. and Hense et al., both prevalence and prognosis are important in the development of risk prediction scores for CHD. Yusuf et al. and Rosengren et al. 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 worldwide. Teo et al. and Yusuf et al. 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 CVD) project , 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 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 (MI); 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 standardised 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 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|
Click here to view
| 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 studies ,,,,,,,,,,,,,,, reported on CVD risk factors and five studies ,,,, 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, two were multicentre studies , and two were conducted in Abu Dhabi., All were cross-sectional with the exception of one review  [Table 1]. Two studies , focussed on HF and revealed 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 in-patient HF; the second reported that the prevalence of HF was higher in women than in men. Almahmeed et al. focussed on the lack of detailed, nationally representative epidemiological data and the need for registry development to reveal the nature of the coronary disease. Shah et al. 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 study 31 offered detailed information on post-discharge GRACE (Gulf Registry of Acute Coronary Events) risk scores in patients from the Arabian Gulf with the acute coronary syndrome (ACS). The results revealed 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 the great discriminatory aptitude.
|Table 1: Papers published between 2007 and 2016 on the prevalence of cardiovascular disease in the United Arab Emirates|
Click here to view
Risk factors of cardiovascular disease
All 21 studies present data on risk factors. Ten studies were cross-sectional,,,,,,,,,, one was a case–control study, two were literature reviews , and three were population-based studies ,, [Table 2]. Five studies were multicentre studies;,,,, seven were conducted in Al-Ain ,,,,,, and three were conducted in Abu Dhabi.,, CVD is largely caused by risk factors that can be modified, treated or controlled, for example, obesity and overweight,,, high BP,,,,,,,, DM,,,,,,, lack of physical activity , and smoking.,,,,
|Table 2: Papers published between 2007 and 2016 on cardiovascular disease risk factors in the United Arab Emirates|
Click here to view
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. 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.,,,,,,, As evidenced by a Framingham heart study, stroke in women and coronary disease in men are the principal primary cardiovascular events after the onset of hypertension. The risk of both stroke and coronary disease rises gradually with the incremental escalation in BP above 115/75 mmHg, as revealed 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. The rate of smoking was found to be 46.4% and DM was present in 38.9% of the population.
| Discussion|| |
The results reveal 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. A research study performed in Abu Dhabi within a mandatory residency visa health screening centre reported an overall hypertension prevalence of 30.5%, while another prospective multicentre multinational registry of individuals hospitalised 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.
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. 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 recognised to be more common in women than in men. In contrast, another GRACE study validated the utilisation of the post-discharge GRACE risk score among Arabian Gulf patients and found that the score can be utilised for stratifying 1-year mortality risk across the population of the Arabian Gulf.
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 study  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 survey  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 analysis  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, DM, increased waist circumference and smoking were associated with hypertension. A case–control study  involving 90 patients with 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-analysis  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 h 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 recanalisation was found to be an effective treatment strategy.
A population-wide cardiovascular screening programme  in Abu Dhabi (with a smaller sample), entitled Weqaya, revealed a large CVD burden. A study  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 study  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 study  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 revealed in the review is consistent with findings from global reports conducted by the 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.
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 minimise 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 a better understanding of the priorities for future research. Although 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 healthcare 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 healthcare 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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hussain SM, Oldenburg B, Wang Y, Zoungas S, Tonkin AM. Assessment of cardiovascular disease risk in South Asian populations. Int J Vasc Med 2013;2013:786801.
Ministry of Health and Prevention. United Arab Emirates; 2015 Report.
Fox CS, Sullivan L, D'Agostino RB Sr., Wilson PW; Framingham Heart Study. The significant effect of diabetes duration on coronary heart disease mortality: The Framingham Heart Study. Diabetes Care 2004;27:704-8.
Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular münster (PROCAM) study. Circulation 2002;105:310-5.
Hense HW, Schulte H, Löwel H, Assmann G, Keil U. Framingham risk function overestimates risk of coronary heart disease in men and women from Germany – Results from the MONICA Augsburg and the PROCAM cohorts. Eur Heart J 2003;24:937-45.
Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:937-52.
Rosengren A, Hawken S, Ounpuu S, Sliwa K, Zubaid M, Almahmeed WA, et al.
Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:953-62.
Teo K, Lear S, Islam S, Mony P, Dehghan M, Li W, et al.
Prevalence of a healthy lifestyle among individuals with cardiovascular disease in high-, middle- and low-income countries: The prospective urban rural epidemiology (PURE) study. JAMA 2013;309:1613-21.
Yusuf S, Islam S, Chow CK, Rangarajan S, Dagenais G, Diaz R, et al.
Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE study): A prospective epidemiological survey. Lancet 2011;378:1231-43.
Evans A, Tolonen H, Hense HW, Ferrario M, Sans S, Kuulasmaa K, et al.
Trends in coronary risk factors in the WHO MONICA project. Int J Epidemiol 2001;30 Suppl 1:S35-40.
Luepker RV. WHO MONICA project: What have we learned and where to go from here. Public Health Rev 2017;33:373.
Baynouna LM, Revel AD, Nagelkerke NJ, Jaber TM, Omar AO, Ahmed NM, et al.
High prevalence of the cardiovascular risk factors in Al-Ain, United Arab Emirates. An emerging health care priority. Saudi Med J 2008;29:1173-8.
Abdulle AM, Nagelkerke NJ, Abouchacra S, Obineche EN. Potential benefits of controlling coronary heart disease risk factors in the United Arab Emirates. Kidney Blood Press Res 2008;31:185-8.
Baynouna LM, Revel AD, Nagelkerke NJ, Jaber TM, Omar AO, Ahmed NM, et al.
Associations of cardiovascular risk factors in al ain, United Arab Emirates. Cardiovasc Diabetol 2009;8:21.
Binbrek AS, Rao NS, Van de Werf F, Sobel BE. Meta-analysis of studies of patients in the United Arab Emirates with ST-elevation myocardial infarction treated with thrombolytic agents. Am J Cardiol 2010;106:1692-5.
Yusufali AM, AlMahmeed W, Tabatabai S, Rao K, Binbrek A. Acute coronary syndrome registry from four large centres in United Arab Emirates (UAE-ACS registry). Heart Asia 2010;2:118-21.
Shehab A, Al-Dabbagh B, Almahmeed W, Bustani N, Nagelkerke N, Yusufali A, et al.
Characteristics and in-hospital outcomes of patients with acute coronary syndromes and heart failure in the United Arab Emirates. BMC Res Notes 2012;5:534.
Almahmeed W, Arnaout MS, Chettaoui R, Ibrahim M, Kurdi MI, Taher MA, et al.
Coronary artery disease in Africa and the middle east. Ther Clin Risk Manag 2012;8:65-72.
Hajat C, Harrison O, Al Siksek Z. Weqaya: A population-wide cardiovascular screening program in Abu Dhabi, United Arab Emirates. Am J Public Health 2012;102:909-14.
Jamil G, Haque A, Namawar A, Jamil M. Personality traits and heart disease in the middle east. Is there a link? Am J Cardiovasc Dis 2013;3:163-9.
Shehab A, Yasin J, Hashim MJ, Al-Dabbagh B, Mahmeed WA, Bustani N, et al.
Gender differences in acute coronary syndrome in Arab Emirati women – Implications for clinical management. Angiology 2013;64:9-14.
Sulaiman KJ, Panduranga P, Al-Zakwani I, Alsheikh-Ali A, Al-Habib K, Al-Suwaidi J, et al.
Rationale, design, methodology and hospital characteristics of the first gulf acute heart failure registry (Gulf CARE). Heart Views 2014;15:6-12.
] [Full text]
Kumar A, Al-Bader M, Al-Thani H, El-Menyar A, Al Suwaidi J, Al-Zakwani I, et al.
Multicenter cross-sectional study of asymptomatic peripheral arterial disease among patients with a single previous coronary or cerebrovascular event in the Arabian gulf. Curr Med Res Opin 2014;30:1725-32.
Saheb Sharif-Askari N, Sulaiman SA, Saheb Sharif-Askari F, Al Sayed Hussain A, Tabatabai S, Al-Mulla AA, et al.
Hospitalized heart failure patients with preserved vs. reduced ejection fraction in Dubai, United Arab Emirates: A prospective study. Eur J Heart Fail 2014;16:454-60.
Yusufali A, Bazargani N, Muhammed K, Gabroun A, AlMazrooei A, Agrawal A, et al.
Opportunistic screening for CVD risk factors: The Dubai shopping for cardiovascular risk study (DISCOVERY). Glob Heart 2015;10:265-72.
Ong ME, Shin SD, De Souza NN, Tanaka H, Nishiuchi T, Song KJ, et al.
Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The pan Asian resuscitation outcomes study (PAROS). Resuscitation 2015;96:100-8.
Shah SM, Loney T, Dhaheri SA, Vatanparast H, Elbarazi I, Agarwal M, et al.
Association between acculturation, obesity and cardiovascular risk factors among male South Asian migrants in the United Arab Emirates – a cross-sectional study. BMC Public Health 2015;15:204.
Thalib L, Furuya-Kanamori L, AlHabib KF, Alfaleh HF, AlShamiri MQ, Amin H, et al.
Validation of the 6-month GRACE score in predicting 1-year mortality of patients with acute coronary syndrome admitted to the Arabian gulf hospitals. Angiology 2016;68:251-6.
[Table 1], [Table 2]