Main Article Content
OBJECTIVE: Cardiovascular disease (CVD) had become a leading cause of deathamong people in developing countries including Thai military officers. No long termdata on preventing CVD events in this group had been published before.Thus, our mainstudy purposes were to identify the target individuals who carried the substantial riskof developing CVD event and prevent them in advance.
MATERIALS AND METHODS: After approved by the ethics committee and medicalorganization of Chandrubeksa hospital in 2006, all in service officers (aged of 35-60years) who undergone annual screening, were voluntarily enrolled. We excluded officerswho were beyond this age range, not willing to participate or already had CVD. Topredict the 10-yr risk of developing CVD events, we used the modified Coronary RiskChart (mCRC) (available at firstname.lastname@example.org) to classify asymptomatic Air Forceofficers into three groups; the low, intermediate and the high risk candidates, accordingto the predicted cardiovascular risk of < 9.9%, 10-19.9% and > 20% respectively. Forall participants, life-style modifications was given, but medication and further screeningwith exercise stress test were provided only in the intermediate and high risk groups.All subjects were followed from 2006-2016 by an annual physical check-up. After tenyears, the clinical outcomes (acute coronary syndrome, stroke, total death and compositeevents) were compared between the three groups.
RESULTS: Of total 410 asymptomatic cases, 85.4% were men and had a mean age of50.9 ± 6.1 years. During 10-yr follow-up, we were able to track the health status of allparticipants. There was total of 52 events, with only 5 events (5.7%) occurring in thelow risk group (including one ACS, one ischemic stroke and 3 non-CVD deaths). Incontradiction, 47 clinical events (14.6%, p = 0.026 for comparison with the low riskgroup) were observed in the combined intermediate and high risk groups (including 7non-fatal ACS, 10 ischemic strokes, 2 CVD and 28 non-CVD deaths). Both ACS andstroke occurred less frequently than predicted rate and no statistical different of actualevents was noted in each assigned risk group. The incidence of ACS and stroke amongthe low, intermediate and high risk candidates were 1.1%, 1.1% and 3.8% and 1.1%,4.2% and 1.5% respectively. The mean time from entering the registry to the occurrenceof an ACS was 4.9 years and the mean age of ACS cases was 55.1 years. Stroke wasobserved 7.1 years on average after entering the registry. All of strokes were ischemicin origin and the mean age of stroke cases was 61.4 years. A total of 33 deaths (8%)occurred 3.4%, 7.9% and 11.3% among the low, intermediate and high risk individuals.Death occurred after on average 6.7 years at a mean age was 59.4 years. The CVD deathwas very low (6%), each of them were from STE-ACS and stroke. The non-cardiovasculardeath was 31 cases (94%). The common causes were cancer (n = 12), cirrhosis (n = 6),accident and drowning (n = 6). The death rate and composite outcome of ACS , strokeor death were significantly higher in the highest risk group when compared with thoseof the low risk candidates: relative risk of 3.6 (95%CI: 1-12.8), p = 0.04 and3.3(95%CI:1.2-9.0), p = 0.016, respectively.
CONCLUSION: By using the mCRC (available at www.thaiafheart.com), predictionand reduction of CVD events in asymptomatic officers were feasible. The observed ACSand stroke rate were > 50% lower than the predicted one and no statistically significancewas found among the three risk groups. Progression to ACS or stroke was observed alsoin non-high risk cases. We therefore recommend re-assessing CV risk every 3-year andre-emphasizing the importance of CV preventive measures. While he ACS and strokerates were lower than expected, we observed the high rate of non-CVD death which wassignificantly increased in the high-risk group. This group of individuals should be targetedfor further preventive measures related e.g. smoking and alcohol consumption.
This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2. World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO, 2002
3. Murray CJ, Lopez AD. The global burden of disease: A comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990 and projected to 2020. Cambridge, MA, Harvard School of Public Health (Global Burden of Disease and Injury Series, vol.I) 1996.
4. Zhang XH, Lu ZL, Liu L. Coronary heart disease in China. Heart 2008; 94:1126-31.
5. Division of Health Statistics Bureau of Health Policy and Planning. Public Health Statistics AD 2008. Bangkok: Office of the Permanent Secretary, Ministry of Public Health 2008.
6. Division of Health Statistics Bureau of Health Policy and Planning. Public Health Statistics AD 1998.Bangkok: Office of the Permanent Secretary, Ministry of Public Health 1999.
7. The annual report 2014-15: Causes of death among the inservice Thai military offcers, Army, Navy and Air Force, an unpublished data.
8. Veerakul G. The developmental standard guideline for treating acute ST elevation myocardial infarction. Official research document for graduating of the 39th Air War College, 2005, Royal Thai Air Force. (https://www.library.rtaf.mi.th.)
9. Veerakul G, Nootaro A, Damrongrat B, et al. Five-Year Outcome of primary cardiovascular prevention in Air Force Offcers. Asian Heart J 2012; 20;1-11.
10. Wood D, De Backer G, Faergemann O, et al. Prevention of coronary heart disease in clinical practice: recommendations of the second joint task force of European and other societies on coronary prevention. Eur Heart J 1998;19:1434 -503.
11. Grundy SM, Pasternak R, Greenland P, et al. Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations: A Statement for Healthcare Professionals From the American Heart Association and the American College of Cardiology.Circulation 1999;100:1481-92.
12. Kannel WB. Global cardiovascular risk evaluation. Preventive Cardiology: A Practical Approach, second edition, edited by Wong ND, Black HR, Gardin JM. The McGraw-Hill Companies 2005:1-21.
13. Sritara P, Cheepudomwit S, Chapman N, et al. Twelve year changes in vascular risk factors and their associations
with mortality in a cohort of 3,499 Thais: the Electricity Generating Authority of Thailand Study.Int J Epidemiol 2003;32:461-8.
14. Conroy RM, Pyörälä K, Fitzgerald AP, et al. Estimation of ten year risk of fatal cardiovascular disease in Europe: the SCORE project.Eur Heart J 2003;24:987-1003.
15. Hippisley-Cox J, Coupland C, Vinogradova Y, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2.BMJ 2008;336:1475-82.
16. Barzi F, Patel A, Gu D, Sritara P, et al. Asia Pacifc Cohort Studies Collaboration. Cardiovascular risk prediction tools for populations in Asia.J Epidemiol Community Health 2007;61:115-21.
17. Laurier D, Nguyen PC, Cazelles B, et al. Estimation of CHD risk in a French working population using a modifed Framingham model. The PCV-METRA Group.J Clin Epidemiol 1994;47:1353-64.
18. Hense HW, Schulte H, Lowel H, et al. Framingham risk function overestimates risk of coronary heart disease in men and women from Germany-result from the MONICA Augsburg and the PROCAM cohorts.Eur Heart J 2003;24:937-45.
19. D’Agostino RB, Grundy S, Sullivan LM, et al. Validation of the Framingham coronary heart disease prediction scores. JAMA 2001;286:180-7.
20. Allan GM, Nouri F, Korownyk C, et al. Agreement among cardiovascular disease risk calculators. Circulation 2013;127:1948-56.
21. Srimahachota S, Kanjanavanich R, Boonyaratavej S, et al. Demographic, Management Practices and In-Hospital Outcomes of Thai Acute Coronary Syndrome Registry (TACSR): The different from the Western World.J Med Assoc Thai 2007;90 (Suppl 1):1-11
22. Maddox TM, MD, Stanislawski MA, Grunwald GK, et al. Nonobstructive Coronary Artery Disease and Risk of Myocardial Infarction.JAMA 2014; 312(17):1754-63.
23. Kositchaiwat J. Treatment outcome in Thai Acute Coronary Syndrome cases, 7R: Ways to reduce mortality in Acute
Coronary Syndrome, Veerakul G and Kositchaiwat J eds; Srinakorn Design Printing, Bangkok, ISBN 978-616-348-612-7, 2015,278-96.
24. World Health Organization, Prevention of Cardiovascular Disease: Pocket Guidelines of Assessment and Management of Cardiovascular Risk (WHO/ISH Cardiovascular Risk Prediction Charts for WHO epidemiological sub-regions AFR D and AFR E), Geneva 2007,https://www.who.int/cardiovascular_disease.
25. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. death from coronary disease, 1980-2000. New Engl J Med 2007;356:2388-98.
26. Vartianinen E, Puska P, Pekkanen J, et al. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland.BMJ 1994;309:23-7.
27. Yilmaz H, Demir I, Uyar Z. Clinical and coronary angiographic characteristics of patients with coronary slow ﬂow. Acta Cardiol2008;63:579-84
28. Fineschi M, Bravi A, Gori T. The “slow coronary ﬂow” phenomenon: Evidence of preserved coronary ﬂow reserve despite increased resting microvascular resistance.Int J Cardiol 2008;127: 358-61.
29. Rubinshtein R, Yang EH, Rihal CS, et al. Coronary microcirculation vasodilator function in relation to risk factors among patients without obstructive coronary disease and low to intermediate Framingham score. Eur Heart J 2010; 31: 936-42.
30. Veerakul G, Ounpothi, Satheeranate N, et al. Coronary slow ﬂow phenomenon: A case report and review literature. BKK Med J 2015; 10: 22-6.
31. Maseri A, Mimmo R, Chierchia S, et al. Coronary spasm as a cause of acute myocardial ischemia in man. Chest 1975;68:625-33.
32. Ong P, Athanasiadis A, Hill S, et al. Coronary artery spasm as a frequent cause of acute coronary syndrome: the ASPAR (Coronary Artery Spasm in Patients with Acute Coronary Syndrome) study.J Am Coll Cardiol 2008;52:523-27.
33. Myerburg RJ, Kessler KM, Mallon SM, et al. Life-threatening ventricular arrhythmias in patients with silent myocardial ischemia due to coronary-artery spasm.N Engl J Med 1992; 326:1451–55.
34. Veerakul G, Sitakalin S, Watanaswad K et al. Atheroma and Coronary Spasm. BKK Med J 2013;6:30-6.
35. Greenspan M, Iskaandrian AS, Catherwood E, et al. Myocardial bridging of the left anterior descending artery: evaluation using exercise thallium-201 myocardial scintigraphy.Cathet Cardiovasc Diagn 1980; 173-80.
36. Morales AR, Romanelli R, Boucek RJ. The mural left anterior descending coronary artery, strenous exercise and sudden death.Circulation 1980;62:230-7.
37. Chen TS, Incani A, Butler TC, et al. The demographic profle of young patients (syndrome in queensland. Heart Lung Circ 2014;23:49-55.
38. Tungsubutra W, Treesukosol D, Buddhari W, et al. Acute coronary syndrome in young adults: the Thai ACS Registry. J Med Assoc Thai 2007;90 (Suppl 1):81-90.
39. Suwanwela NC. Stroke Epidemiology in Thailand. J Stroke 2014;16(1):1-7.
40. Viriyavejakul A, Senanarong V, Prayoonwiwat N, et al. Epidemiology of stroke in the elderly in Thailand.J Med Assoc Thai 1998;81(7):497-505.
41. Hanchaiphiboolkul S, Poungvarin N, Nidhinandana S, et al. Prevalence of stroke and stroke risk factors in Thailand: Thai Epidemiologic Stroke (TES) Study. J Med Assoc Thai 2011;94:427-36.
42. Stamler J, Stamler R, Neaton J, et al. Low Risk-factor profle and long-term cardiovascular and non-cardiovascular mortality and life expectancy: Findings for fve large cohort of young adult and middle age men and women.JAMA 1999;282: 2012-8.
43. Taylor AJ, Bindeman J, Feuerstein I, et al. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: Mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project.J Am Coll Cardiol 2005; 46:807-14.
44. Detrano R, Guerci AD, Carr JJ, et al: Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 2008;358(13):1336-45.
45. Handy CE, Desai CS, Dardari ZA et al. The Association of Coronary Calcium with noncardiovascular Disease. The Multi-Ethnic Study of Atherosclerosis.J Am Coll Cardiol Img. 2016; 9(5):568-76.