Risk Factors for Rheumatic Cardiac Disease (RCD) In Elderly

Outpatients at Langsa District Hospital

Said Usman1, Aris Winandar 2. And Ibrahim Champion 2

1
Medicine Faculty, Syiah Kuala University, Banda Aceh 23245, Indonesia
2
Department of Epidemiology, Serambi Mekah University, Banda Aceh 23245, Indonesia
saidusmanmkes@yahoo.co.id, ariswinandar17@gmail.com, champmega2@gmail.com

Keywords: Rheumatic Cardiac Diseases,Elderly Outpatients

Abstrack: Rheumatic Cardiac Diseases (RCD) are disorders of the heart and the coronary arteries that occur with
blood vessel walls thickening and luminal narrowing of atherosclerotic coronary arteries that disrupt blood
flows to the heart muscles, causing damage and impaired function of the heart muscles. The purpose of this
study was to identify risk factors for precipitating RCD events amongst elderly outpatient at Langsa District
Hospital in 2016.This research was a case study analysis of risk factors for RCD using a case-control
design: Consecutive sampling was used to get a sample of 74 elderly out-patients with RCD and Accidental
sampling was used to get 74 control elderly out-patients that were non-RCD from out-patients going for
treatment to Langsa District Hospital’s polyclinic. Data analysis included bivariate analysis using the chi-
square test and multivariate analysis using multiple logistic regression. The results of this research showed
that there were significant relationships between smoking, hypertension, obesity and diabetes with RCD in
elderly out-patients whilst the most significant factor in the incidence of RCD was hypertension.

1. INTRODUCTION Health Department’s Basic Health Research unit,

One group of not- contagious diseases (NCD) that
concerns people at present are heart diseases and
blocked arteries. Based on 2005 WHO reports, from
58 million deaths world-wide, 17.5 million (30%)
were due to heart disease and blocked arteries,
primarily heart attacks (7.6 million) and strokes (5.7
million). In 2015 deaths due to heart disease
(cardiovascular diseases) and blocked arteries in
Indonesia will increase to more than 20million
(Indonesian Health Dept. {Depkes}2009).
Heart disease still remains the primary cause of
morbidity (serious life threatening diseases) and
death of adults in Europe and north America. Each
year, in the USA, nearly 500,000 people die from
ischemic heart disease. In Asia and Africa, there is
an increasing prevalence of heart disease and death
from heart disease. In Singapore and Malaysia the
rate has increased from a level where they were of
little concern to 10% of all deaths (Remond MG et
al., 2013).
In Indonesia, in 2013, based on data from the
according to dagnoses from doctors, the Province
with the highest rate of coronary heart disease in
people 15 years old and over was Nusa Tenggara
Timur (4.4%). This was followed by Central
Sulawesi (3.8%) and South Sulawesi (2,9%). Whilst
the provinces with the lowest prevalence were Riau
(0,3%), Lampung (0,4%), and Jambi (0,5%)
(Rodriguez-Fernandez R et al., 2016)
Heart disease can come from problems in the
arteries due to narrowing or blockages which disturb
the transportation of materials for energy to the body
so that there is an imbalance between the need for
oxygen and the supply of oxygen. This imbalance
results in disturbance to the pumping (of blood) by
the heart which eventually causes weakness and
death of cells in the heart. Heart diseases are a group
of cardiovascular diseases which are now becoming
a world–wide threat. The September 2009 report
from the WHO said that heart disease now appears
to be the prime cause of death (Yahya, 2010 in Mira,
2012).
The prevalence of Rheumatic Cardiac Disease
(RCD) in Indonesia according to symptoms, based
on interviews, increases with age, the highest
incidence was 2.0% (females) and 3.6% (males) in
the age range 65-74 and then it decreased slightly in
the 75 and over group. The prevalence of RCD when
diagnosed by a doctor or when diagnosed by a
doctor or by symptoms was higher amongst women
(0,5% and 1,5%). Rheumatic Cardiac (Lee ES et
al.,2016)
Disease (RCD) was more prevalent amongst
those who had no schooling and did not work.
Based on diagnosis by a doctor Rheumatic Cardiac
Disease (RCD) was more prevalent in cities,
however based on doctors’ diagnosis and symptoms
it was more prevalent in rural areas and in the lowest
(income) quintile (Stoupel E et al., 2013).
Based on previous diagnosis by a doctor, the
prevalence of RCD in Indonesia was 0.5% and based
on a doctors’ diagnosis or symptoms it was 1.5%.
The prevalence of a heart attack based on previous
doctors’ diagnosis was 0.13% in Indonesia and based
on a doctors’ diagnosis or symptoms was 0.3%. The
prevalence of a stroke in Indonesia based on the
diagnosis of a health worker was 7.0 ‰ (per mil)
and based on a health workers’ diagnosis or
symptoms was 12.1 ‰ (per mil). Thus, 57.9% of
strokes have been diagnosed by health workers. The
prevalence of RCD, heart attacks and strokes
increases with increase in age and the prevalence of
strokes is the same for both sexes. (Riskesdas,
2013).
The increasing number of elderly (in the
population) needs to be handled seriously because
due to natural causes, increasing age brings with it
declines in physical health, both biologically and
mentally and this cannot be separated from
economic, social and cultural factors so it needs an
effort by families and by society to handle it.
(Kiyoshige E et al, 2018)
The decline in functions of various organs
amongst the elderly makes them liable to diseases
which are acute or chronic. There is an increased
tendency to suffer from diseases which are
degenerative, metabolic, infectious and/or which
cause psychosocial disturbance (Jaul E,2017).
Increases in the general health of people will be
accompanied by an increase in life-expectancy in
Indonesia. Based on the 2011 UN Report for
Indonesia, in 2000-2005 life expectancy was 66
(with the total of elderly in 2000 being 8%), this
figure has been projected to increase so that in 2045-
2050 life-expectancy will be 77 (with the elderly, in
2045, being 29% of the total population).
So too in Indonesia, according to the National
Statistics Body, there has been an increase in life-
expectancy. In 2000 it was 64 (with 7.18% elderly)
which increased to 69 in 2010 (with 7.56% elderly)
and increased again in 2011 to 70 (with 7.58%
elderly (Rizky, 2012).
Research done by Mira Rosmiatin to analyse the
risk factors relative to RCD amongst 136 elderly
women patients at the Dr. Cipto Mangunkusumo
Womens’ Hospital in Jakarta with a multi-variant
cross-sectional analysis showed that the most
significant factor was age (OR=3,64), where age
was the most significant predictor of RCD
(p<0,001).
Furthermore, research done by Eko Setiawan in
2012 concerning the risk factors for heart attacks
amongst elderly patients at the geriatric diseases unit
in the Dr Kariadi District Hospital in Semarang,
Central Java, showed that there was a significant
connection between dislipidimia and heart attacks
with p-value 1.000 and Odds Ratio (OR) = 1.00 with
a Confidence Interval (CI=95%).
Based on data from the Langsa Health
Department the death rate from non-infectious
diseases in the City of Langsa during the 5 years
from 2010 to 2015 showed an increase. RCD was in
8th place both for deaths and for serious
diseases/morbidity.
In 2010, there were 1.290 cases (2.17%); in 2009
it doubled to 2.548 cases (2.67%); in 2010 a slight
decrease to 2.132 cases (1.45%); then in 2011 the
number increased 67% to 3,485 cases (2.70%) and
again in 2012 there were 3.532 cases (2.52%). Then,
in 2013 a 50% increase to 5.336 cases but the
incidence decreased (2.10%). This shows that the
number of cases coming to the hospital fluctuated.
The main risk factor for the incidence of RCD
amongst out-patients at the Langsa District Hospital
polyclinic in 2016 was being in the elderly age
group.
2. RESEARCH METHODS
2.1 Type Of Resarch
This study was an analytical research program with
a case control design that started with identifying
subjects/patients with the research condition (the test
group) and also persons/ successive patients without
the research condition (the control group) which met
the criteria for the study.
2.2 Population And Research Samples
The population for this study were all the elderly
patients who attended the Langsa District Hospital
(LDH), Aceh in 2016. These were divided into the
Study Group and the Control Group.
The Study Population were elderly (over 60 years of
age) patients who attended the polyclinic who hypothesis between each dependent variable and
were diagnosed with RCD by the LDH doctors in the independent variable.The statistical test used
2016. was the Chi Squared test with a 95% confidence
1) The Control Population were elderly (over 60) interval, with α = 0.05. This test was to
determine whether Ho was rejected or accepted
patients who attended the LDH polyclinic who
with the criteria that if p-value < 0.05 Ho was
were not suffering from RCD in 2016. rejected meaning that there was a significant
2) The Study Sample were some of the elderly relationship and if p- >0.05 then Ho was
(over 60) patients who attended the polyclinic accepted meaning that there was no significant
who were diagnosed with RCD by the LDH relationship between the two variable.
doctors in 2016. 3) Multivariant Analysis was done to test the
relationships between several independent
3) The Control Sample were successive elderly variables and one dependent variable (Hastono,
(over 60) patients who attended the LDH 2007).
polyclinic who were not suffering from RCD in
2016 and who agreed to be interviewed. 3. RESULTS AND DISCUSSIONS
Based on calculations, the minimum sample size
must be 74 people with a ratio of 1: 1 between the 3.1 Incidence Of Independent Variables
Study Sample and the Control Sample.
The Study Sample was gathered using the Based on table 1, 47 (64%) of those with RCD
Consecutive sampling technique whereby the sample
were smokers and 27 (36%) of the non-RCD
was gathered by chance as candidates that met the
patients were smokers, 41 patients (55%) who had
sampling criteria came forward until the total
number required was met (Q. Ashton, 2011). RCD were physically inactive whilst 23 patients
The Control Sample was gathered using (45%) who did not have RCD were physically
Accidental sampling whereby candidates that met inactive, 45 patients (61%) who had RCD were also
the specified criteria to be controls for the study suffering from diabetes mellitus whilst 29 patients
were accumulated until the total number required (39%) who did not have RCD had diabetes mellitus,
had been gathered (Q. Ashton, 2011). 57 patients (77%) who had RCD also had high blood
The criteria for inclusion in the study sample was pressure whilst 17 patients (23%) who did not have
all successive elderly (over 60) out-patients who RCD had high blood pressure, 42 patients (57%)
went to the LDH polyclinic who were suffering from who had RCD were also obese whilst 32 patients
Rheumatic Cardiac Diseases (RCD) who agreed to (43%) who did not have RCD were obese.
be interviewed until the minimum sample size (74)
was reached: And the criteria for inclusion in the Table 1. Incidence of Variables
control was all successive elderly (over 60) out-
patients who went to the LDH polyclinic who were Variable RCD Non RCD
not suffering from RCD who agreed to be (n=74) (n=74)
interviewed until the minimum sample size (74) n % n %
was reached. Smoking
The criteria for exclusion was all patients as Formerly 47 64 32 43
above who did not agree to be interviewed and/or be Not 27 36 42 57
monitored and/or to have their blood pressure Physical
measured. inactivity
Yes 41 55 27 36
No 33 45 47 64
2.3. Data Analysis Diabetes
Mellitus
After the data had been gathered it was analyzed as Yes 45 61 25 33
follows: No 29 39 49 67
Hypertens
1) Univariant Analysis ion
This was done to look at the frequency distribution Yes 57 77 37 50
of the results for each variable to see whether the No 17 23 37 50
results looked valid using the SPSS program. Obesity
2) Bivariant Analysis was used to test the Yes 42 57 24 32
No 32 43 50 68
Table 2. Effect of Risk Factors on incidence of RCD amongst Samples with RCD and without RCD
at Langsa District Hospital in 2016

RCD Non RCD OR

X2 p Value
Variable (n=74) (n=74) 95% CI
n % n %
Smoker
Yes 47 60 32 41 2.285
6.109 (1.181- 0.021
No 27 39 42 61
4.420)
Inactive
Yes 41 60 27 40 2.163
5.332 (1.119- 0.032
No 33 41 47 59
4,180)
DM
Yes 45 64 25 36 3,041
9.785 (1,555- 0.002
No 29 37 49 63
5,948)
Hypertension
Yes 57 61 37 39 3,353
10.526 (1,652- 0.001
No 17 32 37 68
6,805)
Obesity
Yes 42 64 24 35 2,734
7.903 (1,400- 0.005
No 32 39 50 61
5,342)
*Level of significance of α = 0.05

Table 4. Multivariant Analysis

 95.0% C.I.for
EXP(B)
B S.E Wald Df Sig Exp(B)

Lower Upper
Smoking .891 .408 4.773 1 .029 2.437 1.096 5.419
Inactive .831 .392 4.486 1 .034 2.295 1.064 4.949
DM 1.229 .404 9.240 1 .002 3.417 1.547 7.548
Hypertension 1.350 .428 9.950 1 .002 3.858 1.667 8.926
Obesity 1.216 .404 9.067 1 .003 3.375 1.529 7.449
Constant 8.188 1.507 29.517 1 .000 .000

3.2. Risk Factors

Based on the data in table
2 that follows,
concerning the possibility
of a link between
smoking and RCD, the
value of p =0.021. This
indicates that there was a
link between smoking
and RCD. From the risk
factor analysis the value
of OR = 2.285. This
means that the RCD
sample were 2.285 times
more likely to smoke
than the non-RCD
sample, concerning the
possibility of a link
between physical
inactivity and RCD, the
value of p = 0.032.This
indicates that there was a
link between physical
inactivity and RCD
(p<0,05). From the risk
factor analysis the value
of OR = 2.163. This
means that the RCD
sample were 2.163 times
more likely to be inactive
than the non-RCD
sample, concerning the
possibility of a link
between diabetes mellitus
and RCD, the value of p
= 0.002. This indicates
that there was a link
between diabetes mellitus
and RCD (p<0,05). From
the risk factor analysis
the value of OR = 3.041.
This means that the RCD
sample were 3.041 times
more likely to suffer
from diabetes mellitus
than the non-RCD
sample, concerning the
possibility of a link
between hypertension
and RCD, the value of p
= 0.001. This indicates
that there was a link
between hypertension
and RCD (p < 0.05)..
From the risk factor
analysis the value of OR
= 3.353. This means that
the RCD sample were
3.353 times more likely How large a
to have hypertension population could be =
= 0,606 (3,353)
than the non-RCD saved from RCD if the 67 % 0,606
sample, concerning the risk from hypertension (3,353) + 1
possibility of a link can be managed can be
between obesity and seen from the = 67%
RCD, the value of p = Population Attributable
0.005. This indicates Risk (PAR) in this Based on the
that there was a link research. calculations above, the
between being obese The variable with the value of the Population
and RCD (p<0,05). most influence on the Attribute Risk (PAR) is
From the risk factor dependent variable can 67% which is the
analysis the value of OR be seen from the amount that the
= 2.734. This means that significance of the incidence of RCD
the RCD sample were exponent (B), the larger amongst the elderly
2.734 times more likely the value of (B) the could be reduced if
to be obese than the bigger the influence on their hypertension
non-RCD sample. the variable being could be controlled.
Based on the data in analyzed. Based on the
table 4 the variable with analysis, the variable
the most influence on with the most influence
the dependent variable on RCD was
can be seen from the hypertension ie. high 3.3 Multivariant
significance of the blood pressure (Exp B = Analysis
exponent (B), the larger 3,858).
the value of (B) means Next the Model Multivariant analysis
the bigger the influence assumes from multiple looked at the
on the variable being regression analysis for relationships between
analyzed. Based on the the probability of a the independent
analysis, the variable disease occurring using
with the most influence variables with the one
the formula and dependent variable at
on RCD was calculations as follows:
hypertension ie high the same time in order
1 to find out which
blood pressure. F(Z) =
Elderly patients with 1+e - (α+β1X1+β2X2+β3X3………+βiXi)
independent variable
RCD due to the risk had the most influence
factors of smoking, on the dependent
physically inactive, DM variable and whether
and/or obesity were 39% the effect of any one
more likely to suffer - 1 independent variable on
from hypertension than =1+e the dependent variable
patients who did not
(α+β1X1+β2X 1+e - (8+0,029+0,034+0,002+0,002+0,003)
was affected by any
have RCD. other variables or not
= 39 %
Based on the Odds (Hastono, 2007).
Ratio (OR) the strength The variables which
of each variable – From the foregoing it
can be seen that elderly had already been
smoking, obesity, examined by bivaraiate
physical inactivity, DM out-patients with RCD
with the risk factors of analysis were next
and hypertension on the
smoking, obesity, examined by
incidence of RCD
inactivity and/or DM are multivariate analysis
amongst the elderly, can
be seen. The bigger the 39% more likely to have using logical pairing
value of the OR the hypertension than those regression analysis with
stronger the effect of the not suffering from RCD. the Backward
variable concerned on p (r - 1) Likelihood Ratio
the incidence of RCD. PAR = method.
p (r - 1)+ 1
 Table 3:
Results of on RCD amongst Population. J. 2013;43:386–
Multivariant elderly [PubMed 29312916] 393.
Analysis of outpatients; Kiyoshige E, Kabayama Rodriguez-Fernandez
Candidate d) There was a M, Gondo Y,et al., R, , Amiya
Patients. significant 2018. Association R, Wyber R et al.,
influence from between long-term 2015.
Variable hypertension on care and chronic and Rheumatic heart d
RCD amongst lifestyle-related isease among
Smoking elderly disease modified by adults in a mining
Obesity outpatients; social profiles in community of
e) There was a community-dwelling Papua, Indonesia:
Physically Active significant people aged 80 and findings from an
Hypertension influence from 90; SONIC study. occupational
obesity on RCD [PubMed 30597340] cohort. [PubMed
Diabetes Mellitus
amongst elderly Lee ES, Vedanthan R et 26294934]
outpatient. al., 2016. Quality Stoupel E, Tamoshiunas
2) The risk factor with Improvement for A et al.,2013.
the most influence Cardiovascular Dise Birth month and
4. on RCD was ase Care in Low- and longevity: birth
hypertension/high Middle-Income month of victims
CONCLUSIONS blood pressure. Countries: A of sudden (SCD,
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