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DETERMINANT FACTORS OF EARLY CORONARY ATHEROSCTEROSISAT
DR. WAHTDTNSUDTROHUSODO HOSPTTAL MAKASSA& 2014
Arsunan, A. At. Irwandi Rachman2, Masni3
r'2Departmentof Epidemiology, Faculty of Public Health, HasanuddinUniversity,Indonesia
jDepartment
of Biostatistics,Faculty of Public Health,HasanuddinUniversity, Indonesia
Authors to whom correspondenceshouldbe addressed:[email protected]
ABSTRACT
EarlyVge coronary atherosclerosls ls the incidenc, o7"ororo, atherosclerosis that occurs not in time or
occur at a relatively young age < 55 years. The aim of the study was to determine the riskfactors of early
coronary atherosclerosis at the Dr. Wahidin Sudirohusodo Hospital, Makassar. The study was
obsemation using a case control study. The caseswere patients with early coronary atherosclerosis with
the age of < 55 years, and the controls were non-eqrly coronary atherosclerosis by matching the age
group and gender. Results showed that the risk of occurrence of early coronary atherosclerosis is
hypertension(OR: 2.19, 95% CI: 1.09- 4.36)and a low HDL (OR: 5.08, 95% CI: 2.51 - 10.30),Non
risk factors of early atherosclerosls rs obesity and high total cholesterol and LDL. This study suggested
that need to control bl'ood pressure and HDL cholesterol within normal limits in order to control the
diseaseriskfactors that can prevent cardiovascular diseasein thefuture.
Keywords: early coronary atheroscleros ii, obesity, hypertension, lipid,
INTRODUCTION
Atherosclerosisis the term of process by which a substanceor material deposition of fat,
cholesterol, cell waste products, calcium, fibrin (clotting material in the blood) and substance/
other materials forming the inner layer of the artery blood vessel.These layers are called plaque.
Hardening of the arteries, often occurs with advancing age of a person (American Heart
Association, 2012). Number of patients with atherosclerosisin the dra of globalization and
industrialization tends to increase. In the last decade of heart disease and blood vessels that
constituted by atherosclerosisdevelop into a major killer in Indonesia and the world. Research
shows, the main cause of death of the world's population is at the heart ie (42.9%), stroke
(25.9%), pulmonary diseaseand asthma (12.5%), cancer (5.4%), and other diseases(less than
four percent)(Hura, 2010).
Atherosclerosis occurs over many years, and can be started at the time of young
individuals. According to the Centers Departmentsand CardiovascularDiseasesin Minnesota
(2013), someonesaid to hit atherosclerosisearly age if the patient has any manifestationsof
atherosclerosis,including heart a!!ack, stroke and peripheral arterial diseaseat a relatively young
age (under age 55 in men, under the age of 65 years in women). Lifestyle or certain medical
conditions may lead to atherosclerosisoccurs at an early age. Results of researchconducted by
Robinson (2009) the inc,idenceof subclinical atherosclerosisdyslipidemia associatedwith the
value (OR :2.24), hypertension(OR = 1.74), and total cholesterol(OR = 2.2). Another study
conductedRozanski (2010) in New York, United Stateswho were investigating the incident
coronary arteriesfound that there are significant results between clinical variables including total
2
cholesterol,LDL, HDL, blood glucose levels on the incidence of coronary atherosclerosis.
This study aims to determine the risk, obesity, hypertension and lipid levels consisting of total
cholesterol,LDL and HDL on the incidence of coronary atherosclerosisin the hospital early age.
Dr Wahidin Sudirohusodohospital 2014.
MATERIALS AND METHODS
'',
ResearchSite,
The researchwas conducted in. Dr. Wahidin SudirohusodoHospital, Makassar considering
the prevalenceof cardiac patient visits continue to increasevisits are 17.923 in2006 to 25.490 in
20ll.ln addition, Dr. Wahidin Sudirohusodohospital is one of the main referral hospital in East
Indonesiaand belong to the government
.
-r
Design and Research Variables
analytic
study
applied
case-control
This observational
study design to seethe magnitudeof
risk of the independentvariables, na*.ly obesity, hypertensionand lipid levels consisting of
total cholesterol, LDL and HDL, whereas on the dependent variable is the incidence of coronary
atherosclerosis
early age <55 yearswith atrace risk factors of the subjectby comparingthe case
group and the control group.
Population and Sample
Sampleswere taken in two ways ie for casesusing consecutive sampling technique and for
the control group with accidental sampling technique. The population of this study is the general
public as well as residents who use health care facilities in Poly Heart Hospital Dr. Wahidin
Sudirohusodo.The sample in this study were divided into two patients who've been diagnosed
with ACS (Acute Coronary Syndrome) or CAD (Coronary Artery Disease) <55 years at Poly
Heart Hospital of Dr. Wahidin Sudirohusodo as case group and the healthy respondents< 55
years who never diagnosedheart diseaseand blood vessel as a comparisoncontrol group with
I case: I control by matching the age grouqs and genders.
Data Collection
Primary data were obtained through direct data collection from a sample of respondents
was selectedas the casegroup and control through interviews using questionnaires,measurement
of height, weight, blood pressure and blood sampling of respondents,for respondentslipid
samplestaking then examined in clinical laboratoriesProdia, while secondarydata obtained from
the agency through patient chart I medical record that is in the heart clinic of Hospital of Dr.
Wahidin Sudirohusodo.
Data Analysis
Data analysis was performed using univariate to get an overview of the general
characteristicsof the frequency distribution of the respondentsas well as the dependentvariable.
Bivariate analysis OR test to assessthe risk of independentvariables on the dependentvariable.
Multivariate analysis was also performed to'see the relationship between the variables of
coronary atherosclerosis early age with all the variables studied so unknown independent
variables were the most dominant influence on coronary atherosclerosis early age by using
multiplelogisticregressions
RESULTS
Characteristicsof Respondents
Resultsof the analysisillustratesdistributionof iespondentsbased on demographic
of sample
(age,gender,and occupation).Generalcharacteristics
of respondents
characteristics
in this studyweredividedinto threeagegroups.Most age
accordingto the ageof;respondents
is at ageof 40-49yearsagegroupto 34 people(46.6oh),
groupssuffercbronarya{herosclerosis
early age it was found
whereasin the control group who did not have coronaryatherosclerosis
thattheagegroup50-57yearsis 37 people(50.7%)(Table1).
in Dr. WahidinSudirohusodo
basedon thejr characteristics
Table 1. Distributionof respondents
'- hospital,2014
Control
n%
Characteristics
'r
Total
Age
6
34
30-39
40-49
50-57
aa
JJ
an
JI
9.6
39.7
50.7
13
63
70
8.9
43.2
47.9
80.8
19.2
59
T4
80.8
t9.2
118
28
80.8
19.2
34.2
39.7
5.5
5.5
2.7
12.3
20
15
t3
5t2
8
27.4
20.5
17.8
6.8
t6.4
11.0.
45
44
9
9
t4
l7
30.8
30.1
I 1.6
6.2
9.6
t|.6
8.2
46.6
45.2
7
29
Sex'
Male
Female
Occupation
Privateemployee
Civil servant
Labor
Farmer/ sailor
Business
Jobless
59
'14
25
29
4
4
2'\
9
of respondentsby sex both male and femalehave the sameproportionof
Characteristics
casesandcontrolswith 59 male(80.8%)andfemale14 (I9.2%) andit wasobtainedinformation
early age than female gender
that more the male gendersuffer from coronaryatherosclerosis
(Table.l). Characteristicsof respondentsby occupationon the incidence of coronary
early age showedthat the type of work most highestin the group of cases
atherosclerosis
is the early ageof civil servantsis 29 people(39.7%),
sufferingfrom coronaryatherosclerosis
early age most are
group
not have coronaryatherosclerosis
who
did
the
control
in
whereas
of 20 persons(27.4%).
privateemployees
Risk Analysis
The analysisshows,the statusof obesityis not a risk factor for atheroscleroticeventsearly
of
arerisk factorsfor the incidence
ageOR :0.74 (95% CI:0:37 to l:46) andhypertension
earlyagewith OR:2.19 (95%CI: l:10 to 4:36)wherehypertension
coronaryatherosclerosis
early age2:19 times higher than non-hypertensive
statusat risk for coronaryatherosclerosis
(Table2).
Obesity risks and Hypertension base on sex to the early age Atherosclerosis
occurrencein Dr. Wahidin SudirohusodoHospital,2014
Cases
n%
Variable
Obesity Status
Obesity
Not Obesity'r
I'
Hypertension Status
Hypertension
Not Hypertension
Control
Total
Yo'
OR
95%Cr
23
50
45.t
5 2.6
28
45
54.9
47.4
51
95
100
r 00
0.74
( 0.34- 1.45)
33
40
6 2.3
43.0
20
53
37.7
57.0
53
93
100
100
2.19
(1.10-4,36)
Resultsof the analysisof lipids comprisingthe total cholesterol,-.LDl.
cholesterol,HDL
cholesterolat early age with the incidenceof atherosclerosis
indicatevaluesobtainedfor total
cholesterol
OR : 1:08(95%CI : 0:50to 2:30),LDL cholesterol
valueof OR : 0.68(95yoCI:
:
valueof OR 5.Q9(95%'Cl: 2:15to 10:30).Theresultsfor the
0:34to 1:38),HDL cholesterol
interpretation
of the statusof lipid levelswith the incidenceof atherosclerosis
earlyageonly low
HDL cholesterol
levelsindicaterisk of disease
atherosclerosis
coronerearlyagewith 5:09times
higherrisk thanthosewho do not havelow HDL cholesterolto total cholesterolwhile LDL is
risk factorsearlyage(Table3).
not a incidenceof atherosclerosis
VariabelPenelitian
TotalCholesterol
High
Low
LDL Cholesterol
High
Low
HDL Cholesterol
High
Low
Variable
Total Cholesterol
High
Low
LDL Cholesterol
High
Low
HDL Cholesterol
High
Low
Cases
n%
OR
95%CT
Total
18
55
51.4
49.5
t7
56
48.6
50.5
35
111
100
100
(0.s0-2.30)
20
)-t
43.5
26
\47
53.0
56.5
47.0
46
100
100
100
0.68
(0.33-1.38)
)^i
")r\
6 7 .9
29.4
78
68
100
100
5.09
( 2.s1- 10.30)
OR
95%CI
Cases
n%
I8
.55
1t)
)_)
53
.)/\
25
48
32.1
70.6
Control
1.08
51.4
49.5
T7
56
35
111
100
s0.5
r00
1.08
(0.s0-2.30)
. 4 3' 5
53.0
26
47
56.5
47.0
46
100
100
100
0.68
(0.33-1.38)
6 7 .9
29.4
25
48
32.r
78
68
100
100
5.09
(2.51-10.30)
48.6
70.6
Multivariate Analysis
Based on multivariate analysis using multiple logistic regression, variable low HDL
cholesterolis the most influential determinantof the incidenceof atherosclerosisearly age with
4.
OR: 6.70(95% CI:2.96 - 12.90),Tabte
Table 4. Result of Multivariate analysis of the risks factor of atherosclerosisincidence at
early age in. pr. Wahidin SudirohusodoHospital, 2014
Variable
Status
Hypertension
Cholesterol
-"
HDL
Sig
Exp
B
7.34
0.07
2.96
1.35
6.49
2r.95
0.00
6.07
2.85
12.90
B.
S.E
Wald
1.08
0.40
1.80
0.38
Df
95%CI
Lower U
DISCUSSION
Resultsof this study indicate the statusof obesity more in the control group or who do not suffer
from coronary atherosclerosisatearly age is 54.9% comparedwith the group of casessuffering
from prematurecoronary atherosclerosisthat is 45.1%and the obtainedvalues of 0.74 OR (95%
CI : 0:37 to 1:46) this meansthat the statusof obesity is not a risk factor for incident coronary
atherosclerosisearly age. The results are con'sistentwith research conducted by Supriyono,
(2008) which examinedthe risk factors of obesity on the incidenceof coronary heart diseaseat
an early age is <45 yearswhere his researchshowsobesityis not a risk factor OR of 0.S (95% CI
: 0.4- 1.6).However, different results studiesis shown by Wormser (2011) whose studiesmetaanalysis involving 58 prospective studies showed an associationbetween Body Mass Index
(BMI) with the incidenceof Coronary Heart Disease(CHD), and CardiovascularDisease(CVD).
The results of different studies can be due to differences ir place and demographic factors as
well as from the study. In this study, obesit) by itself a risk factor is not a risk factor for coronary
atherosclerosisat an early age, but obesity remains a risk factor for the.occuffenceof coronary
atherosclerosisconcurrently with the person's age. Hypertension is a condition without
symptoms where abnormally high pressurein the arteriesthat lead to increasedrisk of other
diseasessuch as stroke, diabetesand heart disease.Hypertensionacceleratesatherosclerosisdue
to high blood pressureand settling will causedirect injury to the walls of coronary arteriesthus
facilitating the occurrenceof coronary atherosclerosis(Tony, 2012).
The results of the risk analysis on the incidence of hypertensionateroskelrosisearly age
showed OR of 2,186 (95% CI : 1,096 - 4:36) so that it can be said that a person with
hypertensionstatusat risk for coronary atherosclerosisearly age 2,186 times higher than those
who do not suffer hypertension. The research findings are also consistent with research
conducted Salima (2009) which-examined the risk factors for coronary heart diseasein Dr
Wahidin Sudirohusodoalso found that individuals with hypertensionhave a risk of 6:27 times
higher occurrenceof coronary heart diseasecompared to people who are not hypertensive.
The mechanismby which hypertensionlead to paralysisor deathdirectly relatedto its effect on
the heart and blood vessels. The increase in systemic blood pressure increase resistanceto
pumping of blood from the left ventricle that increasesthe heart's workload. As a result,'
ventricular hypertrophy to increase the strength of contraction. However, the ability of the
ventricle to maintain cardiac output with compensatedhypertrophy and dilation eventually
exceeded and heart trouble. Heart increasingly threatened by the severity of coronary
atherosclerosis.
If the processcontinuescoronary atherosclerosis,myocardial oxygen supply is
reduced. The increase in myocardial oxygen demand caused by ventricular hypertrophy and
increased cardiac work that would eventually lead to angina or myocardial infarction (Price,
200s).
Cholesterol,fat, 4nd other substancescan causethickening of the arteries,so that the lumen
of the blood vbssels'co4strictand the processis called atherosclerosis.The results of this study
showedonly low HDL cholesterolshowedthe risk of coronary diseaseatherosclerosisearly age
where low HDL cholesterol levels at risk of suffering from coronary atherosclerosisearly age
5.088 times highei than in people who do not have low HDL cholesterol to total cholesterol
while, and LDL cholesterolwas not-a risk factor-for incident coronary atherosclerosiseaily age.
The ideal number for HDL cholesterolat leastnot lessthan 40 m,gI dL however,this number can
vary for men and women. HDL cholesterol(high-densitylipoprotein),-.isa type of cholesterol
that carries bad qholesterol (LDL cholesterol), cleans and transports fat from the arteries and
back to the liver. HDL cholesterolalso removesexcesscholesterolfrom plaque, prevent settles
cholesterolin the arteries and protects blood vesselsfrom atherosclerosis(plaque formation in
the blood vesselwalls), (Gulfianti, 2012)
Results are in line with research conducted by NHANES Q.{ational Health and Nutrition
ExaminationSurvey) in the United Statesfrom 2005 to 2008 showedLevels of HDL cholesterol
below 40 mg / dL in'men and below 50 mg / dL in adult women is a factor risk for heart disease
and stroke (American Heart Association, 20L2). The results of another study conducted by
Supriyono (2008) showed inconsistentresults, where coronary heart diseaserisk factors early
age<45 years showed an increasein total cholesteroland triglycerides are risk factors for heart
diseaseearly age and HDL and LDL cholesterolis not a risk factor early age of heart disease.
The results of this study may be due to differencesin different places, demographicfactors as
well as subject-making,especiallyin the control group.
CONCLUSIONS AND RECOMMENDATIONS
Obesity is not a risk factor for incident coronary atherosclerosisearly'age, hypertensionstatus
has 2,186 times the risk compared with those not on the incidence of hypertension and
atherosclerosisearly age to lipid low HDL cholesterolhad 5,088 times the risk comparedwith
thosenot having low HDL levels on the incidenceof atherosclerosis
early age,while the increase
in total cholesteroland LDL cholesterolis not a risk of incident coronary atherosclerosisfactor
early age. This study suggeststhat the need for education to each patient's particular affected
coronary atherosclerosisearly age about the importanceof primary prevention and secondary
prevention, especially hypsrtension and diabetesmellitus, and the need to perform a health
behavior,especiallyfor respondentswho are not affectedby atheroscleroticdiseaseearly age in
order to control the risk factors tlre ilisease so as to prevent future cardiovasculardisease
including controlling blood pressure,blood glucoselevels,HDL cholesterolwithin normal limits
and avoiding smoking. Researchcan also be used as an advancedresearchprimarily related
researchon the incidence of atherosclerosiseaily age,especiallyin the younger age group (<55
years)primarily for risk factors not examinedin this study.
ACKNOWLEDGEMENTS
The authors would like to thank to the Director and the entire staffs of the Dr Wahidin
SudirohusodoHospital on prohibition of implementing this researchin health care institutions
they lead. Also to all patients with cardiac patients and healthy respondentswho had participated
in this study,.aswell ap all thosewho have helpedup to completethis study.
\
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