Serpil Aydin Demira (1)
Ayfer Gemalmaz (2)
Sule Ozkan (3)
Tufan Nayir (4)

(1) MD, Assoc. Professor of Family Medicine, Chair Adnan Menderes University, School of Medicine, Department of Family Medicine, AYDIN (during the study period Suleyman Demirel University, School of Medicine, Department of Family Medicine) Head of Community Based Medicine Training Committee,
Vice-coordinator of internship
(2) MD, Assist. Prof. of Family Medicine, Adnan Menderes University, School of Medicine, Department of Family Medicine, AYDIN
(3) MD, Family Medicine Specialist, Isparta
(4) MD, Resident, Suleyman Demirel University, School of Medicine, Department of Public Health, Isparta,

Corresponding Address:
Dr. Serpil Aydin
Mimar Sinan Mah. Dus Bahçeleri Sitesi 2. Cad. 2429. Sok. No: 39 (P.K. 112)
09100 AYDIN
Telephone: +90 256 219 7188 (office)
Fax: +90 256 219 2011 (office)
Email: serpilden1@yahoo.com, sdaydin@adu.edu.tr , serpilaydin@ekolay.net

As coronary heart disease (CHD) is a very common and important worldwide problem, many attempts are made to decrease its morbidity and mortality rates (1). By 2010, it is expected that there will be 3.4 million cases and 170 thousand deaths because of CHD annually (2). Although its risk factors have been well-known for decades and prevention efforts are increasing, it is not easy to control the disease (3). Individual risk should be assessed for interventions, as it is difficult to treat especially patients with multiple risk factors. For example patients with lower risks need less aggressive management than high risk patients (4). International guidelines emphasized the importance of assessment of individual global risk, and stated that there should be a certain threshold value to begin medical treatment and for global risk for CV event in the next ten years based on Framingham risk equation (5,6). This sex-specified equation can be used for different ethnic groups (7).

Risk factor reduction should be focused for CHD prevention and to decrease the morbidity and mortality rates with primary and secondary prevention, which are necessary to improve public health (1). The undeniable benefits of primary prevention in health, length and quality of life are defined and these approaches take their place in commonly used guidelines. Decreasing blood pressure (BP), cholesterol, increasing physical activity, controlling glucose levels in diabetics, weight loss in obese patients and cessation of smoking in smokers significantly decreases end organ damage (myocardial infarction and stroke), health expenditure and mortality. In USA, primary prevention declined the rate of coronary heart disease deaths by one quarter and secondary prevention declined by 29% and in UK, 58% of the fall in mortality is attributable to risk factor reduction, especially blood pressure, cholesterol and smoking(1). Primary prevention accounted for 81% and secondary prevention accounted for 19% decrease in mortality rates. Besides, secondary prevention can add an additional 7.5 years and primary prevention can add 21 additional years to life (1). This means that both primary and secondary prevention can halve the death rates, so it is important to detect the healthy people for risk identification. Successful CHD strategies should focus on secondary and especially primary prevention including healthy diets and non-smoking population. Although the guidelines suggest detection from earlier ages, studies on risk prediction and prevention in adults younger than 40 years of age are limited (8).

Family physicians have more advantages according to other specialties for the modification of risk factors (9). All of the risk factors should be assessed and modifiable ones should be corrected in individual approaches (10).

Our primary goal in this study was to evaluate patients according to their ten-year-coronary heart disease development risks and reduce this risk by interventions. Secondary aims were to define our patient population, to call attention to this important issue and to call attention to the significance of primary and secondary prevention.

Setting
Suleyman Demirel University School of Medicine, Department of Family Medicine was established in August 2000 in Isparta and began to accept ambulatory patients in December 2001. As a "family medicine and check up clinic" admissions were available every day by appointment. Our day clinic was located in the Suleyman Demirel University Hospital which serves up to about 1,500,000 people.

Patients
All the patients above 20 years and who had attended during December 2001-December 2004 were included in this study. All the patients were informed about the procedure and oral informed consent was obtained. For each patient, medical history was revealed and physical examination was made by S.A and/or S.O. Patients were evaluated according to their CV risk factors and their ten-year-risk was assessed by using Framingham risk scoring tables (11, 12). Diagnostic procedures were performed according to international guidelines (13-17). Body mass index (BMI) was used for assessment of obesity (18).

Smoking status was assessed in each patient. For smokers, patient education was given and they were encouraged to quit.

After evaluating the coronary heart disease risk, ten-year-risk points were calculated for the patients. Each patient was categorized in one of five subclasses according to their multifactor CAD risk (9, 19).

Appropriate interventions and treatments for the risk factors were performed. Life style modifications (physical activities, low cholesterol and saturated fat diet, cessation of smoking, etc) patient education and if indicated intervention and/or treatment were applied. Follow-up appointments were organized and at the 24th month a substantial follow-up was held for each patient, to re-evaluate their subsequent risk scores.

Student T, chi-square and correlation tests were used for statistical analysis. A p value smaller than 0.005, was considered to be statistically significant.

Of 355 adult patients, 342 could be followed up (96.3%). Mean age of females and males were 44.9 11.3, and 46.3 11.9, respectively. 185 of them were female (54.1%). 27 had Type 2 diabetes mellitus (T2DM) (7.9%), 132 had hypertension (HT) (38.6%) and 244 had dyslipidemia (DL) (71.3%). 240 patient's body mass indexes were ?25 kg/m2 (70.2%). 81 patients were smokers (23.7%). 3 patients had a CHD history (0.8%).

10 of the 342 patients were thin (2.9%), 92 were normal (26.9%), 151 (44.2%) were overweight, 83 (24.3%) were obese and 6 (1%) were morbidly obese patients. After physical exercise, education and diet arrangement, if still needed, patients were referred to a diet specialist.

Most common presenting symptoms can be seen in Table 1.

Most common five symptoms:

Table 1. Most Common Presenting Symptoms

The most commonly encountered chronic disease in the medical history of our patients was HT (56.1%). 9 (% 2.6) had T2DM, 6 (1.8%) had chronic obstructive pulmonary disease (COPD), 3 (%0.9) had CHD, 2 (%0.6) had a cancer diagnosis and 51 (14.6%) had other diseases. 180 (52%) had no known chronic disease in their medical history.

261 (76.3%) of patients were either not active smokers at least for 1 year or non smokers. 81 (23.7%) were smoking >20 cigarettes a day. Significant difference was detected in gender distribution and smoking as smoking incidence was higher in males (p=0.0004).

210 of 342 (6.4%) were normal or prehypertensive and the rest were hypertensive (n=132 (38.6%)); of these 73 (21.3%) had grade I HT, 59 (17.2%) had grade II HT. 91 (68.9%) of hypertensive patients were on antiHT medication whereas 41 (31.1%) were not. There were 38 females, and 35 males with grade I and 33 females, and 26 males with grade II HT. 46.2% of HT patients were male and 53.8% female. There was no statistical significance between grades in male and females (p=0.575). A moderate level association had been found between age and systolic (r=0.472, p=0.03) and diastolic hypertension grade (p=0.000).

The difference between BMI in males and females was statistically significant and higher in females. Being female was found to be a risk factor for high BMI (p= 0.045). A significant, positive, moderate level association had been found between BMI grades and HT (r=0.337, p=0.000) and age (p=0.000, r= 0.327). Distribution of BMI percentage according to gender can be seen in Figure 1.

Figure 1. Distribution of BMI percentage according to gender
o.weight: overweight
m.obese: morbid obese

Mean total cholesterol (T-C) value calculated was 194.9 37.4 mg/dl for females, and 197.9 46.9mg/dl for males. Mean high density lipoprotein cholesterol (HDL-C) was 51.1 12.9 mg/dl in females and 44.6 12.6 mg/dl for males. HDL-C levels were significantly higher in females (p=0.000).

HDL-C level distribution according to smoking status can be seen in Table 2.

HDL mg/dl	n	%
40	27	33.3
40-49	29	35.8
50-59	12	14.8
60	13	16.0
Total	81	100.0

Table 2. HDL distribution according to smoking status in 81 smokers

Mean age of patients with DL was 46.8 10.6, while it was 42.2 13.2 for the rest. Mean age was significantly higher in dyslipidemics. The difference between mean age of males and females was found significant (p=0.002). HT incidence in dyslipidemics was found to be significantly higher (p=0.031) (Table 3).

Table 3. Hypertension and Related Entities in Study Population
*Patients with a systolic B.P of 130-139mm/Hg or Diastolic B.P of 85-89 mm/Hg were included in this study. For some of the prevalence assessments these borderline hypertensive patients were accepted as hypertensive so number of hypertensives became 172. The real number is 132.

27 of 342 patients (7.9%) had T2DM (18 of them were female). We compared frequency of HT in diabetics and non diabetics. HT incidence in diabetics was found significantly higher (p=0.015).
3 patients had CHD and coronary angiography history (0.9%). 2 of them were males (54 and 79 years of age), 1 was female (43 years).

In our study group; 191 patients (55.8%) had low, 56 (16.4%) had minor, 52 (15.2%) had moderate, 42 (12.3%) had high and 1 (0.03%) had very high coronary risk. There was a strong, positive and significant association between coronary risk and age (r=0.522, p=0.000) (Table 4).

Table 4. Comparison of high and low Risk Cardiac cases

Male sex is associated with higher coronary risk (p=0.000) (Table 5).

Table 5. Risk Group Distribution According to Gender
(chi square at slope p=0.000)

After interventions, 191 (55.8%) patients remained low; 62 (18.1%) patients had minor; 56 (16.4%) had moderate; 32 (9%) had high and 2 (0.06%) had very high coronary risk. There was no statistical significance between percentages before and after interventions (p=0.355).

Table 6. Risk Group Distribution According to Gender after Interventions
(p=0.0008)

Although there was no statistical significance between risk groups before and after interventions, high risk groups decreased from 42 to 31 (Table 5 and 6). 11 patients consisted of 7 women and 4 men. After interventions, the most successful results were achieved in decreasing BMI.