The influence of gender and place of residence on cardiovascular diseases and their risk factors. The Isfahan cohort study.

OBJECTIVE: To determine the impact of gender and place of residence on cardiovascular disease (CVD) events and related risk factors. METHODS: In a prospective cohort study, 6323 participants free of CVD (3255 women), with age of more than 35 years from 3 cities (Isfahan, Najafabad, and Arak) and their rural districts in central Iran were followed-up from 2001 to 2007. This study was carried out at the Cardiovascular Research Institute of Isfahan University of Medical Sciences, Isfahan, Iran. Endpoints were defined as fatal- and nonfatal myocardial infarction, sudden cardiac death, unstable angina and stroke that constituted CVD events. RESULTS: Subjects in the rural area had significantly better risk factor profile in terms of most CVD risk factors in both genders, but it was reverse for low density lipoprotein (LDL)-cholesterol in both genders, and smoking in men. Except for smoking, men had an overall better risk factor profile compared to women. The age and risk factors adjusted hazard ratio of living in rural area was 0.71 (95% confidence interval [CI]: 0.51-0.99) for men, and 0.63 (95% CI: 0.44-0.91) for women. The age of CVD occurrence was similar in men and women, and in rural and urban areas. Hypertension was the strongest predictor of these events except for rural men showing that high LDL-cholesterol was the strongest risk factor. CONCLUSION: The findings in this study documented differences in CVD risk factors affecting the occurrence of CVD events according to gender and place of residence. Such differences should be taken into account in future preventive public health strategies for CVD prevention.

Do Intervention Strategies of Women Healthy Heart Project (WHHP) Impact on Differently on Working and Housewives?

BACKGROUND: The purpose of this study is to evaluate the possible difference of the impact of Women Healthy Heart Project on lifestyle, as well as physical/biochemical parameters of working women and housewives. METHODS: This was a community-based intervention study conducted over 5 years (2002-2007) in the counties of Isfahan and Najafabad (intervention areas) and Arak (control). Pre-study situation analysis of women was followed by 5 years of wide-ranging interventions (educational/environmental) conducted by various organizations using different methodologies. The interventions were aimed at modifying/improving lifestyle by increasing physical activity, encouraging healthy eating, and tobacco use cessation. The organizations involved in performing the interventions included the local radio and television authority, health/treatment centers, the Red Crescent Society, Municipalities, the Relief Committee, the Center for Retirees' Welfare, and the Literacy Campaign Organization. After 5 years, final phase same as first phase was planed. The subjects studied in all phases' the pre- and post-intervention phases consisted of 10586 women aged above 18 years. Demographic data, obesity index, smoking, physical activity and eating habit were assessed before and after the study. Data were analyzed using SPSS-15 using Student's t-test, chi-square test, the general linear model of ANOVA, and logistic regression. RESULTS: We studied 10586 women (6105 and 4481 women, pre- and post-intervention, respectively). Mean age of working women was 34.14±10.09 and 34.08±9.35 years before and after the study, respectively. Mean age of housewives before and after the study was 40.05±14.61 and 40.36±15.32 years, respectively. Interventions conducted during 5 years improved eating habits and decreased tobacco use in working women and housewives. In every phase of the study, there was a significant age difference between housewives and working women (P<0.001). Hence data were adjusted according to age in each phase. Overall physical activity of housewives and working women increased, but the percentage of passive smokers among housewives remained unchanged. Waist circumference and waist-to-hip ratio changed significantly in housewives following interventions (P<0.001). The parameter which improved significantly in working women was waist circumference (P<0.05). However, after adjusting for age, no significant difference was seen between working women and housewives following interventions. CONCLUSION: Community-based interventions, especially those directed at housewives, can lead to significant improvements in lifestyle and cardiovascular risk reduction. It seems that working women require tailored interventions to suit their conditions. Although short-term outcomes may seem insignificant, persistence and continuity of lifestyle changes may lead to reduced prevalence of cardiovascular diseases. Then longer-term studies are warranted.

Stress level and smoking status in central iran: isfahan healthy heart program.

BACKGROUND: Individuals are faced with numerous stressful life events which can negatively influence mental health. Many individuals use smoking as a means of confronting stress. Given the relatively high prevalence of smoking in central Iran, the present study was conducted to compare stress levels in smokers, non-smokers and those who had quit smoking. METHODS: This study was conducted as part of Isfahan Cardiovascular Research Program on 9752 individuals in the cities of Isfahan, Arak, and Najafabad in 2008. Sampling was performed using multi-stage cluster randomization method. Data on age, sex, demographic characteristics, and smoking status was collected through interviews. Stress level detected by General Health questionnaire.Logistic regression and chi- squere test was used for data analyzing. RESULTS: In the present study, 30% of non-smokers, 32.1% ex- smoker and 36.9% of smokers had GHQ of 4 and higher (P=0.01). In regression analysis, the final model which was controlled for age, sex, socioeconomic statues (including place of residence, marital status and education level) showed that the odds ratio of stress in smokers and ex- smoker was significantly higher than in non-smokers (OR=1.66 and OR=1.12, respectively). CONCLUSION: Since in conducted studies, mental problems and stresses have had an important role in people's smoking, it seems suitable to use the results of this study to present intervention for correct methods of coping with stress towards reducing the prevalence of smoking in the community.

Estimation of left ventricular end diastolic pressure (lvedp) in patients with ischemic heart disease by echocardiography and compare it with the results of cardiac catheterization.

BACKGROUND: Doppler echocardiography has been proposed as an appropriate non-invasive assay to estimate left ventricular end diastolic pressure (LVEDP). The aim of present research was to estimate the LVEDP in patients with ischemic heart disease by echocardiography and compare it with the results of cardiac catheterisation and to determine the effect of different echocardiographic variables on its measurement. METHODS: In this descriptive-analytic study, patients with diagnosed ischemic heart disease were selected by nonrandomized sampling method. Selected population underwent M-mode and pulse doppler echocardiographic evaluation and parameters such as Q-Mitral valve E (Q-MVE), Q-Aortic valve closure (Q-AVC), Aortic valve closure-E (AVC-E), Q-Mitral valve closure/Aortic valve closure-E (Q-MVC/AVC-E), left ventricle-deceleration time (LV-DT), peak velocity-deceleration time (PV-DT) and A/E velocity time integral (A/E VTI) were evaluated. Immediately after echocardiography all patients underwent left heart catheterization for LVEDP measurement. The relation between different echocardiographic measurements and LVEDP, obtained by cardiac catheterization, was evaluated. RESULTS: In this study, 47 patients with ischemic heart disease with mean age (±SD) of 53±13 were studied. There was a significant correlation between LVDEP and A/E VTI (r=0.44, P=0.001, and also between LVEDP and PV-DT in patients with A/E VTI ≥1.1(r=-0.58, P=0.02). There was a significant correlation between LVEDP and Q-MVC/AVC-E in patients with LVEDP >18mmHg (r=0.76, P=0.03) and those with LVEDP ≤18 mmHg and A/E VTI <1.1 (r=0.37, P=0.03). The correlation between LVEDP and A/E VTI was more significant in men, in patients aged >50 years with EF >55%, without LVH, without MR and those with coronary artery disease (P<0.05). CONCLUSION: Some echocardiographic indices such as A/E VTI, Q-MVC/AVC-E and PV-DT are able to measure LVEDP especially in male patients aged >50 years, without LVH, without MR and those with coronary artery disease but it is necessary to determine specific conditions and factors affecting these indices, by further studies.

Percutaneous transvenous mitral commissurotomy in a patient with situs inversus and dextrocardia: a case report.

BACKGROUND: Dextrocardia situs inversus refers to the heart being a mirror image situated on the right side of the body. Distorted cardiac anatomy provides technical difficulties during fluoroscopy-guided transcatheter procedures. This is even more difficult in the case with percutaneous transvenous mitral commissurotomy (PTMC). Mitral valvuloplasty is a minimally invasive therapeutic procedure to correct an uncomplicated mitral stenosis by dilating the valve using a balloon. Here, we describe a case of a 25 years-old male with situs inversus and dextrocardia. CASE REPORT: A 25 years-old man, having situs inversus and suffering from mitral stenosis was referred to hospital for PTMC. His initial examination findings were unremarkable and an electrocardiographic (ECG), trans-esophageal and transthoracic echocardiographic evaluation were performed. Mitral valve (MV) was dome shape and severely stenotic with mild mitral regurgitation (MR). Left ventricularejection Fraction (LVEF) was about 40%, Femoral arterial and venous punctures were made on the left side; the left femoral artery and vein were cannulated with a 5F arterial and 6F venous sheaths, respectively. Then special maneuvers were done to solve the mitral valve stenosis. At the end of the procedure, no MR was documented by checking LV angiogram and there were no signs of mitral stenosis (MS). CONCLUSION: Mirror-image dextrocardia, as in our case, has been estimated to occur with a prevalence of 1:10,000. However, there are only a few case reports in the literature on PTMC in similar settings. This might be due to the fact that many of these patients undergo surgical commissurotomy due to the technical difficulties involved in a percutaneous procedure in general. Trans-septal catheterization is considered a technical challenge in anatomically malpositioned hearts, as it is fraught with a higher risk of cardiac perforation. Despite the challenging anatomy, PTMC has been demonstrated to be a safe and feasible option for MS in patients with unusual cardiac anatomy.

Comparing Diagnostic Techniques of Magnetic Resonance Angiography (MRA) and Doppler Ultrasonography in Determining Severity of Renal Artery Stenosis.

BACKGROUND: Renal artery stenosis is one of the important causes of hypertension and end stage renal failure. Magnetic resonance angiography (MRA) and Doppler ultrasonography are non-invasive and safe diagnostic techniques that have also high sensitivity and specificity. Since the accuracy and reliability of these techniques depend upon technicians and softwares, we decided to evaluate and compare the sensitivity and specificity of these techniques in Isfahan. METHODS: Our study included all the patients (37 patients) who underwent renal artery angiography during 2 years from May 2003 to May 2005 and up to six months after that had underwent MRA (21 patients) and Doppler sonography (16 patients) in Isfahan. Renal artery angiography was considered as the gold standard. RESULTS: Sensitivity, specificity, positive and negative predictive values of 100%, 25%, 25%, and 100% were obtained for MRA respectively. Specificity and positive predictive values (PPV) of Doppler sonography were 67%. Its sensitivity and negative predictive values (NPV) were 57%. CONCLUSION: Although it seems that technician dependency, technical and software problems were the reasons of low specificity of gadolinium-enhanced MRA in our study, further studies with larger sample sizes are recommended.

The Relation Between Ankle-Brachial Index (ABI) and Coronary Artery Disease Severity and Risk Factors: An Angiographic Study.

BACKGROUND: The current study aims to determine the relation between ankle-brachial index (ABI) and angiographic findings and major cardiovascular risk factors in patients with suspected coronary artery diseases (CAD) in Isfahan. METHODS: In this cross-sectional descriptive-analytic research, patients with suspected CAD were studied. Characteristics of studied subjects including demographics, familial history, past medical history and atherosclerotic risk factors such as diabetes mellitus, hypertension, hyperlipidemia and smoking were obtained using a standard questionnaire. ABI was measured in all studied patients. ABI≤0.9 (ABI(+)) was considered as peripheral vessel disease and ABI>0.9 (ABI(-)) was considered as normal. Then, all studied patients underwent coronary artery angiography. The results of the questionnaire and angiographic findings were compared in ABI(+) and ABI(-) groups. Data were analyzed by SPSS 15 using ANOVA, t-test, Spearman's rank correlation coefficient, and discriminant analysis. RESULTS: In this study, 125 patients were investigated. ABI≤0.9 was seen in 25 patients (20%). The prevalence of ABI(+) among men and women was 25.9% and 7.5%, respectively (P=0.01). The prevalence of atherosclerotic risk factors was significantly higher in ABI(+) patients than in ABI(-) ones (P<0.05). ABI(+) patients had more significant stenosis than ABI(-) ones. The mean of occlusion was significantly higher in ABI(+) patients with left main artery (LMA), right coronary artery (RCA), left anterior descending artery (LAD), diagonal artery 1 (D1) and left circumflex artery (LCX) involvements (P<0.05). CONCLUSION: The findings of this research indicated that ABI could be a useful method in assessing both the atherosclerotic risk factors and the degree of coronary involvements in suspected patients. However, in order to make more accurate decisions for using this method in diagnosing and preventing CAD, we should plan further studies in large sample sizes of general population.

The impact of obesity on hypertension and diabetes control following healthy Lifestyle Intervention Program in a developing country setting.

BACKGROUND: The aim of this study was to evaluate the impact of obesity and overweight on diabetes mellitus (DM) and hypertension (HTN) control in a healthy lifestyle intervention program in Iran. METHODS: Within the framework of the Isfahan Healthy Heart Program (IHHP), a community trial that was conducted to prevent and control cardiovascular disease and its risk factors, two intervention counties (Isfahan and Najafabad) and one reference county (Arak) were selected. Demographic information, medical history, anti-diabetic and anti-hypertensive medications use were asked by trained interviewers in addition to physical examination and laboratory tests for 12514 adults aged more than 19 years in 2001 and were repeated for 9572 adults in 2007. RESULTS: In women, the frequency of HTN control change significantly neither in normal weight nor in those with high body mass index (BMI), waist circumference (WC) or waist to hip ratio (WHR). In men, the frequency of HTN control was only significant among those with high WHR, whereas the interaction between changes in intervention compared to reference area from 2001 to 2007 was significant in men with normal or high WC or WHR. In intervention area, the number of women with high BMI who controlled their DM increased significantly from 2001 to 2007 (p = 0.008), however, this figure decreased in men. In reference area, obesity indices had no significant association with DM control. The percentage of diabetic subjects with high WC who controlled their DM decreased non-significantly in intervention area compared to reference area in 2007. A non-significant increase in controlled DM among men and women with high WHR was observed between intervention and reference areas. CONCLUSIONS: Our lifestyle interventions did not show any improving effect on HTN or DM control among obese subjects based on different obesity indices. Other lifestyle intervention strategies are suggested.

The impact of a 6-year comprehensive community trial on the awareness, treatment and control rates of hypertension in Iran: experiences from the Isfahan healthy heart program.

OBJECTIVES: We aimed to evaluate the changes over time in the prevalence, awareness, treatment, and control rate of hypertension in intervention and reference areas of a comprehensive community trial with reference area. METHODS: Data from independent sample surveys before and after implementation of the program (2001 vs.2007) were used to compare differences in the intervention and references areas over time. Hypertension was defined as blood pressure ≥140/90 mmHg in non-diabetic patients and ≥130/80 mmHg in diabetic individuals and or taking antihypertensive medications. Interventional activities included educational strategies at population level as well as for hypertensive patients, their families and health professionals. RESULTS: The study population of the baseline survey included 6175 (48.7% males) in the interventional area and 6339 (51.3% male) in the reference area. The corresponding figures in the post-intervention phase was 4717 (49.3% male) in the interventional area and 4853 (50.7% male) individuals in the reference area. The prevalence of hypertension had a non-significant decrease from 20.5%to 19.6%, in the interventional area whereas in the reference area, it increased from 17.4% to 19.6% (P = 0.003). If we consider Bp ≥ 140/90 in diabetic and non-diabetic patients as hypertension definition, the prevalence of hypertension in the interventional areas had a non-significant decrease from 18.9% in 2001 to 17.8% in 2007, whereas in the reference area, it had a significant rise from 15.7% to 17.9% (P = 0.002) respectively. Awareness, treatment and control rates of hypertension had better improvement in urban and rural part of the interventional area compared to reference area. The awareness, treatment, and control rates of hypertension increased significantly in the age groups of more than 40 years, as well as in all groups of body mass index in interventional areas without significant change in the reference area. Mean systolic blood pressure of study population in the interventional area decreased from 116.13 ±19.37 to 112.92 ± 18.27 mmHg (P < 0.001) without significant change in reference area. CONCLUSIONS: This comprehensive and integrated program of interventions was effective in tackling with the prevalence of hypertension, and may improve the awareness, treatment and control rates of this disorder in a developing country setting.

Multiparity and risk of metabolic syndrome: Isfahan Healthy Heart Program.

INTRODUCTION: More than one third of Iranian adult women have the metabolic syndrome. We conducted this study to assess the effect of parity on the prevalence of metabolic syndrome in analyses controlling for sociodemographic and reproductive variables as well as behavioral risk factors. METHODS: We evaluated the relationship between number of children and metabolic syndrome in 6331 adult nonpregnant women >20 years of age. The data source for this study was Isfahan Healthy Heart Program (IHHP). Metabolic syndrome was defined according to Adult Treatment Panel III (ATP III). RESULTS: Overall, 34.2% of women met the criteria for metabolic syndrome. The number of children borne in women with metabolic syndrome was significantly higher than others (5.2 +/- 3.1 vs. 3.5 +/- 2.6; p < 0.0001). In logistic regression analyses, the odds of metabolic syndrome increased 24% (95% confidence interval [CI], 22-26%) with each additional child, but after adjustment for sociodemographic, reproductive, and behavioral characteristics, the odds of metabolic syndrome was attenuated (odds ratio [OR], 1.03; 95% CI, 1.00-1.06). Further adjustment for body mass index (BMI) yielded similar results (OR, 1.02; 95% CI, 0.98-1.05). CONCLUSION: A combination of lifestyle risk factors and/or biological changes associated with childbearing may explain the positive association between parity and increased risk of metabolic syndrome.

Changes in lipid profile of patients referred to a cardiac rehabilitation program.

BACKGROUND: Cardiac rehabilitation program (CRP) has been demonstrated to have beneficial effects on physical and mental functioning as well as on mortality of patients with cardiovascular diseases, but its exact effect on lipid profile of these patients is still vague. In this study we aimed to evaluate the effect of comprehensive CRP on lipid profile of the Iranian population. DESIGN: Self-controlled descriptive study. METHODS: We evaluated 547 patients with documented coronary heart disease before and after a 24-session CRP between 1998 and 2003. Some of them received antilipid drugs. RESULTS: Except for diastolic blood pressure, all other biophysical, biochemical [total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride (TG)], functional, and psychosocial parameters had significant response to CRP. We can attribute the normalization of lipid in these patients to CRP in combination with medications 34.9% for TC, 17.7% for LDL, and 27.2% for TG (P<0.001 for all). Antilipid drugs had some more effect in normalizing the TC (9.7%), LDL (1.8%), and TG (7.3%). CONCLUSION: Comprehensive CRP improves TC, TG, LDL, and HDL in Iranian patients with cardiovascular disease even without antilipid drugs, and antilipid therapy can boost this effect.

Coronary heart disease in type 2 diabetes mellitus in Isfahan, Iran: prevalence and risk factors.

OBJECTIVE: To estimate the prevalence and risk factors of CHD in people with type 2 diabetes mellitus. METHODS AND RESULTS: A cross-sectional study of type 2 diabetic patients was conducted from 2001 to 2004. 1566 consecutive diabetic patients (524 men and 1042 women) from the Isfahan Endocrinology and Metabolism Research Centre outpatient clinics, Iran, have been examined. Part of the examination included an assessment of CHD including 12-lead resting electrocardiogram and a positive response to the angina pectoris section on the Rose questionnaire and self-reported medical history. The mean (SD) age of participants was 50.6 (12.3) years with a mean (SD) duration of diabetes of 7.6 (6.9) years. The prevalence of CHD was 28.0% [95% confidence interval (CI) 25.8, 30.2]. The prevalence of CHD increased with age (P < 0.001). It was associated with gender (P < 0.01), age at diagnosis of diabetes, duration of diabetes, systolic blood pressure (P < 0.001), low density lipoprotein cholesterol, body mass index and smoking (P < 0.05). The age- and gender-adjusted prevalence rate of CHD was 45% higher among insulin-treated patients, 49% higher among patients with BMI >30, and it was positively associated with increasing triglyceride levels and duration of diabetes. Using a stepwise binary logistic regression model, age, BMI, smoking, and insulin treatment were significant independent predictors of CHD. Gender, duration of diabetes, cholesterol and triglycerides had no significant independent association with CHD when other covariates were considered. CONCLUSION: These findings indicate that there is a high prevalence of CHD among the Iranian type 2 diabetic patients, which underlines the need for more programmes of health promotion and lifestyle changes.

Isfahan Healthy Heart Programme: a comprehensive integrated community-based programme for cardiovascular disease prevention and control. Design, methods and initial experience.

The Isfahan Healthy Heart Programme (IHHP) is a five to six year comprehensive integrated community-based programme for cardiovascular diseases (CVD) prevention and control via reducing CVD risk factors and improvement of cardiovascular healthy behaviour in a target population. IHHP started late in 1999 and will be finished in 2005-2006. A primary survey was done to collect baseline data from interventional (Isfahan and Najaf-Abad) and reference (Arak) communities. In a two-stage sampling method, we randomly selected 5 to 10 percent of households from randomly selected clusters. Then individuals aged > or = 19 years were selected for the survey. This way, data from 12,600 individuals (6300 in interventional counties and 6300 in the reference county) was collected and stratified according to living area (urban vs. rural) and different age and sex groups. The samples underwent a 30-minute interview to complete validated questionnaires containing questions on demography, socioeconomic status, smoking behaviour, physical activity, nutritional habits and other behaviour regarding CVD. Blood pressure and body mass index (BMI) measurements were done and fasting blood samples were taken for two hours post load plasma glucose (2 hpp), serum (total, HDL and LDL) cholesterol and triglyceride levels. A twelve-lead electrocardiogram was recorded in all persons above 35 years of age. Community-wide surveillance of deaths, hospital discharges, myocardial infarction and stroke registry was carried out in the intervention and control areas. Four to five years of interventions based on different categories such as mass media, community partnerships, health system involvement and policy and legislation have started in the intervention area while Arak will be followed without intervention. Considering the results of the baseline surveys, (assessments needed, the objectives, existing resources and the possibility of national implementation) the interventions were planned. They were set based on specific target groups like school children, women, work-site, health personnel, high-risk persons, and community leaders were actively engaged as decision makers. A series of teams was arranged for planning and implementation of the intervention strategies. Monitoring will be done on small samples to assess the effect of different interventions in the intervention area. While four periodic surveys will be conducted on independent samples to assess health behaviours related to CVD risk factors in the intervention and reference areas, the original pre-intervention subjects aged more than 35 years will be followed in both areas to assess the individual effect of interventions and outcomes like sudden death, fatal and nonfatal MI and stroke. The whole baseline survey will be repeated on the original and an independent sample in both communities at the end of the study.