India has been experiencing a rapid epidemiological transition in the last few decades. Along with the increase in life expectancy, there is an emergence of non-communicable diseases (NCD) which is becoming a greater public health concern in India. Major four NCDs namely cardiovascular diseases (CVD), chronic respiratory diseases (CRD), cancers and Diabetes account for more than 80% of the total premature NCD deaths .[1] Globally, around 17.9 million people annually die due to CVDs, followed by cancers (9.3 million), respiratory diseases (4.1 million), and diabetes (1.5 million).[2] More than four out of five CVD deaths are due to heart attacks and strokes, and one third of these deaths occur prematurely in people under 70 years of age.[3]The number of people with total CVD nearly doubled from 271 million in 1990 to 523 million in 2019, and deaths due to CVD climbed significantly from 12.1 million in 1990 to 18.6 million in 2019.[4]

The majority of NCD deaths occur in low and middle-income countries including India.[5] As a result of rapid urbanization and change in lifestyle; the epidemiological health transition has taken place; which has led to an overall economic rise, but with certain associated flipsides (risk factors).With growing burden of NCDs and high case fatality rate in the low and middle income countries; the Unites Nations in 2012 acknowledged that the rising burden of NCDs is one of the serious challenges to sustainable development in the 21st century.

The country wise statistics of the WHO on non-communicable diseases (NCDs) estimate that in India, the non-communicable diseases account for around 53% of the total deaths, among which CVDs have a major share of 24%.[6] With the turn of the century, cardiovascular diseases (CVDs) have become the leading cause of mortality in India.[7] The Global Status on NCDs Report (2010) reported that there were more than 2.5 million deaths from CVD in India in 2008, two-thirds due to Coronary heart disease (CHD) and one-third due to stroke.[8] Studies show that compared to the people of European ancestry, CVD affects Indians at least a decade earlier and in their most productive midlife years.

A global CVD epidemic is rapidly evolving, with the burden of disease shifting. CVD currently kills twice as many people in developing countries as it does in developed countries. Conventional risk factors account for the great majority of CVD cases.[9] Many epidemiological studies of cardiovascular risk factors in the mid and late twentieth century found that the risk factors are higher in upper SES persons than in lower SES subjects (Sapru, 2006).However, some studies reported that risk factors could be more in poor, especially where illiteracy is high.[10]Age plays a vital role in the deterioration of cardiovascular functionality, resulting in an increased risk of cardiovascular disease (CVD) in older adults and.[11] However, sex differences are also frequently perceived in aging adults regarding both onset and prevalence of CVD,[11] Diabetes is a major predisposing factor for developing CVD in the aging population.[12] DCM (diabetic cardiomyopathy) describes heart disease, which develops primarily due to diabetes.[13]Adults with diabetes historically have a higher prevalence rate of CVD than adults without diabetes.[14] The risk of CVD increases continuously with rising fasting plasma glucose levels, even before reaching levels sufficient for a diabetes diagnosis.[15]

Some epidemiological evidence also indicates that CVD is associated with behavioural risk factors like smoking, alcohol use, low physical activity levels, and insufficient vegetable and fruit intake. In elderly persons, hypertension has been found to be an independent risk factor for acute myocardial infarction and stroke.[16] There is substantial epidemiologic evidence for the familial aggregation of CVD. Researchers from the Framingham Study reported that having CVD in at least one parent doubled the 8-year risk of CVD among men and increased the risk among women by 70%.

In order to develop and implement an effective strategy for prevention and treatment of CVD in older people, it is necessary to have a more comprehensive understanding of a wide range of CVD risk factors and the factors relevant to this population. However, few studies focused on the older people.[17] Therefore, the present study tries to assess the prevalence of CVD and its attributable risk factors among the older adults in India.

This is s a prospective and observational study was conducted in the Department of General Medicine, Ayaan Institute of Medical Sciences, Teaching Hospital & Research Centre. To determine the prevalence of lifestyle risk factors among CVD patients attending the hospital. The purposeful sampling method was employed to select all patients who met the study selection criteria.

Inclusion criteria

Adults aged ≥35 years diagnosed with CHD and HTN who attended the at hospital from. The study participants voluntarily consented to participate in the study.

Exclusion criteria

Children (including those with congenital heart diseases), pregnant women and patients with CHD and HTN aged ≥35 years who did not consent to take part in the study.

Assessment of socio-demographic characteristics and lifestyle risk factors

A structured questionnaire with closed questions was adopted from the WHO Stepwise survey  and translated to Local language (national language). The questionnaire was then administered to all participants. The following information was collected: socio-demographic information, lifestyle risk factors and family history of HTN and CHD. The assessed socio-demographic characteristics were: age, gender, marital status, and education level and occupation status. Education level was categorized as primary level, secondary level, higher education learning and uneducated. Marital status (married and no partners), occupation (formal employment, self-employed and unemployed). Lifestyle risk factors included current/history of smoking for the past 5 years (categorized as smoker or non-smoker), history of alcohol use (categorized as current alcohol user or non-alcoholic user), physical activity (categorized as physical exercise at least 2 days per week minimum for 30 minutes or no physical activity), and family history of either HTN or CHD (defined as having at least close relative (father, mother, sister or brother) diagnosed with ether HTN/CHD or both HTN and CHD).

Anthropometric measurements

Weight in kilogram was taken in light clothing by using calibrated weighing scale machine (Seca, Germany), with 150 kg capacity and the accuracy of 0.5 kg. The patient was requested to remain with minimal clothes, remove shoes and excess weight in the pockets before measurements were taken. Height was measured in centimeter (cm) by calibrated stadiometer (Leicester stadiometer) of 0.1 cm accuracy, with the subject standing against the vertical wall, heels together, shoulders and head touching the wall surface and after removal of shoes. Body mass index (BMI) was then calculated by the following formula [BMI = weight (kg)/height (m²)]. BMI was categorized as underweight (<18.5), normal (18.5–24.9), overweight (25.0–29.9) and obese (≥30.0)

Blood pressure measurements

Blood pressure measurement was conducted by the trained clinical officer upon arrival of the patient and after resting for 10–15 minutes. Automatic digital sphygmomanometer with automatic inflation (Life Brand™ BM60) was used to measure blood pressure while the patient seated and relaxed with the left hand at the level of the heart. Three systolic and diastolic blood pressure readings were taken on the left upper arm of the patient. Average systolic and diastolic blood pressure was used in the analysis. Systolic and diastolic blood pressure measurements were used to classify HTN in accordance with the Seventh Joint National Committee.

Blood sample collection

Blood samples for plasma glucose, serum ALT, CRP, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) concentration measurements were obtained by a trained clinician. For each patient, 10 mL of venous blood samples were drawn from the arm and transferred to EDTA (ethylenediaminetetraacetic acid) tube. Blood samples were then taken to a clinical research laboratory at KCMC referral hospital for further analysis procedures. Blood samples were centrifuged at the 3,000-rpm machine (Roche Germany) for 5 minutes at 4 °C. Clarified serum and plasma samples were then pipetted and poured into Eppendorf storage tubes (5 mL), followed by freezing at −20 °C.

Analysis of biomarkers

Before analysis, plasma and serum blood samples were mixed thoroughly by using vortex mixer. Form each sample, 10 µL was pipetted and poured into Microvatte tubes. Plasma blood glucose, HLD-C, LDL-C, and ALT samples were loaded into Cobas Integra 400 plus analyzer (Roche Diagnostics, Germany). Serum blood for measuring CRP concentration was loaded into fully-auto chemiluminescence immunoassay (CLIA) analyzer (MAGLUMI 800), Shenzhen New Industries Biomedical Engineering Co., Ltd. (Snibe Diagnostic, China). According to laboratory protocols, values (concentrations) of studied biochemistry markers were categorized as indicated.

Statistical analysis

Data were entered into Microsoft Excel 2013, then sorted, coded, and cleaned. The analysis was done using SPSS version 20.0 (IBM). Descriptive statistics were used to analyze the frequency and percentages of socio-demographics, lifestyle characteristics, and biomarkers for HTN and CHD. Pearson’s chi-square (χ²) test was used to determine the association between risk factors with HTN and CHDs. Independent variables included in the analysis were: gender, age, education level, occupation, marital status, BMI, blood pressure, physical activity, smoking history, alcohol consumption, plasma blood sugar, ALT, HDL-C, LDL-C, and CRP levels. Independent variables significantly associated with HTN and CHD in chi-square (χ²) test were subjected to a multinomial logistic regression model to reveal independent predictors of HTN and CHD. Statistical significance was tested at 95% confidence interval (95% CI) (alpha ≤0.05).

Table 1: Demographic Characteristics of Patients (n = 560)

Table 2: Lifestyle-Related Risk Factors

Table 3: Clinical Risk Factors

Table 4: Laboratory Findings

Table 5: Distribution of Cardiovascular Disease Events

A total of 560 patients were evaluated for cardiovascular disease (CVD) risk factors. The mean age of the participants was 52.6 ± 14.8 years, with 57.1% (n = 320) male and 42.9% (n = 240) female. The majority of the patients (44.6%) were in the 40-59 years age group.

Among the participants, 37.5% (n = 210) were overweight, and 30.4% (n = 170) were obese, indicating a high prevalence of weight-related risk factors. Lifestyle risk factors were commonly observed, with 39.3% (n = 220) being smokers, 25.0% (n = 140) reporting alcohol consumption, and 51.8% (n = 290) engaging in physical inactivity. Additionally, an unhealthy diet was reported by 55.4% (n = 310) of the participants.

Clinical risk factors were also highly prevalent. Hypertension was the most common condition, affecting 50.0% (n = 280) of the patients, followed by dyslipidemia (35.7%), diabetes mellitus (26.8%), and a family history of CVD (32.1%).

Laboratory results indicated elevated mean values of total cholesterol (210 ± 45 mg/dL), LDL-C (130 ± 35 mg/dL), triglycerides (180 ± 50 mg/dL), and fasting blood glucose (110 ± 30 mg/dL), all of which were above recommended levels.

Regarding CVD outcomes, coronary artery disease (CAD) was observed in 33.9% (n = 190) of patients, followed by heart failure (19.6%), stroke/transient ischemic attack (15.2%), and peripheral artery disease (13.4%).

The present study tries to present the prevalence of cardiovascular diseases and (hypertension, heart disease, and stroke) and the pertinent risk factors among older adults in India. The study indicated that the prevalence of CVD tended to increase with age. With aging, there is an incremental acquisition of several CVD risk factors in an individual’s lifespan. Although CVD remains the leading cause of death of both women and men in India, there are considerable gender differences in the prevalence of CVDs. The study indicated that women were more likely to have CVD than men.[18] This is also line with the study by40 that females have died from cardiovascular disease at a higher rate than males. Despite the fact that women develop heart disease 10 years later than males, they are more likely to suffer from a heart attack.

 It is estimated that 35% of heart attacks in women go unrecognised or unreported. This is further supported by the researcher who state that Women outnumber men in terms of living with and dying from CVD and stroke, as well as the number of hospital discharges for heart failure and stroke.27Sex differences in CVD prevalence largely reflect sex differences in Indian demographics.[19] Because female sex is related to a longer life ex pectancy than male, women comprised a larger share of the elderly population in which the prevalence of CVD is greatest. Along with that the risk of cardiovascular disease in women is often underestimated due to the misperception that women are more ‘protected’ than men against CVD. The neglect of CVD among women leads to less aggressive treat ment strategies.18 The present study showed that the place of residence is significantly related to the prevalence of CVD. Older adults residing in rural areas had a lower chance of having CVD than urban areas. This is further sup ported by researchers who state that urban population had higher prevalence of CVDs as compared to rural population.[20]

Risk factor prev alence from slum/peri-urban areas lay somewhere in between the urban and rural population, but more inclined towards urban trends.42 The study also revealed that high cholesterol, diabetes, were key risk factors for CVD supporting the finding that adults with diabetes are about twice as likely to die from heart disease or stroke as people without diabetes (National diabetes statistical report, 2014).Further studies have also indicated that Cardiovascular disease (myocardialinfarction, stroke, and peripheral vascular disease) is twofold more common in people with type 2 diabetes (T2D), and it is the leading cause of death in T2D patients.19 The study showed that CVD prevalence was higher among the physically inactive older adults, and this difference was statistically significant (p < 0.001).This is line with the study by1 who stated that physical inactivity increases a person’s chances of being overweight, of having high blood pressure and of developing other conditions that make cardiovascular disease more likely.[21]

 Regular, moderate to vigorous physical activity assists in reducing the risk of cardiovascular disease. Participation in 150 min of physical activity of moderate intensity per week was estimated to alleviate Ischemic heart disease by about 30% and diabetes risk by 27% (WHO.2007). The study indicated that most of the individuals with a significant family history of heart dis ease/stroke/hypertension were more likely to develop CVD themselves.14 in their study found that the individuals with a family history (FH), perceived their risk for heart disease to be about twice as high as individuals without a FH (p < 0.001).[21].

In conclusion, the study provided a representative prevalence of CVD and relevant risk factors among older adult population in India. The high prevalence of CVD risk factors among older adults manifested alarming public health concerns and a future health demand. Implementational strategies are required for reducing CVD risk among elderly by focussed promotion of physical activities and early detection of CVDs based on family history. It creates a threat if health promotion and awareness programs are not well designed.

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