70 Chapter 3 DISCUSSION In this population-based study including 634 participants with CHD, we observed a high prevalence of cardiovascular RF individually and in clusters. Overall, women present with a higher number of cardiovascular RF. Sex differences in the number of RF were driven mainly by cardiometabolic RF, which were more common in women and more prevalent than lifestyle RF. There were marked sex differences in the number of RF among participants with low educational attainment, but these differences diluted for those with higher educational attainment. The most common combination of RF was hypertension / dyslipidemia / obesity / unhealthy diet. Our study population was constituted by the same number of men and women. Studies on CHD patients often have a higher proportion of men due to the occurrence of the disease (27,28). The equal proportion of men and women in our study may be explained by the higher occurrence of CHD in men, in combination with the higher participation of women in the study: 57.9% of participants from the overall CESCAS study population were female, and the prevalence of CHD was 6.8% in women and 7.4% in men. We observed that some cardiovascular RF have a very high prevalence: more than 3 of 4 participants were hypertensive, 4 of 5 had an unhealthy diet, more than half of the women were obese, and almost 80% of women had central obesity. The prevalence of most RF was comparable to those observed for Latin American men and women with CHD included in various studies. Higher prevalence estimates for hypertension (75.3%) were reported in the REACH Study, conducted in several Latin American countries (29). The prevalence of obesity in the CESCAS study was higher than in REACH study (22.1%) and the Chilean registry GEMI (33.1%), but similar to the FNR study (46.0%, conducted in Uruguay) (29–31). We observed high levels of central obesity, especially in women: in comparison a lower prevalence was observed in European centres in EUROASPIRE V (50.0%), while SURF CHD, with patients from 3 world regions, reported higher estimates in men (53.0%) and lower in women (68.0%) compared to the CESCAS study (27,32). Clustering of RF was also very common: more than 80% of women and men had ≥ 4 cardiovascular RF. Overall, we observe a higher burden of multiple RF in women. This finding is in line with previous literature (7,28,33,34), though some studies find a higher number of RF in men (35) and others don’t find sex differences (5,8). In our analysis, we show that the higher burden of RF in women is driven mostly by cardiometabolic RF. The higher burden of RF in women may be explained in part because RF that are usually more common in men, such as smoking and excessive consumption of alcohol, were relatively uncommon in our study population. Poortinga et al (5) finds that men in the general adult population in England have a higher risk factor burden, and the study focuses on lifestyle factors only. The higher burden of cardiovascular RF in women, especially cardiometabolic RF, may have several causes. Literature has reported that women have lower awareness of CHD and the importance of treatment. They also show lower adherence to cardioprotective medication (27,36) and to cardiac rehabilitation (11).
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