Assessment of Individual Cardiovascular Risk among Population in Public Pharmacies using the Heart-Score Questionnaire

Cardiovascular disease are the leading cause of mortality in all region of world, except in Sub - Saharan Africa. It accounts for about 49% of all deaths and 30% lost years of life in Europe. They are a significant cause of disability, large health care costs and premature mortality. WHO estimates say that in 2020, 70% of all causes of death will be related to lifestyle, where the most important risk factors are:Unbalanced and improper diet (overweight, obesity), Physical inactivity, Smoking and Alcohol consumption (1, 2, 3, 4, 5)

Risk factors for cardiovascular disease are numerous and have cumulatively effect. Most of the risk factors that are associated with the behavior, such as diet and lifestyle, sedentary life at an early age and have a persistent character (6, 7, 8). The most significant risk factors that can be prevented are: high blood pressure, smoking, high cholesterol, diabetes mellitus, obesity, inadequate nutrition, and physical inactivity. In stopping the unfavorable trend in CVD, the greatest importance that there should be primary prevention. Patients who have already had a cardiovascular event should be subjected to secondary prevention measures ( 9, 10, 11).

In stopping the unfavorable trend of CVD, primary prevention should be of the greatest importance (12). Patients who have already had an ischemic event should undergo secondary prevention measures, especially in view of advances in the interventional, medical and surgical approaches ( 13, 14, 15, 16). Cardiovascular diseases are the most significant cause of death in men and women, and they can be prevented. CVD prevention lasts a lifetime, and the best time to start is before birth, by educating young, future parents, and then should continue in preschool (kindergarten), as well as through failure in the school system. During this phase, the emphasis should be on enjoying a healthy diet and joy and a sense of well-being related to physical activity, instead of focusing on disease prevention. Starting from the 6th grade of primary school (11–12 years, or even earlier, depending on the social environment), a smoke-free lifestyle should be encouraged ( 17, 18, 19, 20).

Secondary prevention is a set of therapeutic measures that reduce the occurrence of recurrent, recurrent cardiovascular events in patients with confirmed atherosclerosis, including coronary heart disease, patients with cerebrovascular disease, peripheral artery and carotid artery disease, and atherosclerotic aortic atherosclerotic disease (21). Equivalents in terms of risk level are people with diabetes, as well as people with chronic kidney disease, and people with asymptomatic atherosclerosis can also be classified in some way (22).

The recommended model for total risk assessment is based on the SCORE (Systematic Coronary Risk Evaluation) system. The SCORE risk assessment is based on a large number of data from prospective European studies and predicts fatal atherosclerotic cardiovascular diseases over a period of 10 years (23, 27). This risk assessment is based on the following risk factors: gender, age, smoking, systolic blood pressure, and total cholesterol (24, 25). The SCORE model was calibrated according to mortality statistics for each European country. If it is used for the population aged 40–65, it will predict the possibility of fatal cardiovascular consequences that will appear after 10 years (26, 29).

The aim of this study was to investigate individual risk factors for cardiovascular complications in the adult population in the city of Belgrade.

Demographic characteristic of study population

In Table 1 are shown basic data about study population.

We observed distribution of location of public pharmacies, age, gender, marital status and education level of participants.

Hypertension as a cardiovascular risk factor in study population

In our study, predominately were present female participants without hypertension, then male. Similar, were frequently male and female participants with hypertension (Figure 1). Also, in the same group, we observed the most frequent self-measuring of blood pressure compared with other groups (Figure 2).

Figure 1.

Figure 2.

Smoking as a cardiovascular risk factor in study population

As we can see on Figure 3, in our study were dominate frequent non-smokers compared with smokers in male and female (Figure 3). Furthermore, in study population were more present smokers with longer duration of smoking (>10 years) (Figure 4). Also, in smokers group there were higher percent of participants who smoked more than 20 cigarets per day (Figure 5)

Figure 3.

Figure 4.

Figure 5.

Body weight as a cardiovascular risk factor in study population

Regarding the body weight, we measured waist size and body mass index of each participant. The most frequent were female participant without CVD risk, and the most unfrequent were male participant without risk (Figure 6). Also, BMI below 30 was significantly present in our study population (Figure 7).

Figure 6.

Figure 7.

Heart Score in study population

We categorized participant into two categories: participants with HS higher than 5 and lower than 5. In our study, in 19,6% were present male with HS higher than 5 and in 6% were female with higher HS than 5 (Fig. 8). Also, after calculated Heart Score, we can see that 25.6% of respondents have a high risk of cardiovascular event, of which 19.6% high risk, 4.4% very high risk, and 1.6% extremely high risk of developing some an adverse fatal cardiovascular event. The workload in relation to gender is 52.7% of all men included in the sample have a high or very high and extreme risk compared to only 6% of all surveyed women. Using regression analysis, it was found that the factors that have statistical significance for the assessment of Heart Score are as follows: age of subjects (F = 12,023; p <0,001), sex of subjects (F = 20,685; p <0,001), smoking (F = 6,249; p = 0.003) and systolic pressure (F = 10.553; p <0.001). Other variables had no effect on the Heart Score value.

Figure 8.

Regarding the variables, the age of the subjects and the value of systolic pressure, with increasing values, the risk measured by Heart Score also increased, which was to be expected. Men also had a higher risk of an unwanted CV event than women. An interesting result was obtained for the variable smoking in the sense that the respondents who smoked had the highest risk, but on the other hand a higher estimated risk was recorded in respondents who did not smoke than in respondents who recently quit smoking.

According to the results of the research, more than 1⁄4 of the examined population of adult inhabitants of the city of Belgrade has a high Heart Score (value higher than 5) (29). Risk factors that affected the value of the Heart Score were: age of the subjects, sex of the subjects, smoking and the value of systolic pressure. Other variables had no effect on the Heart Score value, which can be explained by the relatively small sample examined (14, 15, 16, 17, 18, 19, 20, 21, 22, 23).

Cardiovascular diseases are still leading in the number of patients - both in the world and in our country. About 17.3 million people die each year, most often from heart attacks and strokes. These are conditions that can be treated, and it is possible to prevent them. It is best if we deal with our own cardiovascular risk on time. This mostly applies to men over 40 and women over 45 (11, 30).

According to WHO experts, the number of people suffering from CVD will continue to grow from year to year until 2020 (15, 29). These diseases are increasingly affecting the working age population, and their immediate cause is stress, low standard, daily struggle for survival, low level of general awareness and education about the importance of adequate prevention, which, in addition to proper nutrition, physical activity, includes regular visits to check-ups and taking prescribed therapy (31,32,33).

Mortality, incidence and fatal outcomes of CVD are declining in most countries of northern, southern and western Europe, but either not declining or even rising in Central and Eastern Europe. Although CVD mortality rates are declining in the EU, the number of men and women living with these diseases is growing (34). This paradox is related to increased longevity and improved survival of patients with CVD. The burden of these diseases is unevenly distributed in the world, with higher mortality of people who are in a worse socioeconomic position. In Serbia, every hour, from various manifestations of CVD, 6 people die, of which every eighth is in the most productive years of life (from 25 to 64 years). Compared to all other causes of death during 2013, 24,505 men (45.9% of all causes of death) and 28,862 women (54.1%) died of heart and blood vessel diseases in Serbia. Compared to 2012, when the mortality rate from CVD was 763.6 per 100,000 inhabitants, in 2013 the mortality rate dropped to 744.9 per 100,000 inhabitants ( 32, 33, 34, 35, 36).

From 2001 to 2010, the CVD mortality rate in Serbia fell by 14% for women and by 16% for men, but despite the registered decline in the mortality rate, Serbia is in the group of countries with a higher-than-average risk for the countries of the European region ( 29 , 36). The lack of CVD prevention is evident in the Republic of Serbia. According to a study of the workload of the KVB society (37), Serbia spent much more money on the treatment of cardiovascular diseases and its complications than on prevention; more than 60% of direct health care costs can be attributed to hospitalizations, surgical and diagnostic procedures. An additional problem in the Republic of Serbia is incomplete or missing data regarding funds invested in prevention activities, such as smoking cessation campaigns.

Alarming trends for chronic diseases, such as obesity, cardiovascular diseases and diabetes mellitus, affect people at the earliest age, which indicates a significant need not only for primary and secondary prevention, but also for primordial prevention. Primordial prevention is defined as preventing the development of risk factors, such as smoking, being overweight or consuming alcohol. Smoking significantly reduces the chances of survival in middle age. Three times the percentage of heavy smokers (≥ 20 cigarettes per day) dies from cardiovascular disease compared to people who have never smoked. The beneficial effect of smoking cessation is more pronounced in earlier years, but it is also present in people who quit smoking in their 50s or 60s (38). It has been documented that prevention strategies are not only cost-effective, but also strategies that bring certain savings to the health system. The company’s programs aimed at increasing physical activity, improving nutrition, and preventing smoking provide a return on investment in the sense that for every dollar spent, the company returns $ 5.6 within 5 years. Smoke-free enclosed regulations are also estimated to bring the United States savings in the health care system of $ 10 billion a year (31, 34).

Being overweight has also been shown to be an independent risk factor for CVD. In Serbia, prevention programs are experiencing a low level of implementation. Even more worrying is the fact that only half of the population has received counseling from health professionals to change life risk factors, but only one third of those have actually changed some of their risk factors. Less than 1% of smokers used the smoking cessation counseling service (29, 30, 31, 32, 33, 34).

However, these diseases can be largely prevented. The WHO estimates that a simultaneous reduction in blood pressure, obesity, cholesterol and tobacco use in the majority of the population would more than double the incidence of CVD (39). The presented risk factors and high mortality and morbidity from cardiovascular diseases indicate the need to take preventive measures as early as possible, with the parallel implementation of population strategy and high-risk strategy. The possibility of risk assessment is a step forward in the prevention of CVD.

The present risk factors and high mortality and morbidity from cardiovascular disease indicate the need for taking preventive measures already in children, with the parallel implementation of population strategies and high risk.