The prevalence of and risk factors for cardiovascular disease in patients seeking treatment at the Durban University of Technology Chiropractic Day Clinic

Abstract

Introduction: Cardiovascular disease (CVD) is a major contributor to death in South Africa. Literature suggests that patients with musculoskeletal complaints frequently present with co- morbid pathologies such as hypertension and angina. However, ambiguity exists in the literature as to whether a relationship between the presence of CVD and the presence of musculoskeletal complaints exists.

Methodology: This quantitative cross-sectional retrospective cohort analysis utilised a validated data sheet to collect demographic characteristics; morbidity and prevalence of cardiovascular disease and musculoskeletal complaints; and their associated risk factors from 1066 clinic files of new patients who presented to the Durban University of Technology Chiropractic Day Clinic in one year. The data were manually extracted, coded and were captured on an Excel spreadsheet and imported into IBM Statistical Package for the Social Sciences (SPSS) version 24 for analysis. A two-tailed 0.05 level of significance was used. Where associations were found, Pearson chi-square tests or Fisher exact test was used for categorical variables, and independent t-tests for quantitative variables was utilised to determine the significance of the association, indicating whether the association was greater than chance alone (i.e. a p value <0.05 being considered statistically significant) (Singh, 2014). If the data were not normally distributed a Mann-Whitney U test was utilised. Odds ratios were calculated to determine the risk of the exposure where possible (Singh 2017).

Results: The patients presenting between 9 June 2015 and 9 June 2016 were predominantly Indian males; mean age of 37.87 years (SD 16.53 years); range five weeks to 86 years of age; majority within the 20-29 year age group. Most patients sought treatment for a primary musculoskeletal complaint (25% reported a secondary musculoskeletal complaint), characterised by chronic, moderate lumbar spine/abdomen pain of sharp character, with no associated pain radiation. The prevalence of cardiovascular disease was 25.2%, with hypertension and peripheral vascular disease as the most frequent. Risk factors in both the cardiovascular and non-cardiovascular disease groups included non-modifiable risk factors (viz. advancing age; gender; race/ethnicity and family history of CVD); and modifiable risk factors (viz. overweight/obesity; physical inactivity; blood pressure abnormalities; tobacco use; alcohol use; high fat and carbohydrate diet; diabetes mellitus; connective tissue disease; hypercholesterolaemia; use of non-cardiac medication and mental wellness). About 25% of patients reported the use of medication (the majority having been prescribed multiple medications (including anti-diabetics, anti-hypertensives, cholesterol-lowering drugs and anti-coagulants). Nearly 100% of CVD patients reported

chronic medication use. Univariate logistic regression analysis revealed a number medications and common risk factors influenced the presentation of musculoskeletal complaints between CVD and non-CVD patients. With multivariable analysis, it was found that many of the medications lost significance after adjustment for confounders/influencing factors, although antihypertensive (OR 36.6; p=<0.001) and thyroid agents (OR 5.1; p=0.078) remained associated with CVD. Common/mutual risk factors for CVD and MSD including: increasing age (OR 1.1 p=<0.001), family history of CVD (OR 2.1; p=0.006), smoking (OR 1.9; p=0.054) and grade 1 HTN (OR 2.5; p=0.043) were significantly associated with having CVD. Furthermore, MSCs located in the SI joint/pelvis (OR 7.1; p=0.005) and head (OR 7.3; p=0.019), as well as the thoracic spine/chest/ribs (OR 4.9; p=0.015) and shoulder/brachium (OR 3.1; p=0.090) were shown to be significantly associated with CVD.

Conclusion: The results of this study suggest that patients who seek treatment at the DUT CDC may present with both MSDs and CVD. Moreover, this study suggests that there may be an association between CVD and the presenting MSC. It is evident that the presentation of MSDs in CVD patients is multifactorial involving the use of cardiac and non-cardiac medication, and the presence of common CVD and MSD risk factors. However this study cannot conclusively comment on these pathophysiological changes. The current study can only speculate on causality based on known mechanisms as described in literature, however reverse causality may exist (viz. a lack of exercise, presence of MSCs may actually predispose to the CVDs).

It is possible that CVD patients, who frequently sought treatment at chiropractic teaching clinics, may present with musculoskeletal side-effects associated with the use of cardiac and non-cardiac medications. This may result in the development of chronicity of musculoskeletal complaints, unresponsiveness to treatment and/or delayed recovery. It is important for chiropractic interns to be aware of this association as it affects how these patients are currently treated and managed thus affecting their prognosis. Caution needs to be applied as the outcomes of this study need to be investigated prospectively in larger sample sizes, different contexts and with some refinement of the data collection tool to confirm the outcomes of this study.