MINISTRY OF HEALTH OF THE REPUBLIC OF MOLDOVA [602365]

MINISTRY OF HEALTH OF THE REPUBLIC OF MOLDOVA
STATE OF MEDICAL AND PHARMACEUTI CAL UNIVERSITY
“NICOLAE TESTEMIȚ ANU”
FACULTY OF MEDICINE Nr. II

Health Promotion

DIPLOMA THESIS

Risk factors in the genesis of coronary disease in the
population of Israel

Name Ibrahim Kewan
VIth Year , group 1642
Scientific coordinator: Victor Me șina
Associate professor, Dr., Ph.

Chișină u 2015

2 Index of Contents

Introduction ……………………………………………………………… ..……3 -9
Chapter 1. Biography ……………………………………………………. ….10 -20
1.1. General characteristics of coronary Artery disease …………………. ….10 -12
1.2. Who is affected by coronary artery disease …………………………….12 -15
1.3. What are the risk factors for coronary artery disease ………………….. 16-19
1.4. Prophylaxis ……………………………………………………………..19 -20
Chapter.2. MATERIALS AND METHODS OF THE RESEARCHE .….21 -26
2.1. Methods ………………………………………………………….………. ..21-26
Chapter 3. PERSONAL RESULTS AND DISCUSSIONS …… …..……….27 -29
3.1 Results ……………………………………………………. ……………….27 -29
Chapter 4. GENERAL CONCLUSIONS ………………… …………………….30
4.1. Conclusions…………………………………………………………… ..……30
4.2. Results……………………………………………………… ..………………30
References ……………………………………………………………………. 31-34

3 Introduction
It is estimated that more than 16 million Americans have coronary artery
disease (CAD) and 8 million have had a myocardial infarction (MI). Every year
approximately 1 million will have a new myocardial infarction. Based on data from
the Framingham trial ne arly 50% of males and 30% of females over the age of 40
will develop coronary artery disease. Coronary artery disease is most commonly
due to atherosclerotic occlusion of the coronary arteries. Atherosclerosis is a
process that can involve many of the body ‘s blood vessels with a variety of
presentations. When it involves the coronary arteries it results in coronary artery
disease, the cerebral arteries; cerebrovascular disease (transient ischemic attack,
stroke), the aorta; aortic aneurysms, the ileo -femora l and popliteal arteries;
peripheral vascular disease, the mesenteric arteries; intestinal ischemia. Half of all
deaths in the developed world and a quarter of deaths in the developing world are
du to Cardiovascular Disease which are comprised of hypertens ion and the
diseases caused by atherosclerosis.
Lifestyle factors relevant to coronary risk factors differ between Palestinians
and Israelis. Both have been exposed, albeit differently, to the stressors of the long –
term conflict. We determined the incidenc e of coronary heart disease, previously
unreported in Palestinians, in these Mediterranean populations and made
international comparisons with the MONICA Programme.
Cardiovascular disease (CVD) remains the leading cause of death among
Europeans and around the world. The Global Burden of Disease study estimated
that 29.6% of all deaths worldwide (15 616.1 million deaths) were caused by CVD
in 2010, more than all communicable, maternal, neonatal and nutritional disorders
combined, and double the number of de aths caused by cancers.1 This paper
provides an update for 2014 on the burden of CVD, and in particular coronary

4 heart disease (CHD) and stroke, across the countries of Europe. This overview
updates the work published in this journal in 20132 and provides an up -to-date
synopsis of the key data in relation to mortality and morbidity from CVD across
Europe
International Cardiovascular Disease Statistics; Cardiovascular Disease
(CVD)
• According to WHO estimates, 16.7 million people around the globe die of
cardiovascular diseases each year.
• Of the total CVD deaths annually, about 8.6 million are of women. Heart attack
and stroke deaths are responsible for twice as many deaths in women as all cancers
combined.
• In 2001 CVD contributed to nearly one -third o f global deaths. Low – and middle –
income countries contributed to 85 percent of CVD deaths.
• In developing countries twice as many deaths from CVD now occur. A particular
cause for concern is the relatively early age of CVD deaths compared with those in
the developed regions.
• By 2010 CVD is estimated to be the leading cause of death in developing
countries. By 2020 the WHO estimates nearly 25 million CVD deaths worldwide.
Heart disease has no geographic, gender or socioeconomic boundaries.
• Between 199 0 and 2020, deaths from non -communicable diseases and injury are
expected to rise from 33 million to 58 million annually, with a similar proportional
increase in years of life lost. By 2020, cardiovascular diseases, injury and mental
illnesses will be resp onsible for about one half of all deaths and one half of all
healthy life years lost, worldwide.
• It‘s been projected that by 2020, chronic diseases will account for almost three –
fourths of all deaths.
 71 percent of deaths due to ischemic heart disease, 75 percent due to stroke and

5 70 percent due to diabetes will occur in developing countries.
 60 percent of the burden of chronic diseases will occur in developing countries.
 CVD is now more numerou s in India and China than in all economically
developed countries in the world added together.
• Of the estimated 32 million heart attacks and strokes that occur globally each
year, about 12.5 million are fatal.
• 50 percent of death and disability from CVD can be reduced by a combination fo
simple effective national efforts and individual actions to reduce major CVD risk
factors.
• CVD causes 8.5 million deaths among women annually. It‘s the largest single
cause of mortality among women, accounting for one-third of all deaths in women
worldwide. In developing countries, half of all deaths of women over 50 are due to
heart disease and stroke.• CVD is the leading cause of death in Europe, accounting
for over 4 million deaths each year. Nearly half (49 perc ent) of all deaths are from
CVD (55 percent of deaths in women and 43 percent of deaths in men). About half
of all deaths from CVD are from CHD and nearly one -third are from stroke.
• The average rates of hospital discharges in the European Union (EU) wer e
 For CVD, 2,190,000.
 For coronary heart disease (CHD), 629,000.
 For stroke, 356,000.

6 These data are for the latest available year. Hospital discharges include
people both living and dead.
• CVD is the leading cause of death in the European Union , accounting for over 1.5
million deaths each year. Nearly half (42 percent) of all deaths in the EU are from
CVD (46 percent of deaths in women and 38 percent of deaths in men). Between
one-third and one -half of deaths from CVD are from CHD and over one -fourth are
from stroke.
• CVD accounted for more than 245,000 deaths in the UK in 2001. 40 percent of
deaths in the UK are from CVD. 36 percent of premature deaths in men and 27
percent in women are from CVD.
• An estimated 8 million Canadians (1 in 4) ha ve some form of cardiovascular
disease. CVD accounts for more deaths than any other disease. 1999 CVD
mortality: 78,942; 35 percent of male deaths and 37 percent of female deaths. In
1994 CVD cost the Canadian economy about $18 billion.
• The latest avail able data from the World Health Organization (WHO) MONICA
Project indicate that the coronary event rate (per 100,000) in men was highest in
Finland (North Karelia, 835) and lowest in China (Beijing, 81). For women the
highest event rate was in the United K ingdom (UK) (Glasgow, Scotland, 265) and
the lowest in Spain (Catalonia, 35) and China (Beijing, 35). These data represent
results from 35 MONICA Project populations collected during the mid -1980s until
the mid -1990s.
• About 275,000 heart attacks (myocar dial infarctions) occur annually in the UK
(151,000 in men and 124,000 in women in 2001). The Health Survey for England
shows that more than 1.2 million people living in the UK have had a heart attack
(820,000 men and 390,000 women). Overall, about 1.5 mil lion men and 1.2
million women living in the UK have had CHD (either angina or heart attack or
both).

7 • Total prevalence of heart failure (definite and probable) in the UK is estimated at
880,000 in people age 45 and over (480,000 men and 400,000 women).
• In 2000 -01 there were 25,127 bypass procedures performed in the UK. In
addition, 38,992 angioplasty and other coronary intervention procedures were
performed in 2001.
• According to the WHO, in 1999 there were 7.1 million deaths from coronary
heart dis ease globally. In 2001 there were 7.2 million deaths from heart disease.
• In both developed and developing countries, 40 to 75 percent of all heart attack
victims die before reaching the hospital.
• CHD alone is the most common cause of death in Europe, accounting for nearly 2
million deaths each year. More than 1 in 5 deaths of women (22 percent) and men
(21 percent) are from CHD.
• CHD alone is the most common cause of death in the EU, accounting for over
600,000 deaths each year. One in 6 deaths of me n (17 percent) and 1 in 7 deaths of
women (15 percent) in the EU are from CHD.
• CHD alone is the most common cause of death in the United Kingdom, causing
more than 120,000 deaths in 2001. One in 4 deaths of men and 1 in 6 deaths of
women are from CHD. Other forms of heart disease cause more than 33,000
deaths. Total deaths from heart disease in the UK were just under 154,000.
• The CHD death rate for men ages 35 -74 fell by 39 percent from 1988 and 1998 in
the UK, but by 49 percent in Denmark and 45 perc ent in Norway and Austria. For
women, the death rate fell by 38 percent in the UK, but in Australia the rate fell by
14 percent more than that.
• By 1995 the annual mortality rate of CHD among middle -aged men (under age
65) in North Karelia, Finland, was r educed about 73 percent from the years before
the North Karelia Project (1967 -71). This reduction was especially rapid in North
Karelia in the 1970s and again after the mid -80s. During the last 10 years the

8 decline in CHD mortality in North Karelia has bee n approximately 8 percent per
year. The reduction among women has been of the same magnitude as among men.
• The premature death rate from CHD for male manual workers, such as builders
and cleaners, is 58 percent higher than for non -manual workers, such a s doctors
and lawyers. For female manual workers the death rate is more than twice as high
as that for female non -manual workers.
• The WHO predicts 11.1 million deaths from coronary heart disease in 2020. 4
• About 21 percent of CHD globally is attributa ble to body mass index (BMI)
above 21 kg/m2.
• About 22 percent of CHD globally is caused by physical inactivity.
Stroke
• According to WHO estimates, 15 million people each year survive minor strokes.
• The WHO estimates 5.5 million deaths from stroke wo rldwide in 2001.
• Stroke accounts for a higher proportion of deaths among women than men (11%
vs. 8.4%). Among women, nearly 3 million deaths from stroke occur annually.
• Stroke kills about 16,000 Canadians a year. Almost 60 percent of the 50,000
stroke s each year in Canada affect women. 9,038 women died from stroke in 1999.
About 300,000 Canadians are living with the effects of stroke. It costs about $2.7
billion a year.
• In Canada (1997), Colombia (1996) and Costa Rica (1995) there were more
female th an male deaths from stroke in the 35 -49 age group.
Purpose
Demonstration of risk factors in the genesis of diseases of the cardiovascular
system and develop recommendations for prevention.
Tasks
1. Studying cardiovascular disease morbidity in the populatio n globally .
2. Determination of risk factors in the genesis of cardiovascular diseases .

9 3. Analysis of cardiovascular morbidity in the population of Israel .
4. Select them a set of measures to prevent cardiovascular disease .

10 Chapter I . Biography
1.1. General characteristics of coronary Artery disease

If you or a member of your family has been diagnosed with coronary artery
disease(CAD), you may have questions about the disease and its treatment,
especially if your doctor has recommended balloon angioplasty, implantation of a
coronary stent, or Intravascular Brachytherapy. This booklet answers some of the
questions patients with coronary artery disease often ask.
Angioplasty – A balloon procedure to open an obstruction or narro wing of a
blood vessel. Also known as percutaneous transluminal coronary angioplasty
(PTCA). Stent – An expandable, slotted metal tube, inserted into a vessel. A stent
acts as a scaffold to provide structural support for a vessel. A drug -coated stent
allows for the placement of that particular drug at the stent implantation site. A
drug-eluting stent allows for the active release of that particular drug at the stent
implantation site.
Intravascular Brachytherapy – The administration of a therapeutic do se of
radiation from within a vessel to a specific area of vascular disease to prevent the
re-occurrence of an obstruction or narrowing of that vessel.
Ischemia is a condition described as ―cramping of the heart muscle.‖
Ischemia occurs when the narrowed c oronary artery reaches a point where it
cannot supply enough oxygen -rich blood to meet the heart‘s needs. The heart
muscle becomes ―starved‖ for oxygen. Ischemia of the heart can be compared to a
cramp in the leg. When someone exercises for a very long tim e, the muscles in the
legs cramp up because they‘re starved for oxygen and nutrients. Your heart, also a
muscle, needs oxygen and nutrients to keep working. If the heart muscle‘s blood
supply is inadequate to meet its needs, ischemia occurs, and you may fe el chest
pain or other symptoms.

11 Ischemia is most likely to occur when the heart demands extra oxygen. This
is most common during exertion (activity), eating, excitement or stress, or
exposure to cold. When ischemia is relieved in less than 10 minutes wit h rest or
medications, you may be told you have ―stable coronary artery disease‖ or ―stable
angina.‖ Coronary artery disease can progress to a point where ischemia occurs
even at rest. Ischemia, and even a heart attack, can occur without any warning
signs and is called ―silent‖ ischemia. Silent ischemia can occur among all people
with heart disease, though it is more common among people with diabetes.
Symptoms in Women
Women often have different symptoms of coronary artery disease than men.
For example, sy mptoms of a heart attack in women include:
– Pain or discomfort in the chest, left arm or back
– Unusually rapid heartbeat
– Shortness of breath
– Nausea or fatigue
If any of these symptoms occur, it is important to get medical help right
away – call 9 -1-1 or have someone take you to the nearest emergency .
Symptoms of Heart Disease
Coronary artery disease can progress very slowly, often without symptoms.
Most people do not realize that they have heart disease. In fact, the first sign that
something may be wrong could be an episode of angina, or even a heart attack.
Typical angina symptoms are feelings of pressure, tightness, or pain in the chest,
arm, back, neck or jaw.
Symptoms also include heartburn, nausea, vomiting, excessive sweating,
fatigue or shortness o f breath. Angina may occur as only one or many of these

12 symptoms. Although the exact cause of CAD is not known, there are certain risk
factors that are often seen in patients with coronary artery disease. These factors
include: high blood pressure, having a close relative with heart disease, high
cholesterol and/or triglycerides in your blood, diabetes, smoking, excessive weight,
and lack of a regular exercise program. Males are more likely to develop coronary
artery disease than females. Risk Factors for C AD.
You are at greatest risk for CAD if you:
• are male
• have high blood pressure
• are diabetic
• smoke cigarettes
• are overweight and/or inactive
• have a relative with the disease
Coronary Blood Flow
Perfusion. Under resting condition, the myocardium extracts the maximum
amount of oxygen from the blood it receives. ThThe heart is an aerobic organ that
is dependent for its oxygen supply entirely on coronary O2 saturation of blood
returning from the coronary sinus to the right atrium has the lowest satu ration of
any body organ (30%).
Interruption of coronary blood flow will result in immediate ischemia.
Coronary blood flow is directly dependent upon perfusion pressure and inversely
proportional to the resistance of the coronary vessel.
1.2. Who is affected b y coronary artery disease
Heart disease is the leading cause of death in the United States in men and
women. Coronary artery disease affects 16.8 million Americans. The American
Heart Association (AHA) estimates that about every 34 seconds, an American wil l
have a heart attack. In addition, the lifetime risk of having cardiovascular disease

13 after age 40 is 2 in 3 men and more than 1 in 2 women. Glossary Angina (Pectoris)
– chest discomfort, pain, tightness or pressure. May also have associated pain in
neck, jaw, back or arm. May include profuse sweating, nausea, or shortness of
breath. Angina may be a single symptom or a combination of these symptoms.
Angioplasty – A balloon procedure to open an obstruction or narrowing of a
blood vessel. Also known as percu taneous transluminal coronary angioplasty
(PTCA). Anticoagulant – A substance that slows, suppresses or prevents the
clotting of blood. Antiplatelet – A medicine that reduces the clumping of platelets
in the blood. An antiplatelet medicine helps thin the b lood to prevent clot
formation. Atherosclerosis – A disease process in which fatty substances (plaque),
such as cholesterol, are deposited on the inner lining of blood vessels. Coronary
Artery Bypass Graft (CABG) Surgery – An operation in which a piece of vein or
artery is used to bypass a blockage in a coronary artery; performed to prevent
myocardial infarction and relieve angina pectoris. CAD – Coronary Artery Disease.
Cardiac – Relating to the heart.
Catheter – A tube used for gaining access to one of th e body‘s cavities or
blood vessels.
In angioplasty, a catheter provides access to the heart‘s arteries.
Catheterization – A procedure that involves passing a tube (catheter) through
blood vessels and injecting dye to detect blockages.
Cholesterol – a subst ance that circulates in the blood and plays a role in the
formation of blockages. Cholesterol originates in foods that are rich in animal fats.
Computered Tomography Scanning – A technique for producing cross -sectional
images of the body in which X -rays ar e passed through the body at different angles
and analyzed by a computer; also called CT scanning or CAT scanning. Coronary –
Related to the arteries that supply blood to the heart. Coronary Angiogram – A test

14 used to diagnose CAD using the catheterization procedure. Contrast dye is injected
into the coronary arteries via a catheter, and this allows the doctor to see, on a x –
ray screen, the exact site where the artery is narrowed or blocked.
Coronary Arteries – The coronary arteries are special blood vessel s which
supply the heart with necessary oxygen and nutrients. The heart does not function
properly without enough oxygen. Coronary Artery Disease – Atherosclerosis of the
coronary arteries. CT Scanning – A procedure that uses X -rays and computers to
create cross -sectional images of the body to diagnose and monitor disease.
Diabetes – A disease affecting one‘s metabolism of glucose (sugar) which causes
change in blood vessels. These changes may aid in the development of coronary
artery disease.
EKG – Electro cardiogram. A test that measures and shows the electrical
activity of the heart muscle. Exercise Electrocardiogram. Fluoroscope – Equipment
used in a cardiac catheterization procedure which captures a ―motion picture‖ x -ray
image of the heart and coronary arteries.
In-stent Restenosis – A re-narrowing or blockage of an artery within a stent.
Intravascular Brachytherapy – The administration of a therapeutic dose of radiation
from within a vessel to a specific area of vascular disease to prevent the
reoccurre nce of an obstruction or narrowing. Ischemia – Lack of or insufficient
oxygen to the tissue, in this case, to the heart muscle.
Ischemia is a reversible condition if normal blood flow is restored. Left
Ventricle – The largest chamber of the heart which is responsible for pumping
blood throughout the body.
Lesion – A blockage in a blood vessel. It is also known as a plaque or
stenosis.
MRI – Magnetic Resonance Imaging. A diagnostic study similar to a CT or
CAT scan which creates an image using electromagneti c waves instead of x -ray.

15 Myocardial Infarction – Commonly called a ―heart attack‖. Involves
irreversible damage to heart tissue/muscle. Insufficient oxygen reaching the heart
muscle via the coronary arteries may cause angina, heart attack (myocardial
infarction), or even death to the affected area of the heart.
Percutaneous – Performed through a small opening in the skin.
Percutaneous Transluminal Coronary Angioplasty – See Angioplasty.
Plaque – The accumulated material that causes a blockage in a bloo d vessel.
Also known as a lesion or stenosis.
Platelets – Blood cells that are involved in the formation of a clot.
PTCA – Percutaneous Transluminal Coronary Angioplasty. See Angioplasty.
Restenosis – A re -narrowing or blockage of an artery at the same sit e where
angioplasty was previously done.
Stenosis – A narrowing of any canal, especially one of the cardiac vessels.
Stent – An expandable, slotted metal tube, inserted into a vessel. A stent acts
as a scaffold to provide structural support for a vessel. A drug-coated stent allows
for the placement of that particular drug at the stent implantation site. A drug –
eluting stent allows for the active release of that particular drug at the stent
implantation site.
Stress Test – A test that measures electrical cha nges in the patient‘s heart
(EKG) while the patient is doing controlled exercise. The stress test can show if
there has been damage to the heart or if there is decreased blood flow to areas of
the heart. Thrombosis/Late Thrombosis – A blockage caused by cl umping of cells.
Late Thrombosis occurs after 30 days.
Transluminal – Through the inside opening of an artery.
Triglycerides – Substances in the blood that are a component of the ―bad‖ type of
cholesterol.
Vessel – Any channel for carrying a fluid, such as an artery or vessel

16 1.3. What are the risk factors for coronary artery disease
Non-modifiable risk factors (those that cannot be changed) include:
Male gender. The risk of heart attack is greater in men than in women, and
men have heart attacks earlier in lif e than women. However, at age 70 and beyond,
men and women are equally at risk.
Advanced age. Coronary artery disease is more likely to occur as you get
older, especially after age 65.
Family history of heart disease . If your parents have heart disease
(especially if they were diagnosed with heart disease before age 50), you have an
increased risk of developing it. Ask your doctor when it‘s appropriate for you to
start screenings for heart disease so it can be detected and treated early.
Race. African Am ericans have more severe high blood pressure than
Caucasians and therefore have a higher risk of heart disease. Heart disease risk is
also higher among Mexican Americans, American Indians, native Hawaiians and
some Asian Americans. This is partly due to hi gher rates of obesity and diabetes in
these populations.
Modifiable risk factors (those you can treat or control) include:
Cigarette smoking and exposure to tobacco smoke
High blood cholesterol and high triglycerides – especially high LDL or
―bad‖ cholesterol over 100 mg/dL and low HDL or ―good‖ cholesterol under 40
mg/dL. Some patients who have existing heart or blood vessel disease and other
patients who have a very high risk should aim for a LDL level less than 70 mg/dL.
Your doctor.

17 Modifiable risk factors (continued)
High blood pressure (140/90 mm/Hg or higher)
Uncontrolled diabetes
Physical inactivity
Being overweight (body mass index or BMI from 25 -29 kg/m2) or being obese
(BMI higher than 30 kg/m2) .
NOTE: How your weight is distributed is important. Your waist measurement
is one way to determine fat distribution. Your waist circumference is the
measurement of your waist, just above your navel. The risk of cardiovascular
disease increases with a waist measurement of over 35 inches in women and over
40 inches in men.
Uncontrolled stress or anger
Diet high in saturated fat and cholesterol
Drinking too much alcohol
Reduce your risk factors.
Reducing your risk factors involves making lifestyle changes. Your doctor will
work with you to help y ou make these changes. If you smoke, you should quit.
Make changes in your diet to reduce your cholesterol, control your blood pressure,
and manage blood sugar if you have diabetes. Low -fat, low -sodium and low –
cholesterol foods are recommended. Limiting al cohol to no more than one drink a
day is also important. A registered dietitian can help you make the right dietary
changes. Cleveland Clinic offers nutrition programs and classes to help you reach
your goals.
Risk Factors for Atherosclerotic Coronary Arte ry Disease:
1. Dyslipidemias; particularly high low density cholesterol (LDL -C) and low high
density cholesterol (HDL -C).

18 2. Hypertension (50 million in the US, 1/3 undiagnosed, 3/4 under treated).
3. Diabetes mellitus (8% of US population). (Classification: Normal fasting
glucose < 110 mg/dL, Impaired 110 -≤ 126 mg/dL, Diabetes > 126 mg/dL)
4. Smoking (most important modifiable risk factor), CAD accounts for 35% -40%
of all smoking related deaths
5. Family history of premature coronary artery d isease (CAD); First degree male
relatives < 55 years or females < 65 years.
6. Obesity (18% of US population) and lack of exercise
7. Male sex and advanced age
8. Others (20% of CAD occurs in individuals without any of the classical risk
factors); homocyst einemia, high sensitivity C reactive protein (hs -CRP),
Fibrinogen, Lipoprotein a (Lpa), infection (? Chlamydia pneumoniae )
The metabolic syndrome is a recently identified entity that is associated with
an increase in the risk of developing diabetes mellitu s, cardiovascular disease and
mortality from all causes. It is found in 22% -24% of the US population.
Individuals with three or more of the following high risk features are defined as
having the metabolic syndrome;
1. Abdominal obesity: waist circumference >102 cm in men and >88 cm in
women
2. Hypertriglyceridemia: 150 mg/dL
3. Low high -density lipoprotein (HDL) cholesterol: <40 mg/dL in men and <50
mg/dL in women
4. High blood pressure: 130/85 mm Hg
5. High fasting glucose: 110 mg/dL (6.1 mmol/L).
Conseque nces of Atherosclerosis
1. Calcification, rigidity and increased fragility
2. Rupture of the fibrous cap exposing thrombogenic material to circulating

19 plateletsnand coagulants leading to thrombosis. This would result in vessel
occlusion and distal myocardi al infarction (necrosis).
Unstable angina and myocardial infarction
3. Plaque hemorrhage further narrowing the vessel lumen and occluding distal flow
4. Distal embolization of fragmented atheromatous plaque
5. Weakening of the vessel wall, wall expansion and dilatation (aneurysm)
What are the risks of radiation?!
There are potential risks associated with radiation of the heart. The dose of
radiation is localized to the treatment site in the coronary artery and the risk of
complications is thought to be low . The dose of radiation to the body is generally
less than that received during a heart catheterization. The long -term risks of
Gamma radiation in the coronary artery are unknown at this time.
During clinical studies an observation was made that there is a small chance
o having a blockage occur within the treated stent area when a new stent is used to
re-open the original stent and the patient is not on antiplatelet therapy for more
than 8 weeks. This blockage is caused by clumping of cells and is called la te
thrombosis. The use of antiplatelet therapy (medication used to prevent this
clumping of cells) has demonstrated an ability to reduce the occurrence of late
thrombosis. Your doctor will attempt to avoid placement of a new stent. However,
if placement of a new stent is necessary, you will be placed on antiplatelet therapy
as directed by your physician.
1.4. Prophylaxis
Diet and Lifestyle Changes
To help yourself stay healthy in the future, you are encouraged to make
important diet, exercise and lifestyle chang es. Some patients may need few
modifications while others may need to make many changes. Those patients who
are able to reduce the fats and cholesterol in their diets are less likely to redevelop

20 blockages within the stent. A low -fat, low -cholesterol diet can lower the levels of
fat in your blood and reduce your risk. Eating healthy foods in the right portions
will also help you to maintain or achieve a healthy weight. In addition to a healthy
diet, it is extremely important to avoid smoking. Smoking not on ly increases the
risk of worsening coronary artery disease, but it increases the chance that your
PTCA or stent site will close. If you need help with quitting, notify your health
care provider Other factors that can contribute to heart disease such as str ess and
lack of exercise should also be evaluated. Steps can be taken to reduce stress in
your life and your physician can help you develop a controlled exercise program.
Even after your full recovery, your doctor may want to check your progress from
time to time. You can reduce your risk of developing future disease by making
healthy lifestyle choices. Be sure to contact your doctor or health care provider if
you have any questions or need assistance regarding your lifestyle modifications.

21 Chapter II . MATERIALS AND METHODS OF THE RESEARCHE
2.1. Methods
This overview brings together a number of European and international data
sources to give an outline of comparable data for the region. In selecting the data
sources for inclusion, the key considerations were data quality, sources with
coverage of the greatest number of countries, and the most recently updated
sources. The scope of this update covers the mortality, morbidity, and treatment
data associated with CVD in Europe, with additional focus on the two most
common forms of CVD, CHD, and stroke. These data are fundamental to our
understanding of the burden and distribution of CVD in Europe, and sources arem
updated relatively frequently through routine and administrative data collections .
Information on medical and behavioural risk factors and co -morbidities, by
comparison, tend to be less frequently updated and there are greater challenges to
comparability across countries. Data reported in this paper have been sourced from
the World Hea lth Organization (WHO) mortality database, the WHO European
Region‘s Health for All Database, and the Organisation for Economic Co –
operation and Development (OECD) health statistics. Europe is here defined as the
53 member states of the WHO European region . Comparability and quality of the
data vary by topic, and there were no ‗ideal‘ data sources that provided complete,
up-to-date, high -quality, and representative information for all 53 countries for any
topic in this overview.
All mortality statistics, in cluding estimates of mortality rates and proportions
by cause, were calculated using age – and cause -specific data by country from the
WHO Mortality Database, using the most recent (February 2014) update. All
analyses, interpretations, and conclusions are t hose of the authors, not the WHO,
which is responsible only for the provision of the original information. Age
standardization was to the European Standard Population (ESP). Note that to

22 maintain consistency and comparability with the previous epidemiologi cal update
published in 2013,2 the same ESP has been used, in preference to the more
recently updated standard population developed by the European Commission for
the EU27+EFTA countries. The WHO database collates data reported by national
authorities base d on their civil registration systems and contains data for 52 of 53
European countries (no data available for Andorra). Where data are presented for
the ‗most recent year‘, this relates to the most recent data for which both mortality
and population data were available in the WHO datasets, with the exceptions of
Monaco, Montenegro, and Turkey, for which no population data were available.
These countries are included in the calculations for total numbers of deaths and
premature deaths .
But could not be incl uded in the section on age -standardized death rates. The
data are relatively up -to-date, and data for 40 of the 52 countries were available up
to 2010, 2011, or 2012; however, only 18 countries have provided updated
numbers in the year since our previous r eport.
The years to which the data relate for each country are given in the tables.
Consistent with our previous update, data are presented formortality before both 65
and 75 years. In this report, all data are presented as age standardized, with the
excep tion of the hospital discharge rates, for which this was not possible as no
standardized or age -specific data are published.
Mortality Cardiovascular disease is the leading cause of death in Europe,
and despite recent decreases in mortality rates in many c ountries, it is still
responsible for over 4 million deaths per year, close to half of all deaths in Europe
(Table 1). The proportion of all deaths that are attributable to CVD is substantially
greater among women (51%) than men (42%).Coronary heart diseas e,when
considered separately, accounts for almost 1.8 million deaths, or 20% of all deaths
in Europe annually.

23 The gender differences in the proportional contribution of CVD to total
mortality is driven far more by stroke and other CVD, and among both men and
women, CHD causes one in five of all deaths. Cardiovascular disease continues to
cause a much greater mortality Burden among Europeans than any other disease.
Overall, CVD caused 51% of deaths among women and 42% among men in the
last year of data, com pared with 19 and 23%, respectively, for all cancers (Figure
1).
In individual countries, however, the patterns vary widely. There are now 10
European countries in which cancer is the cause of more deaths than CVD among
men (Belgium, Denmark, France, Israe l, Luxembourg, Netherlands, Portugal,
Slovenia, Spain, and SanMarino).The latest data also show that for the first time,
cancer has surpassed CVD as a cause of death among women in one country
(Denmark). Conversely, in 32 of 52 countries, the most recent d ata show more than
double the number of deaths from CVD compared with cancer in women, and of
those, 15 countries where CVD causes more than four times more deaths than
cancer. Among men, there are 21 countries where CVD deaths are more than
double cancer deaths, and 6 countries where they are more than four times greater.
Premature mortality The proportion of all deaths that are caused by CVD increases
with age, therefore, the proportion of premature deaths among Europeans caused
by CVD was substantially l ower than the overall rate. Three in every ten deaths of
Europeans aged under 65 in the latest year of data were caused by CVD, aswere
37% of all deaths occurring before age 75 (Table 1). In total, 1.48 million deaths
before age 75 in Europe were caused by CVD, more than half of which were in
people aged 65 –74 years. In contrast to overall deaths (‗all ages‘), the proportion of
premature deaths, either before age 65 or before age 75, that are caused by CVD
shows limited gender differences. Mortality rates a cross European countries The
most up -to-date data on CVD in Europe show that the burden of mortality

24 continues to show large geographic inequalities. Updated data from Denmark and
Norway show that they now have among the lowest rates of age -adjusted CVD
mortality (,180 per 100 000 men at all ages, ,120 per 100 000 women), and
Denmark in particular has joined countries, including France, Portugal, the
Netherlands, and Spain, with the lowest rates of CHD mortality . Setting aside
Turkmenistan, for which the l atest available mortality data are from 1998, the
highest rates of CVD mortality were found in the Russian Federation and Belarus
for men (915 and 892 per 100 000, respectively), and Uzbekistan and Kyrgyzstan
for women (662 and 588 per 100 000).Premature m ortality from CVD among men
varied almost 10 -fold from ,65 per 100 000 before age 75 (age standardized) in San
Marino, France, Israel, and Switzerland, to over 560 per 100 000 in the Russian
Federation and Belarus. Among women, the magnitude variation betw een
countries was similar, from five countries with fewer than 25 deaths per 100 000
before age 75 (France, Iceland, Switzerland, Israel, and Spain) to 10 countries with
rates exceeding 200 per 100 000. Details of premature mortality rates are given in
the Supplementary material online, Table S1 (mortality rates before age 65 and
before age 75).
Mortality rates increase with age in all countries; however, due to the wide
variation between countries, there are many cases where the mortality rate among
(for e xample) 65 –69 year olds in one country may be equivalent to or higher than
the mortality rate for 75 –79 year olds in another country. Taking the most recent
mortality rates among 75 –79 year olds in France as the reference (the first age
group not considered a ‗premature‘ death under usual definitions, and the country
with the lowest mortality rates for that age group in both sexes), we calculated the
age groups in all other countries for which the rates in the latest year were equal to
or greater t han the referent (Figure 2). Countries with no data within the last 5
years were excluded. This showed that among men, there were five countries

25 where the CVD death rates among 55 –59 year olds was higher than the referent, a
further 5 countries where the C VD rate among 60 –64 year olds was higher than the
referent, and 10 countries where equivalent mortality rates were reached at ages at
least 10 years younger than in France. This means that CVD mortality rates among
55–59-year-oldmen in Belarus, Kazakhstan, Kyrgyzstan, Russia, and Ukraine were
higher than equivalent rates in French men 20 years older. The results were similar
among women.
Table 2: Age -standardized death rates from cardiovascular disease and
coronary heart disease by country and sex (per 100 000 population)

26

27 Chapter III . PERSONAL RESULTS AND DISCUSSIONS
3.1 R esults
We confirmed a total of 265 coronary events among 76 200 Arabs and 698
among 226 500 Jews. Rates among Arabs were substantially higher than in Jews,
particularly so in women. Age -adjusted rate ratios (RRs) for coronary events were
1.58 [95% confidence inte rval (95% CI) 1.34 –1.87] among men and 2.37 (95% CI
1.81–3.10) among women. When restricted to coronary deaths, Arab: Jewish RRs
were 2.79 (95% CI 2.09 –3.73) in men and 2.66 (95% CI 1.77 –4.00) in women.
Compared with MONICA populations in 20 countries, Ara bs ranked first in total
coronary event rates and first in non -fatal myocardial infarction rates, exceeded
populations in Finland, Scotland, and Northern Ireland, and showed striking
differences from the participating Mediterranean centres.
Since 1967 Palestinian Arabs of east Jerusalem have the legal status of
permanent residents of Israel. This population, distinguishable from Israeli Arabs
who are citizens of the country from 1948, similarly holds Israeli identity cards, is
fully covered b y Israeli national health insurance, is entitled to social security
payments, and has access to the Israeli job market. As such, Palestinians living in
east Jerusalem differ from their compatriots in the West Bank and Gaza Strip.
Israeli Arabs and Jews di ffer in their cardiovascular risk factors. Obesity
(and high waist -to-hip ratios), diabetes, and lack of exercise, but not smoking, were
more prevalent in Arab women, whereas smoking and diabetes were more frequent
in Arab than Jewish men.1,2 It is likely that important lifestyle and risk factor
differences exist also between Israelis and Palestinians. Bot h populations have
been exposed, albeit differently, to the tensions and stressors accompanying the
long-term conflict.3,4 Based on Israeli official cause -of-death statistics, east
Jerusalem Arabs had over double the coronary heart disease (CHD) mortality of

28 the Jewish population between 1984 and 1997, though both populations
experienced a decline during t he period.5
Within this unusual context, we assessed the incidence of CHD to
distinguish whether the higher mortality rate in Palestinians was due to excess
incidence, excess case fatality or both, using a population -based heart attack
registry in the Jerusalem district. This registry, which adhered to the WHO –
MONICA (World Health Organization Monitoring Trends and Determinants in
Cardiovascular Disease) programme protocol,6,7 is comparable with those of 38
centres in 21 countries,7,8 including populations in the Mediterranean basin.
Comparisons with the latter are of special interest because unlike the Israelis,9
West Bank10 and east Jerusalem Arabs (Z Abdeen and M Qleibo, personal
communication) are predominantly olive oil consu mers.
Comparisons with MONICA . Jerusalem Arabs exceeded all 20 countries
with MONICA registers both in coronary event rates and non -fatal infarction rates.
Jewish residents ranked high, third and second, respectively, but significantly
below Jerusalem Ara bs (Figure 1 ). We repeated the comparison with all individual
MONICA populations. Glasgow, Scotland reported the highest age -adjusted sex –
averaged event rate in a MONICA population ( 510 per 100 000),8 similar to that in
East Jerusalem Arabs (516 per 100 000). The east Jerusalem Arab rate exceeded
that of North Karelia, Finland, the next -highest ranking MONICA population (386
per 100 000), by 34% and was more than double the average event rate of all
MONICA populations that registered events between 1991 and 1993 (240 per
100 000). The east Jerusalem non -fatal infarction rate (348 per 100 000) exceeded
the two highest -ranking MONICA populations, Glasgow (291 per 100 000) and
Belfast, Northern Ireland (218 per 100 000), by 19 and 59%, respectively.
Compared with the 20 countries, Arabs ranked high for all coronary mortality

29 (fifth) and prehospital mortality (seve nth), significantly above Jerusalem Jews who
ranked 17th and 18th from the top, respectively ( Figure 2 ). Arabs ranked fourth
lowest in case fatality, above the Jewish population (sec ond lowest) (not shown in
figures). However, this low ranking belies high case fatality among 65 – to 74 -year-
old Arab men, an age group not studied in MONICA. After exclusion of past
myocardial infarction, the top Arab ranking for coronary event and non -fatal
infarction rates persisted (not shown). Overall, Jerusalem Arabs differed
diametrically from populations in the Mediterranean countries —Spain, Italy, and
France, characterized by low incidence and low coronary mortality, whereas the
Jewish population e xhibited Mediterranean -like low prehospital mortality and
overall coronary mortality, but discrepantly high total and non -fatal event rates.

30 Chapter IV . GENERAL CONCLUSIONS
4.1. Conclusions
Coronary risk appears to be particularly high in Palestinian Arabs.
Determinants of these unexpected findings should be sought and prevention
programmes initiated .
4.2. Results
In 1997 we confirmed a total of 963 events that fulfilled MONICA criteria,
265 in Arab and 698 in Jewish residents. At ages studied by the MONICA project
(35–64 years) there were 159 events in Arabs and 407 events in Jews. Compared
with Jews, Arab patients were more likely to be female, were less educated, had
higher diabetes prevalence, and higher prevalence of smoking (among men) ( Table
1). A higher proportion of Arab than Jewish male patients had fatal events,
particularly prehospital deaths. The proportion of sudden death among the
prehospital deaths ( occurring within 1 h of symptom onset), however, did not
differ significantly between the population groups. Typical symptoms, ECG
characteristics, and enzyme levels did not differ significantly between the ethnic
groups among patients with definite myocar dial infarction, except for less typical
symptoms in Arab women. Elapsed time from symptom onset to hospital arrival
did not appear to differ significantly between Arab and Jewish patients.

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