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Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 116-121

Assessing a change for acute myocardial infraction and its risk factors in a rural cohort of northern state of India

1 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
2 Department of Biochemistry, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
3 Department of Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Web Publication12-Sep-2017

Correspondence Address:
D Kumar
Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra - 176 001, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_21_17

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Background: Rising trend of cardiovascular diseases (CVDs) and associated factors has already substantiated across various population settings. The present study aims to study the degree of change Framingham risk score in a recruited cohort of a rural population in a hilly Northern state of India.
Materials and Methods: A prospective cohort study was done where 607 (171 migrated; 19 died) individuals were recruited in the year 2010, and follow-up assessment was done in the year 2015 for change in body mass index, hypertension (HTN), lipid profile, blood sugar, Framingham risk score, and acute myocardial infarction (AMI).
Results: Individuals with high systolic blood pressure increased from 32.7% to 47.4%, but a significant decline was found for diastolic HTN (45.3%–34.1%). Obesity increased from 12.7% to 23.7% (P = 0.000). Mean levels of total cholesterol (199.7–187.4 mg/dl) and triglyceride (211.7–153.7 mg/dl) decreased significantly, but decline was not significant for mean low-density lipoprotein. Framingham 10-year risk assessment showed a significant increase (62.0%–73.0%) in individuals with lowest risk score (<1%) and none of individual was observed with high score (>30.0%) neither at the time of recruitment nor at follow-up. Electrocardiography assessment based on rose screening questionnaire observed no signs suggestive of AMI.
Conclusion: Recruited cohort observed a slow rise in the development of known risk factor for CVDs such as obesity, systolic HTN, and blood sugar, but without overt manifestations of AMI warranting surveillance for risk factors for CVDs.

Keywords: Cohort, Framingham risk, rural

How to cite this article:
Kumar D, Sharma S B, Bhardwaj A K, Raina S K, Raina S. Assessing a change for acute myocardial infraction and its risk factors in a rural cohort of northern state of India. Heart India 2017;5:116-21

How to cite this URL:
Kumar D, Sharma S B, Bhardwaj A K, Raina S K, Raina S. Assessing a change for acute myocardial infraction and its risk factors in a rural cohort of northern state of India. Heart India [serial online] 2017 [cited 2020 May 28];5:116-21. Available from: http://www.heartindia.net/text.asp?2017/5/3/116/214425

  Introduction Top

World has observed a changing pattern in mortality as cardiovascular diseases (CVDs) become a leading cause for mortality.[1],[2],[3] About two-third of CVDs are due to ischemic heart diseases (IHDs) largely apportioning deaths of low- and middle-income countries of South Asia.[4] For quite a long period of time, it was considered as a public health problem for urban areas and hypothesized to be associated with a different lifestyle. Urbanization and exposure to urban environment such as proportion of time spent in cities have associated with unhealthy lifestyle and chronic diseases.[5],[6] Literature supports that an upsurge of CVDs associated with and attributed to change in lifestyle such as dietary behavior, physical inactivity, alcohol, and tobacco use of individuals.[7],[8],[9] Such changes have directly influenced the appearance of immediate risk factors such as hypertension (HTN) and diabetes mellitus (DM) for CVDs.[4] Urban areas such as metropolitan and large cities of India have observed rising trends for diabetes and HTN which has influenced mortality due to CVDs, mostly IHDs.[4],[10],[11],[12] In addition, in rural areas of country IHDs along with DM and HTN have dominated the mortality and morbidity chart list.[13],[14],[15],[16],[17],[18],[19] It can be though as an extent of change in lifestyle pattern depends on the exposure to an urbanized environment or there may be other associated factors. The present study was planned to observe a change in Framingham risk score for IHDs over 5-year period in a rural community proximal to a suboptimally urbanized setting.

  Materials and Methods Top

A cohort study was carried out in a Community Health Block of district Hamirpur of Northern State (Himachal Pradesh) of India. State has 12 districts and about 6,900,000 population and Hamirpur is a district headquarter with a suboptimally urbanized city with 32,430 population.[20] The selected community was living in 15 villages with a varying population from 150 to 1000 and is about 30–60 min away from the city using public transport. Apparent healthy individuals were assessed whereas known cases with acute myocardial infarction (AMI), DM, and HTN on treatment were excluded from the study. In year 2010, at the time of recruitment, first assessment was done and in year 2015 repeat assessment was done to observe a change in the status of body mass index (BMI), DM, HTN, lipid profile, and Framingham risk score. Data were collected by a team of 1 Laboratory Technician and 2 Field Assistants (FA) by house-to-house survey. All members were again requested to participate in the study with an informed consent. Once consent was obtained then FA administer a structured interview based questionnaire which was adapted from the World Health Organization (WHO) STEPwise approach chronic disease risk factor surveillance.[21] All participants were screened for the presence of any episode(s) of myocardial infarction with rose questionnaire and for stroke using WHO STEPS Stroke Instrument.[22],[23] Electrocardiography (ECG) changes suggestive of AMI were studied among screened patients with rose questionnaire. After an interview, 5 ml venous blood was collected following universal precautions along with anthropometry assessment such as height, weight, and blood pressure. The serum was separated and assessed for fasting blood glucose (FBG), total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and Triglycerides (TGs) using L-300 fully automated biochemistry analyzer (Mumbai, Tranasia biomedical limited). Individuals were categorized for HTN as per 7th report of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) by the National Heart, Lung, and Blood Institute. Individuals were categorized for “at risk” levels based on cutoff using the National Cholesterol Education Program Adult Treatment Panel III guidelines.[24] Death-related information was collected using validated verbal autopsy tool from those who died during follow-up period. Ascertainment of cause of death was done according to the International Classification of Disease 10th version (ICD-10).[18],[25] Prior ethical approval was obtained from the Institute Ethics Committee of Dr. RPGMC, Himachal Pradesh.

  Results Top

As 607 individuals were followed, of which 171 (28.2%) migrated and 19 (3.1%) died by the time of follow-up. Baseline profile of migrated individuals was compared with followed individuals and observed to be statistically similar. Observe data of followed individuals after 5 years finds an expected change in average age was observed from 46.5 to 50. Two years (P = 0.000) with a shift for fraction of individuals across age groups. Anthropometric assessment observed a significant increase for average BMI (22.6–24.4 kg/m 2 [P = 0.000]) due to a significant increase in obesity (12.7%–23.7%) and simultaneous decrease in fraction of undernourished (18.8%–11.8%; P = 0.035) individuals. Similarly, an average systolic blood pressure (SBP) observed an increased from 132.0 to 140.5 mm of Hg (P = 0.000) with a significant decline for normotensive (40.3%–25.4%) and rise for stage-2 hypertensive (9.7%–21.3%) individuals. Contrary to SBP, average diastolic blood pressure (DBP) decreased from 87.5 to 84.4 mm of Hg (P = 0.001). Based on DBP, proportion of individuals with pre HTN significantly increased (10.3%–24.0%) whereas insignificant change was observed for normotensive and hypertensive individuals. Hence, looking for change in blood pressure, the prevalence of systolic HTN (>140 mm of Hg) significantly increased from 32.7% to 47.4%, but a significant decline was found for diastolic HTN (45.3%–34.1%) [Table 1].
Table 1: Follow-up assessment of an established rural cohort from 2010-2015, Himachal Pradesh, India

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Based on FBG criteria, the prevalence of DM observed to be statistically similar, i.e. 10.5% in 2010 and 13.2% in 2015 with a statistical similar average FBG levels (2010: 100.2; 2015: 103.2 mg/dl; P = 0.258). Assessment for lipid profile observed a significant decrease for average levels of TC (199.7–187.4 mg/dl; P = 0.007) and TG (211.7–153.7 mg/dl; P = 0.000), but decline was not significant for average LDL (105.6–101.5 mg/dl). Average levels of HDL observed a significant increase from 49.7 to 55.9 mg/dl (P = 0.001). Individuals with “at risk” levels of TC (12.2%–16.1%; P = 0.197) and LDL (5.4%–6.3%; P = 0.706) increased insignificantly, but there was significant decline for individuals with “at risk” levels of HDL (18.6%–10.1%; P = 0.005) and TGs (45.7%–19.2%; P = 0.000) [Table 1].

Average Framingham 10-year risk for AMI was declined significantly from 1.52 (+0.77) to 1.32 (+0.59) in follow-up period of 5 years. This change was significant as there was an increase in individuals with a Framingham risk of <1% (62.0%–73.0%) and an insignificant decrease was observed for risk of 1–9% (26.6%–20.2%) and >10% (11.4%–6.3%). None of the individuals observed with high Framingham risk (>30.0%) either at the time of recruitment or follow-up [Figure 1]. Risk for AMI decreased, as females with <1% of Framingham 10-year risk increased significantly (70.1%–84.9%) along with a significant decline in risk with 1%–9% (25.0%–13.8%). Males showed an insignificant change for all categories of 10-year risk score. Age group analysis revealed that the 10-year risk decreased for low risk (<1%) in individuals of 41–60 years (51.9%–66.7%) and increased for 61–80 years (10.0%–28.4%). A significant decrease in fraction of individuals with a risk score of 1%–9% was observed only for age group of 41–60 years (41.5%–27.8%). ECG assessment based on rose questionnaire observed [Table 2] no signs suggestive of myocardial ischemia or infract. Totally 19 individuals died at the time of follow-up and ICD-10 based cause of death classification observed four deaths due to AMI and three due to insulin-dependent diabetes mellitus, whereas, five deaths remained unclassified [Table 3].
Figure 1: Framingham Risk for 10 years (%) for individuals recruited at the time of establishment of cohort in rural area of Himachal Pradesh, 2009–2010

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Table 2: Framingham 10-year risk (%) change from baseline to follow-up across different age groups baseline in an established rural cohort, 2010-2015, Himachal Pradesh, India

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Table 3: International Classification of Diseases 10th version classification based cause of death for deceased observed to be dead at the time of follow.up visit in year 2015, Himachal Pradesh, India

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At the time of recruitment individuals suggested for DM (FBG >126 mg/dl) found with high baseline and followed-up average, Framingham 10-year-risk score as compare to individuals with normal FBG. Decline in average risk score was significant (P = 0.000) both in diabetic (FBG >126 mg/dl), from 1.94 (+0.94) to 1.43 (+0.64) and individuals with normal FBG (<110 mg/dl), from 1.49 (+0.77) to 1.27 (+0.55).

  Discussion Top

Findings for the current study observed an expected change in age structure along with a significant increase in individuals with obesity (12.0%–23.7%) and systolic stage-1 HTN (32.7%–47.4%). Statistical insignificant decline was found for diastolic HTN (45.3%–34.1%). Individuals with DM increased insignificantly from 10.5% to 13.2% after 5 years. Change in lipid profile was also observed as there was a significant decrease in individuals with “at risk” levels of HDL (18.6%–10.1%) and TGs (45.7%–19.2%). Whereas, insignificant increase for individuals with “at risk” levels of TC (12.2%–16.1%) and LDL (5.4%–6.3%) increased and were statistically insignificant. Largely, the change reflects an insignificant change for risk factors of chronic diseases in rural settings. It was supported by the fact that most of the individuals had Framingham risk score of <10% both during recruitment and follow-up. Individuals with score of 1%–9% observed a nonsignificant decline, and there was increase for low-risk score (<1%). There was no individual with high-risk score (>30%) neither at the time of recruitment nor at the time of follow-up. Commensurately none of the individual had ECG changes suggestive of AMI during a 5-year-follow-up. Initial 5 years follow-up in this study observe no changes for putting individuals at risk for AMI, but immediate risk factors such as obesity, DM, and HTN did slow a rising pattern.

Significant rising trend of CVDs has been observed over a period in various countries, including India. It has influenced by associated morbidities such as HTN, DM, deranged lipid profile along with age, and place of residence.[1],[3],[7],[10],[26] Among diabetics, the relative risk (RR) observed to be 1.62 for stable angina, 1.56 for heart failure, and 1.54 for nonfatal myocardial infarction in1.9 million study cohort followed for median 5.5 years.[15] RR for CVDs among hypertensive individuals was observed to be 6.19 in male and 2.78 in female as compare to individuals with normal/optimal blood pressure.[27]

Supported evidence observed an increase in incident cases (7.2%) of DM in 3981 nondiabetics after an average follow-up period of 6.2 years associated with baseline FBG levels.[28] Similarly in primary care settings, 13-year cohort study observed an increase in the prevalence of DM (2.4%–5.3%) in a population of about 9 million.[29] Other cohort studies also observed on increase in diabetes with varying follow-up periods.[30],[31] In India, the prevalence of DM observed with an increasing trend over a follow-up period of 5–10 years, both in rural and urban areas.[14],[19],[32] Like DM, a cohort study of 2,227 Japanese population with a median follow-up period of 11.8 years in 707 normotensive (31.7%) found that 34.1% progressed to pre-HTN and 6.6% to HTN.[33] Such increase in incident cases of high blood pressure was also observed in a rural cohort of South India where individuals of 15–64 years were followed for an average period of 7 years.[13] Like DM, an increasing trend for HTN along with other risk factors for CVDs was observed in Indian settings.[8],[11],[12],[16] HTN is a known risk for CVDs as increase in cardiac events was found even in normotensive (1%–27%) and prehypertensive (4%–59%) in a prospective cohort of 3602 Taiwanese individuals.[34]

Association of cholesterol with CVD was also evident as in a follow-up study of 8393 Japanese individuals for 20 years where age- and sex-adjusted hazard ratio for CVD was observed to be increasing from 1.27 to 2.40 in participants with increasing levels of non-HDL cholesterol.[35] Deranged lipid profile such as high levels of TC observed to be associated with morbidity and mortality associated due to CVDs.[36],[37] Lowering of TC and LDL has observed with a benefit,[37] but HDL has considered for its nonbeneficial effect for CVDs in large clinical trials despite its endothelial repair and anti-inflammatory function.[38]

Hence, risk for CVDs depends on lifestyle which itself varies from place to place in its contextual settings which can be related to matrices of individual lifestyle, environmental settings, and genetic predisposition. The current study observed by a large a normal lipid profile for its cohort as individuals with “at risk” levels of TC and LDL were less both at the time of recruitment and follow-up. High fraction of people were of young age, female, less number of individuals with high TC and low HDL in the current study justifies low Framingham risk score as it is predominantly influenced by age, gender, and TC matrices.[39] SBP increased significantly and individuals with high FBG suggestive of DM did not increase significantly in the current study. Apart from DM and HTN, increase body weight due to unhealthy lifestyle considered to be associated with AMI, and in the current study, an average BMI and obesity increased significantly. Although generated evidence observed a curvilinear relationship between BMI and CVDs in a 4-year follow-up study in 113,194 adults which concluded no benefit of underweight with regard to risk of CVDs.[40]

The current study has a major limitation as less number of individuals was contacted. Reasons for change in risk factors such as change in environment, dietary habits, and physical activity were not delineated but increase in SBP, obesity, and DM was observed. Another limitation is loss to follow-up due to a high rate of migration. Although with a generated evidence, it can be concluded that though the rural cohort is optimally healthy with no immediate risk for AMI but early rising trend warrants community-based promotive and preventive health facility-based services and surveillance for HTN and DM in study area.

  Conclusion Top

Current study observed a low rate of rise in development of risk factors of CVDs like; obesity, systolic HTN, and blood sugar. It is without an overt manifestations of AMI, which warrants surveillance for risk factors for CVDs.


We express our sincere thanks to the Indian Council of Medical Research, New Delhi, for providing financial assistance.

Financial support and sponsorship

This study was financially supported by the Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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