Atypical symptoms other than chest pain in patients with CAD make them more likely to face unfavorable prognoses such as under-treatment and poor clinical outcomes [7]. Early reperfusion in the setting of an acute myocardial infarction is of utmost importance for reducing myocardial damage, reducing infarct size, and decreasing morbidity and mortality [8-10]. Accordingly, recognition of heart attack warning symptoms and CAD’s risk factors may influence an individual’s, the family’s, or bystander’s decision time in accessing health care, which in turn, affects the time-sensitive benefits of reperfusion therapy [11].
An observed delay in presentation of patients with Acute Coronary Syndrome (ACS) to emergency services in Prince Sultan Cardiac Centre-Qassim (PSCCQ) is possibly because of inability to recognise the symptoms and lack of perception of their own risk factors, which influence their outcomes. Young individuals show a high prevalence of risk factors for cardiovascular disease, such as obesity, physical inactivity, and poor diet [12]. Recent study documented a 1.2% prevalence of CAD cases in the young-age group [13].
Knowledge about heart disease and its symptoms is necessary for patients so that they can promptly identify symptoms of ACS and take immediate action to pursue care [14]. To the best of our knowledge, no previous study has evaluated the knowledge and perception of CAD in patients with CAD and the general population in the Al-Qassim Region. The present study was designed with the aim to assess the level of awareness for CAD symptoms and risk factors in Saudi population in Al-Qassim Region, Saudi Arabia.
Materials and Methods
Study Design and Population
A cross-sectional, hospital and community-based descriptive study was conducted from May 2018 to October 2018, in which 3235 Saudi citizens were recruited; comprising of 3085 subjects without documented CAD and 150 patients with documented CAD.
Recruitment of patients was from Cardiology Department and outpatient clinics at PSCCQ, King Fahd Specialist Hospital (KFSH). Eligible patients were those admitted with ACS, stable angina or a previous history of Coronary Artery Bypass Graft/Percutaneous Coronary Intervention (CABG/PCI). Inpatients with life-threating conditions were excluded. PSCCQ is the only specialised tertiary governmental centre for cardiovascular diseases in Al-Qassim Region.
Healthy participants were recruited through convenience sampling from community and from patients’ companions in non-cardiac clinics, KFSH. Inclusion criteria for the healthy participants were Saudi citizen, age >18-years-old, resident in Al-Qassim Region, with no documented CAD.
Instrument: Questionnaire Structure
In collaboration with experts from PSCCQ, a pre-piloted well-structured questionnaire was applied after a comprehensive review of the literature [15-17]. The corresponding author translated and verified the questionnaire into Arabic. All the questions were closed-ended with the only responses of yes, no, or don’t know.
The questionnaire was arranged into four sections. The first section comprised questions about participants’ demographic and clinical data (including age, gender, education, marital status, working status, smoking status, and family history of CAD). The second and third sections queried each participant’s knowledge about CAD risk factors and symptoms (10 questions each). Two questions in the fourth section asked about basic life support knowledge i.e., knowledge about Cardiopulmonary Resuscitation (CPR) and ambulance number. In addition, the resources of information on CAD for all participants were recorded. The alpha coefficient for the questions was 0.752. Participants responded ‘yes’, ‘no’, ‘don’t know’ to whether a particular symptom or risk factor was associated with CAD; know cardiopulmonary resuscitation or ambulance number.
Each correct answer was evaluated by one point while false and ‘don’t know’ answers were given a zero. The mean score for each section (second, third, and fourth) was calculated based on the total score in each; then it was expressed as mean±standard deviation. Well-trained research assistants, fourth-year medical students-Qassim University, administered the questionnaire to the patients with CAD through face-to-face interviews, and to the healthy participants through an online survey and face-to–face interviews.
Ethics
The protocol of this study conformed to the Declaration of Helsinki. Participation was voluntary, and each participant gave a verbal consent following a thorough explanation of the study goals by the research assistants. It maintained confidentiality of all participants, as the study did not request the names of the participants. The Regional Research Ethics Committee, Al-Qassim Region, Saudi Arabia approved the study (No. 20180808).
Statistical Analysis
IBM Statistical Packages for the Social Sciences (SPSS) version 23.0 software was used to analyse data. Results were presented as the mean±standard deviation or percentage where relevant. Difference between patients and healthy participants was tested for significance by a Student’s t-test (for continuous data) or chi-square test (for categorical data). Value of p<0.05 was considered statistically significant.
Results
A total of 3235 Saudi citizens, comprising 3085 healthy participants (without documented CAD) and 150 patients (with documented CAD) agreed to participate in the study. The male to female ratios were 2.9:1 and 3.7:1 for the healthy participants and patients, respectively. A total of 54.4% of the general population and 13.3% of patients had an education at the university level or above. Students represented 19.5% of the general population; however, 38.7% of patients were retired. [Table/Fig-1] summarises the main characteristics of the patients and the general population.
Characteristics of the study participants.
| Variable n, % | | General population (n=3085) | Patients (n=150) | All (3235) | p-value Chi-square |
|---|
| Gender, Male | | 2296, 74.4% | 119, 79.3% | 2414, 74.7% | 0.177 |
| Age | 15-24 years | 860, 27.9% | 00, 0% | 860, 26.6% | <0.05* |
| 25-54 years | 1950, 63.2% | 51, 34% | 2001, 61.9% | |
| 55-64 years | 209, 6.8% | 60, 40% | 269, 8.3% | |
| ≥65 years | 66, 2.1% | 39, 26% | 105, 3.2% | |
| Education | Illiterate | 88, 2.9% | 43 28.6% | 131, 4.0% | <0.05* |
| ≤Secondary school | 1026, 33.2% | 78, 52.0% | 1104, 34.1% | |
| Diploma | 293, 9.5% | 10, 6.7% | 303, 9.4% | |
| ≥University | 1678, 54.4% | 19, 13.3% | 1697, 52.5% | |
| Marital status | Single | 1324, 42.9% | 06, 4.0% | 1330, 41.1% | <0.05* |
| Married | 1697, 55% | 140, 93.3% | 1837, 56.8% | |
| Divorced | 39, 1.3% | 02, 1.3% | 41, 1.3% | |
| Widowed | 25, 0.8% | 02, 1.3% | 27, 0.8% | |
| Working status | Student | 601, 19.5% | 00, 0% | 601, 18.6% | <0.05* |
| Working | 1617, 52.4% | 48, 32% | 1665, 51.4% | |
| Not working | 577, 18.7% | 44, 29.3% | 621, 19.2% | |
| Retired | 290, 9.4% | 58, 38.7% | 348, 10.8% | |
| Smoking status | Non smoker | 2372, 76.9% | 97, 64.7% | 2469, 76.3% | <0.05* |
| Smoker | 553, 17.9% | 23, 15.3% | 576, 17.8% | |
| Quit smoking | 155, 05% | 30, 20% | 185, 05.7% | |
| Family history of CAD | Yes | 892, 28.9% | 37, 24.7% | 929, 28.7% | <0.05* |
*p<0.05, compared patients with CAD to general population
As presented in [Table/Fig-2], the knowledge and perception about CAD risk factors was above average (i.e., more than 50% of respondents answered correctly for each risk factor) for almost all risk factors. However, levels of awareness for questions “incidence of CAD is increasing in young people” and “diabetes as a risk factor increases the chance of CAD” were 31.4% and 57.9% (respectively) among all participants.
Percent of correct responses for CAD risk factors in study participants.
| CAD Risk factor, N, % correct responses | General population (n=3085) | Patients (n=150) | All (n=3235) | p-value Chi-square |
|---|
| The incidence of CAD is increasing in young people | 939, 30.4% | 78, 52.0% | 1017, 31.4% | <0.05* |
| Stress increases the chance of CAD | 1745, 56.6% | 98, 65.3% | 1843, 57.0% | 0.034* |
| Smoking increases the chance of CAD | 2784, 90.2% | 129, 86.0% | 2913, 90.0% | 0.090 |
| CAD is often associated with a raised blood cholesterol | 2431, 78.8% | 115, 76.6% | 2546, 78.7% | 0.796 |
| CAD is often associated with a lack of exercise | 2565, 83.1% | 108, 72.0% | 2673, 82.6% | <0.05* |
| CAD is often associated with an increased blood pressure | 2220, 72.0% | 111, 74.0% | 2331, 72.1% | 0.587 |
| Family history of CAD increases the chance of CAD | 1581, 51.2% | 70, 46.7% | 1651, 51.0% | 0.273 |
| Old age increases the chance of CAD | 2104, 68.2% | 97, 64.7% | 2201, 68.0% | 0.365 |
| Diabetes increases the chance of CAD | 1761, 57.1% | 111, 74.0% | 1872, 57.9% | <0.05* |
| Obesity increases the chance of CAD | 2578, 83.6% | 120, 80.0% | 2698, 83.4% | 0.252 |
*p<0.05, compared patients with CAD to general population
[Table/Fig-3] illustrates the perception of CAD symptoms that showed a serious lack of knowledge among all participants. The perception of majority CAD symptoms was below average (less than 50%) among study participants.
Percent of correct responses for CAD symptoms in study participants.
| CAD symptoms, N,% correct responses | General population (n=3085) | Patients (n=150) | All (n=3235) | p-value Chi-square |
|---|
| CAD causes chest discomfort/burning sensation of the chest | 1597, 51.9% | 121, 80.7% | 1718, 53.2% | <0.05* |
| CAD causes pain in the arms/shoulders | 1543, 50.0% | 114, 76% | 1657, 51.2% | <0.05* |
| CAD causes fatigue | 2211, 71.7% | 116, 77.3% | 2327, 71.9% | 0.132 |
| CAD causes upper back discomfort | 1101, 35.7% | 81, 54.0% | 1182, 36.5% | <0.05* |
| CAD causes discomfort in the jaw | 703, 22.8% | 48, 32.0% | 751, 23.3% | 0.074 |
| CAD causes shortness of breath | 2284, 74.0% | 116, 77.3% | 2400, 74.2% | 0.654 |
| CAD causes sweating | 1865, 60.5% | 106, 70.7% | 1971, 60.9% | 0.043* |
| CAD causes nausea and vomiting | 1299, 42.1% | 85, 56.7% | 1384, 42.8% | 0.002* |
| CAD causes dizziness and collapse | 1882, 61.0% | 96, 64.0% | 1978, 61.1% | 0.748 |
| CAD causes indigestion or upper gastric discomfort | 883, 28.6% | 60, 40.0% | 943, 29.2% | 0.029* |
*p<0.05, compared patients with CAD to general population
Surprising finding [Table/Fig-4] was that only 36.8% of all participants knew CPR which is an emergency lifesaving procedure to save a cardiac patient’s life while approximately half (50.1%) could report accurately the contact number of Emergency Medical Services (EMS) which is 997 in Saudi Arabia.
Basic life support knowledge.
| Positive responses, N, % | General population (n=3085) | Patients (n=150) | All (n=3235) | p-value Chi-square |
|---|
| Do you know cardiopulmonary resuscitation (CPR) | 1167, 37.8% | 24, 16% | 1191, 36.8% | <0.05* |
| Do you know the contact number of emergency medical service (EMS) | 1587, 51.4% | 35, 23.3% | 1622, 50.1% | <0.05* |
*p<0.05, compared patients with CAD to general population
As documented in [Table/Fig-5], total score of CAD overall knowledge for general population was 12.66±5.1 and 13.59±4.8 for patients (p=0.015). No significant difference in total score knowledge of CAD risk factors between the two groups was recorded. However, patients had statistically significant higher total score for knowledge of CAD symptoms when compared to healthy participants.
The mean CAD overall knowledge score, and the mean scores for CAD risk factors and CAD symptoms in Al-Qassim Region (values expressed as mean±SD).
| General population (n=3085) | Patients (n=150) | All (n=3235) | p-value t-test |
|---|
| Total score for knowledge of CAD risk factors, mean±SD (out of 10) | 6.72±2.4 | 6.91±27 | 6.73±2.4 | 0.373 |
| Total score for knowledge of CAD symptoms, mean±SD (out of 10) | 5.01±3.1 | 6.29±2.7 | 5.07±3.1 | <0.05* |
| Total score of CAD overall knowledge, mean±SD (out of 22) | 12.62±5.1 | 13.59±4.8 | 12.66±5.1 | 0.015* |
*p<0.05, compared patients with CAD to general population
As displayed in [Table/Fig-6], for general population media represented the major source of information on CAD (22.8%) while newspaper was the least source (8.7%). However, self-previous experience was the major tool for educating patients with CAD about the disease (58%).
Participants’ source of information for CAD in Al-Qassim Region (values expressed as number, %).
| Source | General population | Patients | p-value |
|---|
| Media | 962, 22.8% | 20, 13.3% | <0.05* |
| Newspaper | 368, 8.7% | 09, 6.0% | 0.085 |
| During study | 817, 19.4% | 08, 5.3% | <0.05* |
| Friend/Relative | 783, 18.6% | 54, 36.0% | 0.004* |
| Health sector | 516, 12.2% | 27, 18.0% | 0.899 |
| Social media | 770, 18.3% | 25, 16.7% | 0.066 |
| Self-previous experience | 0 | 87, 58.0% | -- |
Discussion
Making a lifestyle change in patients is difficult with inadequate knowledge about CAD, which may increase mortality and morbidity [18]. Data from this study displayed a lack of knowledge and perception about CAD among all participants (12.66±5.1 out of 22). However, patients with CAD have better overall knowledge of the disease when compared with general population (13.59±4.8 vs. 12.62±5.1, p=.015) although education at university level or above was represented in 54.4% of general population and 13.3% in patients. This may reflect the experience of the patients from the disease itself. To support this, patients reported that self-previous experience was their major source of information about CAD disease. A history of CAD in patients or family members could increase the awareness of patients about symptoms of CAD [19].
Although all participants had a score above average (6.73±2.4) for knowledge of CAD risk factors, there was a lack of knowledge regarding some risk factors. Only around one-third (31.4%) of the study sample perceived that the incidence of CAD is increasing in young people. Diabetes is a well-established cardiovascular risk factor [20]. Cardiovascular disease causes most death in patients with type 2 diabetes [21]. The Kingdom of Saudi Arabia has a high prevalence of diabetes, which is considered one of the highest worldwide; however, only 57.9% of participants knew that diabetes increases the chance of CAD. In a hospital based cross-sectional study to evaluate the risk factors for myocardial infarction in Taif region, Saudi Arabia; Ahmed ET et al., reported that more than half of patients (n=39) had a low level of knowledge about risk factors [22]. In other studies, it was found that most participants could not identify personal cardiovascular risk factors and that the risks identified were considerably fewer and differed from those documented in the medical record [23-26]. Another cross-sectional study conducted among the Saudi general population in Tabouk city showed critical deficiencies in CAD risk factors knowledge and perception [26]. In addition, a descriptive cross-sectional pilot study in Oman showed a low level of knowledge for CAD risk factors [27]. Another study, indicates that high TG, low HDL, high Lp(a) and the presence of small, dense LDL may contribute to the incidence of coronary heart disease and that TC was not significantly associated with incidence of coronary heart disease in the Saudi population [28].
On the other hand, participants showed very shallow knowledge regarding CAD symptoms. Neither the general population nor patients with CAD could have good knowledge about most CAD symptoms. Less than 50% of participants in the study identified CAD symptoms. However, 33% of heart attack sufferers may not experience classic chest symptoms during the attack [29]; therefore, knowledge and recognition of all symptoms of the heart attack by the public is a crucial issue in reducing presentation delay time [8,11].
Sudden cardiac death is a catastrophic sequela of CAD [30]. Effective CPR as a Basic Life Support (BLS) is a critical component of initial care. Only 38.7% from the general population knew what CPR is and the percentage was far less among patients (16%). Worryingly, around half of the general population (51.4%) and less than quarter of patients (23.3%) could tell the ambulance number. In Jeddah, recent study demonstrated that the theoretical knowledge level of BLS among the general population was below average [30]. BLS education, training programs and CPR public awareness campaign are critically needed.
In this study the awareness of CAD risk factors and the perception of CAD symptoms showed a lack of knowledge among all participants. The population in Jeddah, Saudi Arabia also showed an evident lack of awareness of CAD risk factors [6,30].
Public awareness campaigns, creation of a series of social media graphics and improving patient and family education should be implemented to improve public awareness about CAD.
Limitation(s)
The participants in this study were selected based on a convenience sampling method. Sample size was not calculated. This limitation was reflected by the non-equitable balance between female and male participants.
Conclusion(s)
This study revealed that the general population in Al-Qassim Region showed a lack of knowledge in CAD symptoms. The question in the study questionnaire that affects the most on the CAD was “Does CAD causes chest discomfort/burning sensation of the chest?” which only 51.9% of participants knew the information.
*p<0.05, compared patients with CAD to general population*p<0.05, compared patients with CAD to general population*p<0.05, compared patients with CAD to general population*p<0.05, compared patients with CAD to general population*p<0.05, compared patients with CAD to general population