Prevalence and presentation of chronic venous disease in Pakistan: a multicentre study

Abstract

Our objective was to study the prevalence and clinical pattern of chronic venous disease (CVD) in the Pakistani population. This was a multicentre cross-sectional study in which 100 primary care physicians examined 3000 subjects. The study population was aged 18–95 years (mean ± SD = 39 ± 13.2) comprised 47.4% women and 52.6% men. The prevalence of CVD was 34.8%, being significantly higher (P < 0.04) among men (36.4%) than women (33.0%). The maximum prevalence was of C3 (36.7%), followed by C2 (15.8%). The most frequent symptom was pain in the legs (59.2%) followed by heavy legs (42.7%) and night cramps (34.4%). The prevalence of symptoms increased with age but was similarly distributed between men and women. Family history of CVD, blood clots in veins and lack of exercise were significant risk factors. The roles of age or gender as risk factors could not be established. In conclusion, the prevalence and presentation of CVD in Pakistan is similar to most other countries.

Keywords

chronic venous insufficiency prevalence varicose veins venous ulcers risk factor

Introduction

Chronic venous disease (CVD) describes morphological and functional abnormalities of the venous system of long duration that are manifested either by symptoms and/or signs, and which indicate the need for investigation and/or care.¹ The clinical presentation of this disorder spans a spectrum from asymptomatic but cosmetically troublesome small blue ectatic veins and varicosities, to severe fibrosing panniculitis, dermatitis, oedema and ulceration.²

CVD is a major cause of discomfort and disability and its long-term consequences may be serious for the patient.³ Unfortunately, the literature concerning the prevalence and incidence of CVD has varied greatly because of differences in the methods of evaluation, criteria for definition and the geographic regions analysed.⁴ Even in Western countries, where the disease is very common, prevalence estimates vary widely and have generally focused on patients with specific clinical signs such as varicose veins or venous ulcers.^5–9 Some studies are restricted to occupational patient groups such as office workers¹⁰ or workers in departmental stores.¹¹ Epidemiological studies that have investigated the full range of venous symptoms and signs in the general population are scarce, particularly in developing countries.

It is worth pointing out that most people will not consult a physician at the onset of the disease, as it is widely believed that symptoms like pain or leg heaviness are a normal consequence of today's ordinary lifestyle. Most often, consultations for leg problems only occur at a much later stage, although an earlier diagnosis of the disease would lead to a much faster initiation of care and thus to a reduction in physical and psychological suffering, and also a reduction in health-care costs. For this reason, it is important to have updated information on the prevalence of CVD and to have an improved description of this disease in accordance with the CEAP (clinical, aetiological, anatomical, pathophysiological) classification.¹²

The CEAP classification, initially developed in 1994, was reviewed and improved with the aim to make its use easier and to extend its scope towards the earliest stages of CVD that are of high prevalence.

Therefore, the CEAP classification appears to be a valuable tool to help doctors in their daily practice to diagnose the disease early and to offer their patients the most suitable treatment.

C0s	With symptoms and no signs
C1	Reticular veins
C2	Varicose veins
C3	Oedema
C4	Eczema, pigmentation
C5	Healed ulcer
C6	Active ulcer

The VEIN CONSULT Program is an international educational programme to raise awareness of CVD among physicians and patients. The VEIN CONSULT Program aims to assess the prevalence of CVD in adult patients >18 years and the management of their disease in varying geographical areas. The programme being carried out under the patronage of the International Union of Phlebology is the largest worldwide CVD detection programme ever undertaken and aims to provide a picture of the typical adult patient with CVD and their care in varying geographical areas. It has been conducted in 20 participating countries (Brazil, Columbia, France, Georgia, Hungary, Indonesia, Mexico, Pakistan, Romania, Russia, Serbia, Singapore, Slovakia, Slovenia, Spain, Thailand, Ukraine, United Arab Emirates, Venezuela and Vietnam) and has gathered epidemiological data on the prevalence of CVD symptoms, signs, CEAP classes, quality of life and costs among patients attending for routine consultations in general practice. The programme has used the CEAP clinical classification to ensure that data collected on the reporting, diagnosing and treatment of CVD are consistent and can be compared worldwide.

Pakistan is part of this international VEIN CONSULT Program. A large, observational, multicentric, descriptive survey of CVD was conducted in Pakistan during July 2010 to October 2010. The survey involved 100 primary care physicians and screening of 3000 patients. This report is based on the results of data collected through the VEIN CONSULT Program in Pakistan.

Methods

For the purpose of this study, the definition of CVD given by the VEIN-TERM update on terminology of chronic venous disorders, as mentioned in the Introduction, was used. One hundred primary care health providers from various cities in Pakistan took part in the study and each physician was requested to interview/examine 30 patients. Thus, a total of 3000 patients were included in the study. After obtaining informed consent, the doctors in the primary care setting completed a case report form assessing their patients’ history, listing any CVD risk factors, screening for CVD symptoms and performing a clinical examination of both legs according to the CEAP classification. The oedema was diagnosed on examination as pitting oedema. If the patient showed signs of having any CVD symptoms, the patient was asked to complete a questionnaire and the general practitioner then recommended a follow-up consultation with a venous specialist.

The data were entered in double-entry format in Excel. Both files were compared and after cleaning the data were transferred to SPSS-17 (Statistical Package for Social Sciences, version 17) for in-depth analysis. Odds ratios (OR) were calculated to assess the role of risk actors.

Results

Study population

The demographic characteristics of 3000 individuals participating in the study are shown in Table 1. There were 47.4% women and 52.6% men. Their ages ranged from 18 to 95 years (mean ± SD = 39.0 ± 13.3) and 81.7% were ≤50 years.

Table 1

Demographics of study population

Characteristics	Presentation	Statistics
Age (years)	Mean ± SD	39.0 ± 13.3
Age groups (years)
18–34	%	40.5
35–50	%	41.2
51–64	%	13.6
≥65	%	4.7
Gender
Male	%	52.6
Female	%	47.4
Weight (kg)	Mean ± SD	69.7 ± 13.4
Height (cm)	Mean ± SD	162.7 ± 14.3
BMI (kg/m²)	Mean ± SD	31.51 ± 232.74
Male	Mean ± SD	26.80 ± 10.38
Female	Mean ± SD	36.82 ± 339.25
Occupation
Full-time	%	38.0
Part-time	%	8.0
Unemployed	%	5.6
Others	%	48.8
Current use of birth control pills among women	%	22.6
Women with menopause	%	28.8
Use of hormonal replacement therapy	%	3.8

BMI, body mass index

Prevalence of CVD

The overall prevalence of CVD was 34.8% (Figure 1), being significantly higher (P = 0.04) among men (36.4%) than among women (33%).

Figure 1

Prevalence of CVD according to gender

CEAP classification

Figure 2 shows the prevalence of CVD on the basis of the CEAP classification. Maximum prevalence was of C3 (oedema, 36.7%), followed by C2 (varicose veins, 15.8%), C0s (with symptoms and no signs, 14.6%), C1 (reticular veins, 13.8%), C4 (eczema, pigmentation, 13.2%), C5 (healed ulcer, 3.2%) and C6 (active ulcer, 1.7%).

Figure 2

CEAP classification of CVD

Symptoms

Table 2 depicts the prevalence of various symptoms. The most frequent symptom was pain in the legs (59.2%) followed by heavy legs (42.7%), night cramps (34.4%), sensation of swelling (28.8%), sensation of pins and needles (20.6%), sensation of burning (19.2%) and itching (15.2%).

Table 2

Symptoms according to CEAP classification (C0s–C6)

Symptoms	Healthy C0w	CEAP classification of diseased cases								P value Healthy versus diseased
		C0s	C1	C2	C3	C4	C5	C6	Total
Heavy legs	8.4	43.3	68.0	82.6	76.0	71.8	81.8	64.7	42.7	<0.0001
Pain in the legs	18.0	72.1	84.0	93.4	83.0	84.5	84.8	70.6	59.2	<0.0001
Sensation of swelling	4.98	23.4	48.5	56.3	61.2	54.9	66.7	58.8	28.8	<0.0001
Sensation of burning	2.7	16.1	34.3	34.7	36.7	48.6	51.5	52.9	19.2	<0.0001
Night cramps	6.7	34.6	55.0	60.5	62.2	66.2	57.6	47.1	34.4	<0.0001
Itching	4.6	13.8	27.2	40.7	21.0	33.1	27.3	35.3	15.2	<0.0001
Sensation of 'pins and needles’ in the legs	4.6	24.0	34.9	30.5	29.2	36.6	60.6	29.4	20.6	<0.0001
No symptoms	54.4	0.0	0.0	00.0	0.2	0.7	0.0	0.0	17.4	–
No. of cases	830	1052	169	166	465	142	34	18	2044	–

CEAP, clinical, aetiological, anatomical, pathophysiological

Data were missing in 126 cases: 124 healthy and two diseased subjects

Risk factors

The risk factors have been mentioned in Table 3. Family history of CVD was present in 17.1% of CVD patients (C0s – C6) as compared with 10.6% of healthy persons (C0w) showing a significant association with CVD (P < 0.0001). A total of 111 subjects presented with a personal history of deep vein thrombosis: 103 among diseased (C0s – C6) and eight among healthy subjects (P < 0.0001). Lack of exercise was another significant risk factor (P < 0.0001).

Table 3

Risk factors associated with CVD

Risk factor	C0w	C0	C1	C2	C3	C4	C5	C6	C0–C6	P value
Family history of CVD										<0.0001
Absent	65.4	54.0	43.8	37.1	46.6	47.9	27.3	35.3	49.1
Present	10.6	12.9	23.1	24.0	18.2	24.6	33.3	17.6	17.1
No information	24.0	33.1	33.1	38.9	35.2	27.5	39.4	47.1	33.8
Blood clots in veins or legs										<0.0001
Absent	81.7	81.8	64.5	71.9	70.6	60.6	48.5	29.4	75.4
Present	0.8	0.9	8.3	6.6	7.5	15.5	21.2	29.4	4.0
No information	17.5	17.3	27.2	21.6	21.9	23.9	30.3	41.2	18.8
Practice of regular exercise										<0.0001
Absent	79.2	85.0	89.3	91.0	91.8	91.5	90.9	76.5	0.3
Present	17.6	14.8	10.1	7.8	8.2	8.5	6.1	23.5	87.9
No information	3.1	0.2	10.7	1.2	0	0	3.0	0	11.8
No. of hours standing daily										0.008
<5 hours of standing daily	41.8	40.0	43.8	35.9	224	47.2	48.5	41.2	42.4
5–10 hours of standing daily	50.8	56.1	57.5	47.9	223	50.0	45.5	41.2	53.4
>10 hours of standing daily	3.1	3.9	2.4	6.6	16	2.8	6.1	17.6	3.5
History of smoking										0.3950
Smoker	26.5	28.0	29.6	35.9	22.5	36.6	27.3	64.7	29.4
Non-smoker	7.2	70.1	68.6	49.7	73.2	62.0	69.7	35.3	70.5
No response	3.2	1.9	1.8	14.4	4.3	1.4	3.0	0	0.6
No. of cases	954	1052	169	167	466	142	33	17	2046

CVD, chronic venous disease; DVT, deep vein thrombosis

All figures represent percentages

Family history of CVD, history of DVT and lack of exercise were significant risk factors (P < 0.0001)

Further assessment of risk factors was done by calculating ORs. Family history of CVD, presence of blood clots in veins and lack of exercise were the significant risk factors while age, gender, smoking and standing for more than five hours per day did not achieve significance level.

Discussion

The reported prevalence of CVD varies from 14.6% in Turkey¹³ to 77.3% in Italy.¹⁴ Table 4 summarizes the results of various published studies. The prevalence in Pakistan seems to be similar to that reported from Poland,¹⁵ Austria,¹⁶ Portugal,¹⁷ the UK¹⁸ and France,¹⁹ but significantly lower (P < 0.005–P < 0.001) than the figures reported from the USA,²⁰ Italy¹⁴ and Slovakia.²¹ These variations may reflect differences in the variability of study populations including geographical location, age, race, gender, methods of measurement and disease definition.⁹

Table 4

Comparison with other studies

Author	Country	Year	Number	Population	Prevalence (%)	Reference
Evans et al.	UK	1999	1566	Adults > 55 years	Men = 40.0 Women = 32.0	23
Sam et al.	UK	2007	100	Adults > 15 years (Asian)	Men = 40.0	18
Criqui et al.	USA	2003	2211	Adults 40–80 years	Men = 24.4 Women = 30.0	28
McLafferty et al.	USA	2008	2234	Adults 60–79 years	Combined = 71	20
Jawien et al.	Poland	2003	40,095	Adults > 18 years	Men = 34.3 Women = 34.6	15
Maffei et al.	Brazil	1986	1755	Adults > 15 years	Men = 37.9 Women = 50.9	29
Chiesa et al.	Italy	2005	5187	Adults > 18 years	Combined = 77.3	14
Ziegler et al.	Austria	2003	209	Hospital Employees	Combined = 34.0	16
Zahariev et al.	Bulgaria	1995	26,785	Adults > 18 years	Combined = 44.0	32
Capitao et al.	Portugal	1995	44,777	Adults 50–60 years	Men = 17.8 Women = 34.0	17
Laurikka et al.	Finland	1995	6,874	Adults 50–60 years	Men = 19.0 Women = 43.0	31
Komsuoglu et al.	Turkey	1994	312	Adults 50–60 years	Men = 14.6 Women = 22.1	23
Stvtinova	Slovakia	2009	2009	Adults 50–60 years	Combined = 93.0 (C4 to C6 only)	21
Carpentier et al.	France	2004	2000	Adults > 18 years	Men = 30.1 Women = 50.5	19
Bawakid et al.	Saudi Arabia	2005	2350	Adults > 18 years	Combined = 45.6	30
Present study	Pakistan	2010	3000	Adults > 18 years	Combined = 34.8 Men = 36.4 Women = 33.0	-

According to Robertson et al.,⁹ age and pregnancy have been established as risk factors for developing varicose veins while evidence on other risk factors for venous disease is inconclusive. The proportion of disease risk attributable to age (at ascertainment) and sex, the two main risk factors for CVD, was estimated to be 10.7% (Kullback–Leibler deviance R²).²² Most studies have shown that CVD is more prevalent among women, yet in our series the disease was more prevalent among men than women (P = 0.04). Similar observations have been made by the Edinburgh Vein Study^23,24 and Labropoulos et al.,²⁵ who reported a higher prevalence among men. In a recent study from the UK, Clark et al.²⁶ observed that though numerically women seemed to be at greater risk than men, this was not statistically significant (OR 1.53, 0.99–2.38, P = 0.056).

The role of age as a risk factor mentioned by many researchers could not be established in the present data. The prevalence of CVD among participants aged 50 years and above was 37.6% as compared with 34.4% among those aged less than 50 years showing a non-significant difference (P = 0.215).

Heredity has also been claimed to be a risk factor for CVD. According to Fiebig et al.,²² narrow-sense heritability of CVD equals 17.3% (standard error 2.5%, likelihood ratio test P = 1.4 × 10^–13). In our study, 17.1% participants gave a family history of CVD and family history was a significant risk factor (OR = 2.2; P < 0.0001).

The prevalence of oedema (C3) in our study (36.7%) was significantly (P < 0.0001) lower than the figures quoted in the San Diego Study (48.2%),²⁷ but significantly higher (P < 0.05) than the figures reported from Poland (10%),¹⁵ Bulgaria (13%)²⁸ and Slovakia (25%).²¹ There was no significant difference between men and women in C0s, C4, C5 and C6.

The pattern of symptoms observed in the present study is similar to that reported by most of the studies.^4,20,23 CVD has been associated with a wide range of lower limb symptoms including tingling, aching, burning, pain, muscle cramps, swelling, sensations of throbbing or heaviness, itching skin, restless legs, leg tiredness and/or fatigue. These symptoms are predictive of CVD, particularly if they are exacerbated by heat or worsen towards the end of the day.¹ In the present study, pain in the legs (59.2%) and heavy legs (42.7%) were the most frequent symptoms. The other frequently reported symptoms were sensations of swelling and night cramps, reported by 28.8% and 34.4% of participants, respectively. In most cases the percentage of patients with symptoms increases with age whatever the symptom considered (from 26.8% for 18–34 years old to 48.6% for 35–50 years old: P < 0.05). The prevalence of symptoms increased with age but remained similarly distributed between men and women.

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