Introduction

Cardiovascular diseases (CVD) are the leading cause of death and major burden on health care systems.^[1],[2] CVD is primarily caused by metabolic, environmental, behavioral, and social risk factors. There are well-known established risk factors such as diabetes mellitus, hypertension, hyperlipidemia, smoking, stress, and sedentary life. While genetic factors contribute to the onset and progression of CVD, we are now aware that many of the cardiovascular (CV) risk factors are mediated by lifestyle. Diet, exercise, adherence to medications, sleep, and other environmental factors are also important to be healthy. Approximately 80% of heart disease, stroke, and Type 2 diabetes cases can be prevented by modifying undesirable lifestyle behaviors.^[3],[4]

A healthy lifestyle is well defined with a lower risk of CV and metabolic morbidity; hence lifestyle modification is a cardinal component of both personalized and public health. Several lifestyle intervention studies among patients at high risk revealed that changing lifestyle could reduce the risk of diabetes mellitus and improve CV health.^{[5],[6],[7],[8]}

The aim of this study was to provide insights into CV risk awareness, current lifestyle habits, drug usage, and medical behavioral patterns of Turkish patients with CV risk factors and/or diseases who admitted to outpatient cardiology clinics.

Materials and Methods

Patients admitted to the cardiology outpatient clinics for diagnostic or therapeutic purposes, who were over 18 years of age and agreed to participate in the study were included. The participants signed informed consent and completed a self-administered questionnaire in the following sections: baseline characteristics, awareness of CV risk factors and individual CV risk, lifestyle habits, medical behaviors, and CV medication. Patients from 27 hospitals in different regions of Turkey participated between November 2018 and March 2019.

On physical examination, pulse rate and blood pressure were recorded. Actual CV risk levels were calculated by the physicians according to the Framingham risk score which is a simplified and common tool for the assessment of risk level of CAD over 10 years.^[9] Office scale was used for weight measurements and body mass indexes were calculated by the formula recommended by the World Health Organization (ratio of weight and height, expressed as kg/m²).

Patients performing at least 30 min of moderate exercise at least 3 days a week were defined as regular exercisers. Patients were considered hypertensive if they were on antihypertensive medications or had high blood pressure on examinations (>140/90 mmHg), performed twice for confirmation. Blood pressure measurements were done as office measurements with validated digital sphygmomanometer. Patients were considered diabetic if they were using the antidiabetic medication, or had a fasting blood glucose higher than 126 mg/dL. Hyperlipidemia was diagnosed if the patients were taking lipid-lowering drugs or their lipid levels were high according to the hyperlipidemia guidelines.^[10]

History of CV interventions (percutaneous coronary interventions or bypass grafting), myocardial infarction, dysrhythmia, peripheral arterial disease, valvular heart disease (moderate or severe), cerebrovascular diseases, renal diseases, medication (including over the counter drugs) were questioned and noted after searching the medical records of study subjects.

The electrocardiography (ECG) of each patient was evaluated by the cardiologist.

Ethical statement

The study was performed in compliance with the Declaration of Helsinki.^[11] and ethics approval was obtained from the local ethics committee of Istanbul Bakırkoy Dr. Sadi Konuk Training and Research Hospital (16/09/2019, 2019-18-07).

Statistical analysis

All statistical analysis was conducted using MedCalc Statistical Software version 18 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2018). Continuous variables were presented as mean, standard deviation (SD), median, minimum and maximum values and data on frequency were presented as percentage (%) for categorical variables. Chi-square analysis was used for correlation between categorical variables. Where appropriate, categorical variables were evaluated by Fisher exact and Fisher Freeman Halton Test. P < 0.05 was considered statistically significant. The summary of data analysis was shared as tables. Since it was an observational, noninterventional study, there were no specific hypotheses to be tested, no comparisons and no endpoints.

Results

Baseline characteristics

A total of 2793 patients, 52.1% female with a mean age of 57.0 ± 14.0 years were included. Only 10.5% of patients were university graduates. The most common risk factor was hypertension (62.5%). The most common CVD was coronary artery disease with a prevalence of 35%. On ECG, most of the patients had sinus rhytm (93,3%) and atrial fibrillation prevalence was 6,3% [Table 1]. The mean systolic and diastolic blood pressure was 130.8 ± 19.3 mmHg, 78.1 ± 11.4 mmHg respectively.

Cardiovascular risk awareness

The calculated CV risk level of 1041 patients (37.3%) was high and only 20.4% of all participants identified themselves as high risk [Table 2]. Although the risk factor with the highest awareness was hypertension, only 31.5% of the participants knew that it was a risk factor for CVD. Among participants, the ratio of awareness about CV risk factors was 22.5% for smoking, 18.0% for diabetes mellitus, and 10.6% for hyperlipidemia, <10% of the participants knew that sedentary life, genetic history, and aging were also CV risk factors [Table 3].

Lifestyle habits

The mean body mass index was 28.4 ± 4.9 kg/m², the rate of regular exercise was 35.8% [Table 4]. Most of the patients (58.0%) stated that they did not skip any meal and didn't consume any fast food (53.9%). The most consumed bread types were white (61.0%) and bran (13.9%) bread. The frequency of using additional table salt was 44.1%. Despite 31.9% of the participants added no sugar to tea and/or coffee, 27.0% preferred 2 sugar cubes and 31.4% of them preferred 1 sugar cube. The herbal product and vitamin usage rates were low [Table 4].

Medical attitudes and drug use

Approximately one-third (36.7%) of all participants used to visit outpatient clinics with an interval of 3–6 months. More than two-thirds of participants (76.7%) get medical information from their doctors, not from medical television programs or Internet sources [Table 5]. When the drugs were examined, it was seen that only 7.6% of patients did not have a regular drug, whereas 70.0% of them were taking at least 1 drug daily and 22.5% of patients were taking more than 5 drugs per a day. Most of the patients (80.0%) stated that they use their drugs regularly (defined as using a prescribed medication suggested by the medical doctor without interruption till recovery or change in medication) [Table 5]. The most commonly used drugs are shown in [Table 6]. The most commonly prescribed CV drug was beta-blockers (44.9%) followed by ASA (41.1%), renin-angiotensin-aldosterone system blockers, and statins. The statins were believed to be harmful by 38.4% of participants. The most common non-CV medications were proton-pump inhibitors (35.8%) and nonsteroidal anti-inflammatory drugs (24.1%).

Discussion

In the present study, we found that the awareness of all CV risk factors is still low in our study population. In parallel with this, the calculated CV risk level of patients applied to cardiology outpatient clinics was high in most. CVD is the leading cause of death.^[1] Although there are well-known established CV risk factors such as diabetes mellitus, hypertension, and hyperlipidemia which increase the risk of CVD, the researchers also described behavioral risk factors as well as clinically measured risk factors. Nonsmoking, high-quality diet, and exercise are in relation to a lower risk of CV and metabolic diseases.

The prevalence of CV risk factors in a population may vary, influenced by changes in lifestyle and medical behavior over time. According to the International Diabetes Federation Diabetes  Atlas ^{More Details}, approximately half a billion people worldwide have diabetes mellitus, with the number expected to rise by 25% in 2030 and 51% in 2045.^[12] The prevalence of diabetes mellitus was reported to be 13.7% in the general Turkish population in the TURDEP study,^[13] in our study population it was 26.9%. The reason for this difference may be the mentioned increase of global diabetes mellitus prevalence or the fact that our study was conducted among people who applied to cardiology outpatient clinics, and did not include the general population. While the rate of hyperlipidemia in population aged over 50 years was reported to be 32% by Onat et al.,^[14] mean age ± SD was 57.0 ± 14.0 years and hyperlipidemia prevalance was 26.3% in this study. Ozkara et al. showed that 75.4% of the population aged over 60 years was hypertensive.^[15] However, the mean age of our study population was under 60 years and 62.5% of the patients were hypertensive. On the other hand, smoking prevalence was higher in our study population (30.5%) compared to the adult population (27.1%) based on the World Health Organization. Global Adult Tobacco Survey.^[16]

Previous studies revealed that adherence to some healthy lifestyles were associated with a decreased risk of major coronary events.^[17] At that point, the knowledge level of the population regarding healthy lifestyle and awareness of CV risk is important. Hence, American Heart Association works to reduce cardiac morbidity and mortality by improving public's knowledge level and management of modifiable risk factors. Our study results showed that the majority of Turkish patients who applied to the cardiology outpatient clinic did not know their individual CV risk levels correctly. Although 37.3% of all participants had a high CV risk, only 20.4% of them defined themselves as at high risk. This may result in them not making enough efforts to change their lifestyle and behavior patterns to improve their health. For this reason, the knowledge level of the patients should be increased. As the lifestyles, medical behaviors and CV risk awareness vary among different segments of the community, all healthcare professionals have a critical duty both in the screening of CV risk factors and in consulting for changing risky behaviors. Health-care providers should advise for lifestyle modification.^[18],[19] Although it was evidenced that modifying medical behaviors improve health outcomes and reduce health-care costs, lifestyle counseling in physicians' offices is not routinely carried out, physicians give this kind of advice in only 34% of clinical visits.^[20],[21] Our study results also showed that the primary source of medical information is physician visits. Therefore, during these visits, medical advice about dietary habits, smoking, and physical activity should be improved to achieve a healthy lifestyle and to prevent CVD.

When compared between developed and developing countries, lifestyles, medical behaviors, and CV risk awareness differ among communities and this may also contribute to the national differences in the prevalence of CVD. For example, when looking at food consumption, it is seen that the recommended amount of vegetables (400 g/day) or fruit (300 g/day) is consumed by only 0.4% of countries. Besides, only 20% of countries meet red meat consumption recommendations (<100 g/week).^[22] While recommended food intake goals (400 g/day for vegetables, 28.35 g/week for nuts/seeds, 50 g/day for whole grains, 100 g/week for seafood, 100 g/week for red meats) could not be achieved; fruit, nuts, and seed intake increased from 1990 to 2010, consuming whole grains decreased globally and the consumption of red meat also increased.^[22] Besides all these, to achieve an improvement in public health, it must be kept in mind that it is recommended to focus not only on what should be eaten or not but also on public education, nutrition policies, and research. Countries should create cost-effective public health programs to address modifiable risk factors and minimize CVD-related disability and early death.

Public policies, educational initiatives or clinical interventions aimed at both improving healthy lifestyle awareness and changing medical behaviors should take place among the priority objectives.^[23] Unfortunately, the scientific communities give inconsistent messages about nutrition and exercise. While healthcare professionals report that exercise improves CV health, there are also some controversial issues about intense endurance exercise and CV risk.^[24] However, over the past 30 years, significant gains have been made in tobacco control worldwide^[25] and smoking trends are better than diet and exercise trends.

In addition, another health problem is noncompliance with drug therapy. Despite effective therapies exist, adherence to drug schedules is still inadequate. Misinformation on the internet, television, and newspapers worsen drug compliance. In our study population, even if 80% of participants report that they use their drugs regularly, outpatient pharmacy data shows that only 43% of patients conform to statins, 40% to beta-blockers, and 38.8% to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.^[26] The figures in low-income countries are worse, for example, only < 5% of some Africans use statins given for secondary prevention.^[27]

There are some limitations of this study. First, only patients who admitted to outpatient cardiology clinics were included in the study, hence the results may not reflect all segments of the society. Furthermore, we are aware about the fact that Framingham's risk score underestimates the risk status of patients under the age of 30. Yet, to our knowledge, there are no validated risk scores in this age group Hence, all patients were evaluated according to Framingham's score. In addition, in some parts of the country, the fact that people speak different local languages may have affected the comprehensibility and accuracy of the questionnaire. Furthermore, access to medical records of some patients (especially echocardiography reports) was limited.

Conclusion

Despite these limitations, this study provides us valuable real-life data in terms of lifestyle habits, awareness of both CV risk factors and individual CV risk levels of patients admitted to cardiology outpatient clinics. The results obtained from this study could inspire researchers for future public health studies in the CV field.

Acknowledgments

This research was carried out with the contributions of the MedLlife –TR study clinical investigators (Hayati Eren, MD [Department of Cardiology, Elbistan State Hospital, Kahramanmaraş, Turkey], Hazar Harbalıoğlu, MD [Department of Cardiology, Düzca Atatürk State Hospital, Düzce, Turkey], Vahit Demir, MD [Department of Cardiology, Faculty of Medicine, Bozok University, Yozgat, Turkey], Lütfü Bekar, MD [Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey], Tufan Çınar, MD [Department of Cardiology, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey], Mustafa Talha Güneş, MD [Department of Cardiology, Faculty of Medicine, Ege University, İzmir, Turkey], Veysel Ozan Tanik, MD [Department of Cardiology, Ankara Dışkapı Yıldırım Beyazit Training and Research Hospital, Ankara, Turkey], Dilay Karabulut, MD [Department of Cardiology, Bakırköy Dr Sadi Konuk Training and Research Hospital, İstanbul, Turkey], Mehmet Mustafa Yılmaz, MD [Department of Cardiology, Faculty of Medicine, Hitit University, Çorum, Turkey], Aslı Sönmez, MD [Department of Cardiology, Institute of Cardiology, Istanbul University, Istanbul, Turkey], Ali Çoner, MD [Department of Cardiology, Faculty of Medicine, Baskent University Alanya Application and Research Hospital, Antalya, Turkey], Assoc Prof Ozlem Arıcan Ozluk, MD [Department of Cardiology, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey], Hasan Kudat, MD [Department of Cardiology, Faculty of Medicine, Istanbul University, Istanbul, Turkey], Mustafa Yenerçağ, MD [Department of Cardiology, Samsun Training and Research Hospital, Samsun, Turkey], Bilal Çuğlan, MD [Department of Cardiology, Faculty of Medicine, Istinye University Liv Hospital, Istanbul, Turkey], Mustafa Kutay Yıldırımlı, MD [Department of Cardiology, Kızılay Hospital, Kayseri, Turkey], Gamze Çelik, MD [Department of Cardiology, American Hospital, Istanbul, Turkey]).

Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for clinical information to be reported in the journal.The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.