1. El estudio del estrés y su papel en la situación sin hogar
1.4. El caso específico de la situación sin hogar
1.4.1. Conceptualización de la situación sin hogar
Rajeev Gupta, Vijay Kaul, H Prakash, Mukesh Sarna, Shalini Singhal, VP Gupta
Departments of Medicine and Pathology, Monilek Hospital and Research Centre, Jaipur and Departments of Medicine and Biostatistics, Mahatma Gandhi National Institute of Medical Sciences, Jaipur
S
tudies among emigrant Indians have reported a very high incidence of and mortality from coronary heart disease (CHD).1,2 Risk factor studies have shown that thesesubjects have a unique dyslipidemia characterized by normal to borderline-high levels of low-density lipoprotein (LDL)-cholesterol, raised triglycerides, low high-density lipoprotein (HDL)-cholesterol and higher small-dense LDL
particles.1–4 Insulin resistance and increased serum
lipoprotein(a) have been reported to be other important CHD risk factors.2,4 A high prevalence of abnormalities of
coagulation and platelet functions have also been reported in some studies.5
Conversely, studies within India have shown that on case–control comparison, there is a higher prevalence of smoking, sedentary lifestyle, hypertension and hypercholesterolemia in patients with CHD.6–14 Higher levels
of total- and LDL-cholesterol and triglycerides, and lower Background: We performed a case–control study to estimate lipid–cholesterol fractions in patients with coronary heart disease and compared them with population-based controls.
Methods and Results: A total of 635 newly diagnosed patients with coronary heart disease (518 males and 117 females) and 632 subjects (346 males and 286 females) obtained from an ongoing urban coronary heart disease risk factor epidemiological study were evaluated. Age-specific lipid values (total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and total:high-density lipoprotein cholesterol ratio) were compared using the t-test. Age-adjusted prevalence of dyslipidemia as defined by the US National Cholesterol Education Program was compared using the Chi-square test. In all the age groups, and in both males and females, levels of total and low-density lipoprotein cholesterol were not significantly different. In males, the high-density lipoprotein cholesterol (mg/dl) was significantly lower in patients with coronary heart disease as compared to controls in the age groups 30–39 years (35.1±11v. 43.7±9), 40–49 years (39.0±10 v. 47.1±8), 50–59 years (38.9±11 v. 43.8±9) and 60–69 years (38.6±11, v. 42.8±7) (p<0.05). In females, high-density lipoprotein cholesterol was less in the age groups 30–39 years (30.2±9 v. 40.7±9), 50–59 years (39.7±12 v. 44.7±8) and 60–69 years (35.6±11 v. 42.2±9). The level of triglycerides was significantly higher in male patients in the age groups 40–49 years (195.3±96 v. 152.8±78), 50–59 years (176.7±76 v. 162.9±97), 60–69 years (175.5±93 v. 148.1±65) and >70 years (159.8±62 v. 100.0±22); and in female patients in the age group 30– 39 years (170.8±20 v. 149.9±9) (p<0.05). The total:high-density lipoprotein cholesterol ratio was significantly higher in all age groups in male as well as female patients with coronary heart disease (p<0.05).
Conclusions: An age-adjusted case–control comparison showed that the prevalence of hypertension, diabetes, high total cholesterol (>200 mg/dl) (males 48.8% v. 20.2%; females 59.8% v. 33.4%) and high low-density lipoprotein cholesterol (>130 mg/dl) (males 42.1% v. 15.0%; females 52.1% v. 31.0%) was significantly more in cases than in controls. The prevalence of low high-density lipoprotein cholesterol (<35 mg/dl) (males 39.6% v. 6.2%; females 39.3% v. 9.5%), high total:high-density lipoprotein ratio (>5.0) and high triglycerides (>200 mg/ dl: males 39.6% v. 10.2%; females 17.1% v. 11.9%) was also significantly higher in cases (p<0.05). (Indian Heart J 2001; 53: 332–336)
Key Words: Lipids, Coronary disease, Population
Correspondence: Dr Rajeev Gupta, 16 Hospital Road, C-Scheme,
Jaipur 302001
Indian Heart J 2001; 53: 332–336 Gupta et al. Lipid Abnormalities in Coronary Heart Disease 333
levels of HDL-cholesterol have also been reported.7,9,11,13
Epidemiological studies within India have shown that in urban subjects, who show a three-fold greater prevalence of CHD compared to rural subjects, levels of total- and LDL- cholesterol and triglycerides are higher while there is no significant difference in HDL-cholesterol levels.14,15 Most of
the CHD case–control studies within India have been performed in tertiary-care hospitals and used hospital-based controls. These subjects are neither appropriate cases nor controls, as has been commented upon previously.16 To
remove this possible bias, we performed a case–control comparison of lipid levels using cases presenting to a charitable hospital and population-based controls obtained from an ongoing epidemiological study.
Methods
Successive patients presenting to this charitable hospital between 1997 and 1999 were enrolled in the study. These patients were all newly diagnosed as having CHD according to the criteria reported previously17 and were either
survivors of a recent myocardial infarction (>28 days old) or had classical angina pectoris confirmed either by a positive stress test or coronary angiogram. Of the 750 patients seen during this period, 635 (84.7%) patients with CHD (518 males and 117 females) were found to be eligible. History of risk factors such as smoking, hypertension and diabetes was obtained and fasting blood glucose and lipid levels were determined. The methodology of determination and standardization of lipid levels has been described in earlier studies.18
Controls were obtained from an ongoing population- based epidemiological study in Jaipur. The recruitment strategy was similar to that reported in a previous study.19
In brief, individuals from randomly selected locations (municipal wards) in the city were recruited using the stratified random sampling technique. Population proportionate adults >20 years of age according to the voters’ lists were examined by a house-to-house survey in these locations. In each location, 500 subjects were contacted for examination. Subjects in two of the six locations that have been covered so far have been included in the present study. History of coronary risk factors was obtained and a physical examination and fasting blood analysis for lipids and glucose was performed. Serum lipid levels in 632 of the 1000 eligible subjects (345 males and 286 females) were available (response rate 63.2%). Statistical analysis: Numerical variables are reported as mean ±1SD. Case–control comparison was performed using
the Chi-square test for categorical variables and unpaired t-test for continuous variables. Comparison in lipid levels at various age groups was done using the t-test. Age distribution was significant in both the patient and control populations, hence an age-adjusted comparsion was performed after matching controls with cases using the indirect method of age-standardization as described by Rao and Richards.20 A p value of <0.05 was considered
significant.
Results
We studied 635 cases (518 males and 117 females) and 632 controls (346 males and 286 females) within an age range of 20–75 years. Age-group distribution and cholesterol, lipoprotein and triglyceride values are shown in Table 1. In all the age groups, and in both males and females, the levels of total- and LDL-cholesterol were not significantly different, although there was a trend towards higher LDL-cholesterol in cases.
In males, the level of HDL-cholesterol (mg/dl) was significantly lower in patients with CHD compared to controls in the age groups 30–39 years (35.1±11 v. 43.7±9), 40–49 years (39.0±10 v. 47.1±8), 50–59 years (38.9±11 v. 43.8±9) and 60–69 years (38.6±11 v. 42.8±7), (p<0.05). In females, HDL-cholesterol was less in the age groups 30–39 years (30.2±9 v. 40.7±9), 50–59 years (39.7±12 v. 44.7±8) and 60–69 years (35.6±11 v. 42.2±9). The level of triglycerides was significantly higher in male patients in the age groups 40–49 years (195.3±96 v. 152.8±78), 50–59 years (176.7±76 v. 162.9±97), 60– 69 years (175.5±93 v. 148.1±65) and >70 years (159.8±62 v. 100.0±22); and in female patients at 30–39 years (170.8±20 v. 149.9±9) (p<0.05). Total:HDL- cholesterol ratio was significantly higher in all age groups in male as well as female patients with CHD (p<0.05).
Age-adjusted case–control comparison of risk factors (Table 2) showed that prevalence of smoking (current or previous tobacco use) was similar in cases as compared with controls in both males (24.3% v. 21.2%) and females (2.6% v. 10.6%). The prevalence of hypertension either in known hypertensives on drug therapy or patients with a current blood pressure >140 mmHg systolic and/or >90 mmHg diastolic on repeated measurements, as well as prevalence of diabetes, were significantly higher in cases than in controls.
In cases as compared to controls, the prevalence of high total cholesterol (>200 mg/dl) (males 48.8% v. 20.2%; females 59.8% v. 33.4%), high LDL-cholesterol (>130 mg/ dl) (males 42.1% v. 15.0%; females 52.1% v. 31.0%), and
334 Gupta et al. Lipid Abnormalities in Coronary Heart Disease Indian Heart J 2001; 53: 332–336
low HDL-cholesterol (<35 mg/dl) (males 39.6% v. 6.2%; females 39.3% v. 9.5%) was significantly higher (p<0.01). High total:HDL-cholesterol ratio (>5.0) was significantly higher in both males (56.9% v. 10.4%) and females (51.3% v. 16.7%) (p>0.01). The prevalence of borderline-high triglycerides (150–199 mg/dl: males 53.9% v. 9.1%; females 37.6% v. 8.8%) as well as high triglycerides (>200 mg/dl: males 39.6% v. 10.2%; females 17.1% v. 11.9%) was also significantly higher in cases (p<0.05) as compared to controls.
Discussion
This case–control study shows that low HDL-cholesterol, high total:HDL-cholesterol and high triglyceride levels,
apart from high total- and LDL-cholesterol, are important lipid abnormalities in Indian patients with CHD. These lipid abnormalities are similar to those reported in emigrant Indians in Britain1,4 and the USA.2,3
Case–control studies within India have reported high total- and LDL-cholesterol and triglyceride levels in patients suffering from CHD,6–9, 11–13 while low HDL-cholesterol was
reported in only a few studies. Kumar et al.6 from
Chandigarh, Misra et al.7 from Madras, Wasir et al.8, Vashist
et al.9 and Bahl et al.12 from Delhi, Sahi et al.11 from Bombay
and Krishnaswamy13 from Vellore reported that total
cholesterol levels were 20%–40% more in patients with CHD compared to hospital-based controls (p<0.05). Vashist et al.9 from Delhi studied 702 clinically documented CHD
cases and 186 normal healthy controls and reported that
Table 1. Cholesterol and other lipids in cases and controls
Males Females
Age Lipids No. Cases No. Controls No. Cases No. Controls
(in years) (518) (346) (117) (286) <30 CHOL 5 163.0±16 65 189.3±39 — — 53 187.7±33 LDL 89.9±6 119.4±35 121.7±33 HDL 42.6±12 42.5±9 41.8±9 TG 152.4±110 137.1±64 121.0±44 CHOL/HDL 4.24±1.8 4.66±1.5 4.69±1.3 30–39 CHOL 29 188.9±35 104 201.8±41 5 200.4±25 66 198.3±40 LDL 116.2±32 125.5±34 136.2±33 127.7±35 HDL 35.1±11* 43.7±9.3 30.2±9* 40.7±9 TG 187.8±97 162.8±101 170.8±20* 149.9±9 CHOL/HDL 5.82±1.7* 4.82±1.5 7.41±3.6* 5.10±1.6 40–49 CHOL 118 211.4±49 180 202.2±38 34 207.6±56 65 204.5±40 LDL 133.4±41* 123.1±31 131.7±54 131.7±35 HDL 39.0±10* 47.1±8 44.9±13 42.1±9 TG 195.3±96* 152.8±78 155.3±56 153.5±79 CHOL/HDL 5.70±1.7* 4.35±1.0 5.20±2.6* 5.03±1.3 50–59 CHOL 163 200.6±40 41 199.6±38 58 207.6±36 61 223.7±39 LDL 126.8±45 123.2±35 137.7±36 145.1±40 HDL 38.9±11* 43.8±9 39.7±12* 44.7±8 TG 176.7±76* 162.9±97 150.9±58 169.1±70 CHOL/HDL 5.53±1.8* 4.76±1.5 5.70±2.0* 5.21±1.5 60–69 CHOL 189 200.5±50 16 189.5±36 16 191.9±28* 32 219.8±36 LDL 126.8±45 117.1±32 122.1±25* 145.4±37 HDL 38.6±11* 42.8±7 35.6±11* 42.2±9 TG 175.5±93* 148.1±65 170.8±44 161.5±55 CHOL/HDL 5.59±2.1* 4.53±1.1 5.68±1.3 5.48±1.6 >70 CHOL 14 204.1±27* 5 175.2±20 4 192.5±9* 9 219.0±37 LDL 130.5±19* 110.0±15 110.0±10* 145.6±37 HDL 41.6±13* 45.2±9 48.0±2 41.8±13 TG 159.8±62* 100.0±22 122.5±20 158.0±68 CHOL/HDL 5.16±1.0* 3.95±0.6 4.32±0.1* 5.67±2.0
CHOL: cholesterol; LDL: low-density lipoprotein cholesterol; HDL: high-density lipoprotein cholesterol; TG: triglycerides All the values are in mg/dl with ±1SD No.: number of cases/controls
*p <0.05
Indian Heart J 2001; 53: 332–336 Gupta et al. Lipid Abnormalities in Coronary Heart Disease 335
total- and LDL-cholesterol, LDL/HDL ratio and triglyceride levels were significantly higher in CHD cases while HDL- cholesterol was not different. Sahi et al.11 additionally
reported low HDL-cholesterol along with higher apolipoprotein-B levels in cases.
On the other hand, Pais et al.10 studied 200 patients with
acute myocardial infarction and compared coronary risk factors with 200 hospital-based controls and reported no dif ference in total-, LDL- and HDL-cholesterol, and total:HDL-cholesterol ratio as well as triglyceride levels. In angiographic studies, no significant correlation of cholesterol levels with angiographic disease was seen.8,12
All these studies were performed in tertiary-care hospitals where only patients suffering from advanced disease are seen. The socio-economic characteristics of these patients are also different from those seen in primary care centres.16
Many of these patients are diagnosed elsewhere and follow a modified lifestyle or drug therapy which influence lipid levels and, hence, are not representative. Controls in these studies were also hospital-based patients collected from other wards and hence biased. In the present study, cases were recently diagnosed and treated only in a primary care charitable hospital and controls were taken from a population-based survey; thus, some biases were eliminated. Age-adjusted prevalence of smoking was similar in male cases and controls. The absolute number of smokers in female cases was low and thus not comparable with
controls. Prevalence of hypertension and diabetes was significantly higher in both male and female cases. Unlike some recent Indian10 and international studies,1,4 we found
that lipid profile abnormalities in Indian patients with CHD are similar to many other ethnic groups characterized by mixed dyslipidemia (increased levels of LDL and triglycerides and low HDL). A high prevalence of diabetes in cases with CHD explains the diabetic dyslipidemia characterized by low HDL and high triglycerides.21 Diabetes is a major risk factor
in emigrant Indians with CHD1, 2, 4 and this study highlights
its importance. One drawback of the present study is that we did not measure small-dense LDL which is an important lipid abnormality in Asian Indians settled in the USA.22
Studies have reported increasing total- and LDL- cholesterol and triglyceride levels in Indian urban subjects, associated with increasing prevalence of CHD.23–25 Dietary
and lifestyle-related coronary risk factors could thus be important in accelerating the CHD epidemic in India23,25 but
more studies are needed. The importance of LDL- cholesterol, total:HDL-cholesterol ratio, triglycerides, HDL- cholesterol and small-dense LDL particles should be confirmed by well-designed Indian prospective studies.
References
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Table 2. Age-adjusted coronary risk factor prevalence
Males Females
Cases Controls Cases Controls (n=518) (n=346) (n=117) (n=286) Smoking 126 (24.3)* 73 (21.2) 3 (2.6)* 30 (10.6) (current/previous) Hypertension 176 (34.0)* 43 (12.4) 35 (29.9)* 41 (14.3) (past diagnosis or BP >140/90 mmHg) Diabetes (past 104 (20.1)* 11 (3.1) 29 (24.8)* 14 (4.8) diagnosis or fasting glucose >126 mg/dl) Cholesterol 253 (48.8)* 70 (20.2) 70 (59.8)* 95 (33.4) (>200 mg/dl) LDL-cholesterol 100–129 mg/dl 166 (32.0)* 52 (15.0) 30 (25.6)* 36 (12.7) >130 mg/dl 218 (42.1)* 52 (15.0) 61 (52.1)* 89 (31.0) HDL-cholesterol <35 mg/dl 205 (39.6)* 21 (6.2) 46 (39.3)* 27 (9.5) Total:HDL >5.0 295 (56.9)* 36 (10.4) 60 (51.3)* 48 (16.7) Triglycerides 150–199 mg/dl 279 (53.9)* 31 (9.1) 44 (37.6)* 25 (8.8) >200 mg/dl 205 (39.6)* 35 (10.2) 20 (17.1)) 34 (11.9)
Numbers in parentheses are percentages * significant difference p<0.05
336 Gupta et al. Lipid Abnormalities in Coronary Heart Disease Indian Heart J 2001; 53: 332–336
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Indian Heart J 2001; 53: 337–339 Gupta et al. Transcatheter Fenestration of a TCPC Baffle 337