JCDR - Register at Journal of Clinical and Diagnostic Research
Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X
Internal Medicine Section DOI : 10.7860/JCDR/2020/43124.13423
Year : 2020 | Month : Jan | Volume : 14 | Issue : 01 Full Version Page : QC10 - QC14

Awareness of Coronary Artery Disease among Population of Al-Qassim, Saudi Arabia: A Community-Based Study

Fatin Ahmad1, Rami M Abazid2, Abdulaziz Suliman Allihimy3, Dawood Abdurhman Aldrewesh4, Sarah Abdulrahman Alkuraydis5, Shaima Abdullah Alharb6, Marghoob Hasan7, Abdelmarouf Hassan Mohieldein8

1 Cardiology Fellow, Prince Sultan Cardiac Center, Buraidah, Qassim, Saudi Arabia.
2 Consultant, Prince Sultan Cardiac Center, Buraidah, Qassim, Saudi Arabia.
3 Medical Student, College of Medicine, Qassim University, Qassim, Saudi Arabia.
4 Medical Student, College of Medicine, Qassim University, Qassim, Saudi Arabia.
5 Medical Student, College of Medicine, Qassim University, Qassim, Saudi Arabia.
6 Medical Student, College of Medicine, Qassim University, Qassim, Saudi Arabia.
7 Lecturer, College of Applied Medical Sciences, Qassim, Saudi Arabia.
8 Associate Professor, College of Applied Medical Sciences, Qassim, Saudi Arabia.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Fatin Ahmad, Prince Sultan Cardiac Center, P.O. Box 4560, Buraidah 51412., Qassim, Saudi Arabia.
E-mail: yafatina@hotmail.com
Abstract

Introduction

Recognition of Coronary Artery Disease (CAD) symptoms affects the time-sensitive benefits of reperfusion therapy in case of acute myocardial infarction.

Aim

To evaluate awareness of CAD symptoms and risk factors in population of Al-Qassim Region, Saudi Arabia.

Materials and Methods

A cross-divtional, hospital and community-based descriptive study was conducted from May to October 2018. Total of 3235 Saudi citizens, comprising of 3085 healthy participants (without documented CAD) and 150 patients (with documented CAD) participated in the study. A pre-piloted well-structured questionnaire was used. The questionnaire included questions about participants’ demographic characteristics, CAD risk factors and symptoms. Data were analysed by using SPSS. Descriptive statistics (mean, standard deviation, percentage, Student’s t-test, chi-square test) was applied.

Results

Participants’ baseline data revealed 54.4% of healthy participants and 13.3% of patients had an education at a university or higher level (p<0.001). Out of overall score 22 points, mean±SD for CAD knowledge was 12.62±5.1 and 13.59±4.8 (p=0.015) for healthy participants and patients, respectively. For all study participants, total score for knowledge of CAD risk factors was 6.73±2.4 (out of 10), while total score for knowledge of CAD symptoms was 5.07±3.1 (out of 10). One remarkable finding was that only 37.8% of healthy participants and 16% of patients knew cardiopulmonary resuscitation.

Conclusion

This research revealed that general population in Al-Qassim Region showed a serious lack of knowledge about CAD symptoms when compared to CAD patients. Authorities should implement great efforts to improve public perception about CAD and its symptoms. This could support in diminishing the morbidity and mortality of the disease.

Keywords

Introduction

The CAD is a leading cause of morbidity and mortality worldwide [1,2]. A statistical report from the American Heart Association showed that in USA the leading cause of death was CAD followed by the stroke, heart failure and high blood pressure [3]. Not only high-income countries but in developing countries, CAD is the leading cause of death [4]. In Saudi Arabia, the rise in the burden of cardiovascular diseases is one of the serious problems created by rapid industrialisation and urbanisation [5]. The prevalence of CAD risk factors is substantially higher in Saudi patients when compared to the Western population [6].

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, Male2296, 74.4%119, 79.3%2414, 74.7%0.177
Age15-24 years860, 27.9%00, 0%860, 26.6%<0.05*
25-54 years1950, 63.2%51, 34%2001, 61.9%
55-64 years209, 6.8%60, 40%269, 8.3%
≥65 years66, 2.1%39, 26%105, 3.2%
EducationIlliterate88, 2.9%43 28.6%131, 4.0%<0.05*
≤Secondary school1026, 33.2%78, 52.0%1104, 34.1%
Diploma293, 9.5%10, 6.7%303, 9.4%
≥University1678, 54.4%19, 13.3%1697, 52.5%
Marital statusSingle1324, 42.9%06, 4.0%1330, 41.1%<0.05*
Married1697, 55%140, 93.3%1837, 56.8%
Divorced39, 1.3%02, 1.3%41, 1.3%
Widowed25, 0.8%02, 1.3%27, 0.8%
Working statusStudent601, 19.5%00, 0%601, 18.6%<0.05*
Working1617, 52.4%48, 32%1665, 51.4%
Not working577, 18.7%44, 29.3%621, 19.2%
Retired290, 9.4%58, 38.7%348, 10.8%
Smoking statusNon smoker2372, 76.9%97, 64.7%2469, 76.3%<0.05*
Smoker553, 17.9%23, 15.3%576, 17.8%
Quit smoking155, 05%30, 20%185, 05.7%
Family history of CADYes892, 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 responsesGeneral population (n=3085)Patients (n=150)All (n=3235)p-value Chi-square
The incidence of CAD is increasing in young people939, 30.4%78, 52.0%1017, 31.4%<0.05*
Stress increases the chance of CAD1745, 56.6%98, 65.3%1843, 57.0%0.034*
Smoking increases the chance of CAD2784, 90.2%129, 86.0%2913, 90.0%0.090
CAD is often associated with a raised blood cholesterol2431, 78.8%115, 76.6%2546, 78.7%0.796
CAD is often associated with a lack of exercise2565, 83.1%108, 72.0%2673, 82.6%<0.05*
CAD is often associated with an increased blood pressure2220, 72.0%111, 74.0%2331, 72.1%0.587
Family history of CAD increases the chance of CAD1581, 51.2%70, 46.7%1651, 51.0%0.273
Old age increases the chance of CAD2104, 68.2%97, 64.7%2201, 68.0%0.365
Diabetes increases the chance of CAD1761, 57.1%111, 74.0%1872, 57.9%<0.05*
Obesity increases the chance of CAD2578, 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 responsesGeneral population (n=3085)Patients (n=150)All (n=3235)p-value Chi-square
CAD causes chest discomfort/burning sensation of the chest1597, 51.9%121, 80.7%1718, 53.2%<0.05*
CAD causes pain in the arms/shoulders1543, 50.0%114, 76%1657, 51.2%<0.05*
CAD causes fatigue2211, 71.7%116, 77.3%2327, 71.9%0.132
CAD causes upper back discomfort1101, 35.7%81, 54.0%1182, 36.5%<0.05*
CAD causes discomfort in the jaw703, 22.8%48, 32.0%751, 23.3%0.074
CAD causes shortness of breath2284, 74.0%116, 77.3%2400, 74.2%0.654
CAD causes sweating1865, 60.5%106, 70.7%1971, 60.9%0.043*
CAD causes nausea and vomiting1299, 42.1%85, 56.7%1384, 42.8%0.002*
CAD causes dizziness and collapse1882, 61.0%96, 64.0%1978, 61.1%0.748
CAD causes indigestion or upper gastric discomfort883, 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±2.46.91±276.73±2.40.373
Total score for knowledge of CAD symptoms, mean±SD (out of 10)5.01±3.16.29±2.75.07±3.1<0.05*
Total score of CAD overall knowledge, mean±SD (out of 22)12.62±5.113.59±4.812.66±5.10.015*

*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, %).

SourceGeneral populationPatientsp-value
Media962, 22.8%20, 13.3%<0.05*
Newspaper368, 8.7%09, 6.0%0.085
During study817, 19.4%08, 5.3%<0.05*
Friend/Relative783, 18.6%54, 36.0%0.004*
Health sector516, 12.2%27, 18.0%0.899
Social media770, 18.3%25, 16.7%0.066
Self-previous experience087, 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

References

[1]. Wakil SM, Ram R, Muiya NP, Mehta M, Andres E, Mazhar N, A genome-wide association study reveals susceptibility loci for myocardial infarction/coronary artery disease in Saudi Arabs Atherosclerosis 2016 24562-7010.1016/j.atherosclerosis.2015.11.01926708285  [Google Scholar]  [CrossRef]  [PubMed]

[2]. Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A, Epidemiology of coronary heart disease and acute coronary syndrome Ann Transl Med 2016 4(13):25610.21037/atm.2016.06.3327500157  [Google Scholar]  [CrossRef]  [PubMed]

[3]. Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Heart disease and stroke statistics-2018 update: a report from the American Heart Association Circulation 2018 137(12):e467-e92.10.1161/CIR.0000000000000558PMC6085757   [Google Scholar]  [CrossRef]  [PubMed]

[4]. Quertermous T, Ingelsson E, Coronary artery disease and its risk factors: leveraging shared genetics to discover novel biology Circ Res 2016 118(1):14-16.10.1161/CIRCRESAHA.115.307937  [Google Scholar]  [CrossRef]

[5]. Ahmed AM, Hersi A, Mashhoud W, Arafah MR, Abreu PC, Al Rowaily MA, Cardiovascular risk factors burden in Saudi Arabia: The Africa Middle East Cardiovascular Epidemiological (ACE) study J Saudi Heart Assoc 2017 29(4):235-43.10.1016/j.jsha.2017.03.00428983166  [Google Scholar]  [CrossRef]  [PubMed]

[6]. Almalki MA, AlJishi MN, Khayat MA, Bokhari HF, Subki AH, Alzahrani AM, Population awareness of coronary artery disease risk factors in Jeddah, Saudi Arabia: a cross-sectional study Int J Gen Med 2019 12:63-70.10.2147/IJGM.S18473230666149  [Google Scholar]  [CrossRef]  [PubMed]

[7]. Hwang SY, Park EH, Shin ES, Jeong MH, Comparison of factors associated with atypical symptoms in younger and older patients with acute coronary syndromes J Korean Med Sci 2009 24(5):789-94.10.3346/jkms.2009.24.5.78919794972  [Google Scholar]  [CrossRef]  [PubMed]

[8]. Henriksson C, Larsson M, Arnetz J, Berglin-Jarlöv M, Herlitz J, Karlsson JE, Knowledge and attitudes toward seeking medical care for AMI-symptoms Int J Cardiol 2011 147(2):224-27.10.1016/j.ijcard.2009.08.01919853936  [Google Scholar]  [CrossRef]  [PubMed]

[9]. Bagai A, Dangas GD, Stone GW, Granger CB, Reperfusion strategies in acute coronary syndromes Circ Res 2014 114(12):1918-28.10.1161/CIRCRESAHA.114.30274424902975  [Google Scholar]  [CrossRef]  [PubMed]

[10]. Koul S, Andell P, Martinsson A, Smith JG, Pals Jvd, Scherstén Fr, Delay From first medical contact to primary PCI and all-cause mortality: a nationwide study of patients with st-elevation myocardial infarction J Am Heart Assoc 2014 3(2):e00048610.1161/JAHA.113.00048624595190  [Google Scholar]  [CrossRef]  [PubMed]

[11]. Hwang SY, Ryan CJ, Zerwic JJ, Korean immigrants’ knowledge of heart attack symptoms and risk factors J Immigr Minor Health 2008 10(1):67-72.10.1007/s10903-007-9053-y17503183  [Google Scholar]  [CrossRef]  [PubMed]

[12]. Andersson C, Vasan RS, Epidemiology of cardiovascular disease in young individuals Nat Rev Cardiol 2018 15(4):230-40.10.1038/nrcardio.2017.15429022571  [Google Scholar]  [CrossRef]  [PubMed]

[13]. Aggarwal A, Srivastava S, Velmurugan M, Newer perspectives of coronary artery disease in young World J Cardiol 2016 8(12):728-34.0.4330/wjc.v8.i12.72828070240  [Google Scholar]  [CrossRef]  [PubMed]

[14]. El-Menyar A, Zubaid M, Sulaiman K, AlMahmeed W, Singh R, Alsheikh-Ali AA, Atypical presentation of acute coronary syndrome: a significant independent predictor of in-hospital mortality J Cardiol 2011 57(2):165-71.10.1016/j.jjcc.2010.11.00821242059  [Google Scholar]  [CrossRef]  [PubMed]

[15]. Løvlien M, Johansson I, Hole T, Schei B, Early warning signs of an acute myocardial infarction and their influence on symptoms during the acute phase, with comparisons by gender Gend Med 2009 6(3):444-53.10.1016/j.genm.2009.09.00919850240  [Google Scholar]  [CrossRef]  [PubMed]

[16]. McKee G, Mooney M, O’Donnell S, O’Brien F, Biddle MJ, Moser DK, Multivariate analysis of predictors of pre-hospital delay in acute coronary syndrome Int J Cardiol 2013 168(3):2706-13.10.1016/j.ijcard.2013.03.02223578888  [Google Scholar]  [CrossRef]  [PubMed]

[17]. Kayar NB, Doğan FG, Özdemir T, Dalkıran SB, Gül F, Gözütok V, Awareness and knowledge of patients with acute coronary syndromes about coronary artery disease Journal of the American College of Cardiology 2013 62((18) supplement 2)10.1016/j.jacc.2013.08.142  [Google Scholar]  [CrossRef]

[18]. Farshidi H, Shafei R, Abdi A, Salehi S, Madani A, Factors associated with pre-hospital delay in patients with acute myocardial infarction Iran Red Cres Med J 2013 15(4):312-16.10.5812/ircmj.236724083004  [Google Scholar]  [CrossRef]  [PubMed]

[19]. Magri CJ, Fava S, Should diabetes still be considered a coronary artery disease equivalent? J Cardiovasc Med (Hagerstown) 2012 13(11):760-65.10.2459/JCM.0b013e328357729522885535  [Google Scholar]  [CrossRef]  [PubMed]

[20]. Bittencourt C, Piveta VM, Oliveira CS, Crispim F, Meira D, Saddi-Rosa P, Association of classical risk factors and coronary artery disease in type 2 diabetic patients submitted to coronary angiography Diabetol Metab Syndr 2014 6(1):4610.1186/1758-5996-6-4624678928  [Google Scholar]  [CrossRef]  [PubMed]

[21]. Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, Diabetes mellitus in Saudi Arabia Saudi Med J 2004 25(11):1603-10.  [Google Scholar]

[22]. Ahmed ET, Youssif MA, Ayasreh IR, Al-Mawajdeh NA, Assess the risk factors and knowledge on modification of lifestyle among patients who have experienced Acute Myocardial Infarction in Taif International Journal of Medical Science and Public Health 2013 2:354-59.10.5455/ijmsph.2013.2.368-373  [Google Scholar]  [CrossRef]

[23]. Oliver-McNeil S, Artinian NT, Women’s perceptions of personal cardiovascular risk and their risk-reducing behaviors Am J Crit Care 2002 11(3):221-27.10.4037/ajcc2002.11.3.22112022485  [Google Scholar]  [CrossRef]  [PubMed]

[24]. Hamner J, Wilder B, Knowledge and risk of cardiovascular disease in rural Alabama women J Am Acad Nurse Pract 2008 20(6):333-38.10.1111/j.1745-7599.2008.00326.x18588661  [Google Scholar]  [CrossRef]  [PubMed]

[25]. Zerwic JJ, King KB, Wlasowicz GS, Perceptions of patients with cardiovascular disease about the causes of coronary artery disease Heart Lung 1997 26(2):92-98.10.1016/S0147-9563(97)90068-6  [Google Scholar]  [CrossRef]

[26]. Alwakeel AA, Alshehri RA, Merghani T, Evaluation of knowledge, attitudes and practice of coronary artery disease risk factors among general population in Tabuk City, Saudi Arabia The Egyptian Journal of Hospital Medicine 2018 73(7):7064-68.  [Google Scholar]

[27]. Ammouri AA, Tailakh A, Isac C, Kamanyire JK, Muliira J, Balachandran S, Knowledge of coronary heart disease risk factors among a community sample in Oman: pilot study Sultan Qaboos Univ Med J 2016 16(2):e189-96.doi: 10.18295/squmj.2016.16.02.00910.18295/squmj.2016.16.02.00927226910  [Google Scholar]  [CrossRef]  [PubMed]

[28]. Ashmaig ME, Ashmeik K, Ahmed A, Sobki S, Abdulla M, Association of lipids with coronary heart disease in a Saudi population J Vasc Bras 2011 10(2):131-36.10.1590/S1677-54492011000200007  [Google Scholar]  [CrossRef]

[29]. Hess PL, Wojdyla DM, Al-Khatib SM, Lokhnygina Y, Wallentin L, Armstrong PW, Sudden cardiac death after non-ST-segment elevation acute coronary syndrome JAMA Cardiol 2016 1(1):73-79.10.1001/jamacardio.2015.035927437658  [Google Scholar]  [CrossRef]  [PubMed]

[30]. Subki AH, Mortada HH, Alsallum MS, Alattas AT, Almalki MA, Hindi MM, Basic life support knowledge among a nonmedical population in jeddah, saudi arabia: cross-sectional study Interact J Med Res 2018 7(2):e1042810.2196/1042830487122  [Google Scholar]  [CrossRef]  [PubMed]