Common Chronic Disease Patterns in Arabian Gulf, Saudi Arabia & YemenDr. O. P. Kapoor
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Cardiovascular Diseases

I will discuss these diseases under the following headings:—
  1. Heart disease
  2. Hypertension
  3. Diseases of Aorta
  4. Diseases of Peripheral arterial vessels of limbs
  5. Venous disorders
  6. Raynaud's phenomenon

Before I discuss these, I would first like to analyse the common symptoms of heart disease seen in Arab population.

Dyspnoea on exertion ("Taab Tanafass Baadein Aimshey")— is one of the most common symptoms heard of in Arab population, especially if you elicit it by asking a leading question. If an Arab patient says "no" to your question, ask him if off and on, ("Saa aad" or "Aao Kaat") he gets dyspnoea on climbing steps ("Tatla Daaraj"). The answer will invariably be "yes". The following is the etiology of this symptom—

  1. This population is very conscious of dyspnoea ("Tanafass") and takes it very seriously.
  2. Except Yemenis, most of the Arabs are overweight.
  3. Mild Anaemia—is a common "associated"cause, mainly in Bahraini female population. Of course severe anaemia is commonly picked up in many males and females when they do complain of dyspnoea on exertion. So often with severe anaemia (sickle cell or Thalassaemia) the dyspnoea complained of is very little. They get so adapted that they can do their normal activities at this lower level of haemoglobin at which a Westerner would be confined to his house only.
  4. Smoker's bronchitis is an additional factor responsible for dyspnoea on exertion and is noted off and on.
  5. Heart disease is an uncommon cause of this symptom and that too if seen, it is more often either rheumatic heart disease or a cardiomyopathy rather than ischaemic heart disease.

2. Palpitations—("Gulb Hiduk" or "Dakka" or "Itaharak") is a very common symptom in majority of Arabs and one of the most common symptoms complained of by Bahrainis. This symptom is also complained of, in decreasing order of frequency, by Yemenis, Saudis, Qataris, Omanis and other patients from U. A. E. who point at the epigastrium. These patients place their hand on the precordium unlike those complaining of "Fooaat". Often they explain that this symptom occurs after climbing steps ("Daaraj") or excessive walking ("Aimshey"). in majority of females it is a symptom of fear, anxiety, nervousness and consciousness of heart beat. It is the same in the males as well, except in a few, where ventricular ectopic heart beats are the cause. These patients consume excessive cigarettes ("Shigaraa"), tea ("Shaye") or coffee ("Qahwah").

The amusing part of the symptom is the associated "gestures" with which they demonstrate this symptom. The gesture consists of a closed hand, with pronated wrist, and the shaking of it forwards and backwards in front of the precordium (see fig alongside).

While looking out for the other causes of this symptom, the following are my observations:—

  1. Rheumatic heart disease is seen off and on in Arabs and definitely more frequently than in Western countries. Incidentally innocent murmurs are not so common in Arabs (and if they were, the amount of 'neurosis' which would increase in Arab population is unimaginable). I do not know the cause for this, but probably, most of the haemic murmurs we hear in majority of Indian female population, are not present in these patients.
  2. Mitral valve prolapse syndrome is rare in this population. Some of my colleagues in echocardiography department have come across a few Arabs suffering from this disorder.
    Rarely this entity can be present without physical signs, even when midsystolic click or late systolic murmur at the mitral area are absent in Iying, sitting and standing positions. I sent many of these young women with chest pains and palpitations for routine echocardiography to rule out this disorder. Out of one group of hundred young female patients of mine, there was not a single patient whose M-mode or 2 D-echocardiography showed a prolapse of mitral valve leaflets.
  3. Similarly in practice although I see so many elderly Arab patients, sick sinus syndrome is rare.
  4. Though hypertension is a very common disease, severe diastolic hypertension is rare as a cause of this symptom. More often it is the anxiety of suffering from hypertension which is responsible for the symptom of palpitations.
  5. Thyrotoxicosis—though rare, should be excluded Incidentally, examination of thyroid gland is one of the most difficult part of the physical check up to perform in a female Arab, not only because of the "Veil" which many middle aged and elderly Bahrainis, Saudis and Qataris wear, but also the heaps of cloth tied round the neck like a bandage in Yemeni women! And then, to raise their chin up, to stretch the neck, in order to bring out a thyroid swelling from behind the upper sternum, is often very time consuming. It is also a problem to tell them to swallow ("Iblaa") saliva ("Moiyee") during the examination for thyroid swelling.

3. Oedema feet—Oedema of feet as a symptom of congestive cardiac failure is very rare in Arab population.

In fact oedema ("Waram") of the feet even otherwise is a "symptom" rarely heard from an Arab patient, though on examination a slight pitting is often found in obese patients having possibly additional venous insufficiency. And, if present, the patient is usualiv a Bahraini or less commonly a patient from Saudi, Qatar, Oman, U. A. E.—in this order of diminishing frequency. It is a very rare symptom in Yemenis. Whenever present, unilateral or even bilateral, deep venous thrombosis is the underlying cause (incidentally many Bahraini women use oral contraceptive pills).

Other causes of oedema of feet like severe anaemia, nephrotic syndrome, cirrhosis of liver are rare in this population.

4. Chest Pain—This is such a common complaint in Arab population and yet ischaemic chest pain i.e. Angina Pectoris is rare except in Bahrainis. It is also seen in Arabs from Saudi Arabia and Qatar. And of course, when present, Angina can be easily missed because retrosternal discomfort is complained of by majority of the Arab patients. However, it is important to note that these patients keep on moving their hands up and down in the retrosternal area (like a cardiac ischaemic patient). But if questioned, majority of them are sure that the symptom is "burning" ("Harara" or "Homoda") which is due to hyperacidity (often related to intake of Chillies in food) and has no relation to exertion.

Other causes of chest pain seen in Arab population are as follows—

  1. Chondritis—or Teitz's syndrome is a very common cause if not the most common cause of chest pain. It is very common in Bahrainis and Yemenis.
  2. Costalgia Fugax—This type of shooting, momentary pain felt in one of the costal cartilages, is best heard in Yemenis who describe this symptom very vividly with associated facial gestures.
  3. Rib Tip Syndrome—This syndrome is very common in Arabs especially Yemenis. The patient pin-points one of the anterior ends of the floating ribs and presses it with a finger to demonstrate tenderness.

Surprisingly ' pseudo mammary" neuralgia and a frank D'Costa's syndrome is very rare in Arab patients. In fact the moment these patients complaining of chest pain, are told that the heart, the electrocardiogram and the fluoroscopy or the Chest X-ray are normal, they seem to be satisfied easily! Severe cardiac neurosis is a rarity in an Arab and even in a Yemeni!

A. Ischaemic Heart Disease—Although in many Arabs, multiple risk factors are present, and retrosternal symptoms are complained of, ischaemic heart disease is less common. Thus an Arab who is obese, leads a sedentary life, suffers from diabetes mellitus, has mild hypertension, smokes cigarettes and consumes alcohol, yet he is found to have chest pains of "non-ischaemic" origin.

But if you see a Bahraini, not only is ischaemic heart disease seen frequently but precocious coronary artery disease also manifests in this population. So many Bahrainis are seen, often below the age of forty five (sometimes even females), in whom coronary by-pass surgery has already been done! Some of the gross ischaemic patterns are seen in the electrocardiograms of Bahrainis. Similarly gross ischaemic heart disease is often seen in Bahrainis with minimal evidence of diabetes, hypertension, smoking (as in women, who are non-smokers) and obesity. Often their blood lipids are elevated. There are families in Bahrain with extremely elevated lipid levels. But, frequently, family history ("Fi Ailitik") of ischaemic heart disease cannot be elicited because the patient's father, mother may never have undergone a medical check up, but the fact that they are alive and healthy and are more than 60 or 70 years old is against their having suffered from ischaemic heart disease.

Ischaemic heart disease is also seen in patients coming from Saudi, Qatar and Oman. But one Arab community where this disease is very very rare is Yemenis. Here I must hasten to add that there are a few Yemenis whose constitution is like Saudis. In fact they have been doing business or are living in Saudi for years together. The health problems e.g. hypertension, diabetes, ischaemic heart disease in these Yemenis are like Saudis.

Congestive cardiomyopathy is more likely to be the cause if an Arab is diagnosed as 'ischaemic heart disease' and has a gross cardiomegaly and chronic congestive cardiac failure.

Finally, following heart diseases which may "appear" to be common, are very rare in Arab patients:

  • Diabetic heart disease
  • Hypertensive heart disease
  • Obesity - Pickwickian syndrome
  • Alcoholic cardiomypathy

B. Hypertension

Hypertension is a common disorder amongst Arab patients. The incidence of this disease is highest in Bahrain, followed in decreasing order by Saudi, Qatar, Oman and U.A.E. (in U.A.E.— highest in Abu Dhabi). It is rare in Yemenis (except "Saudi" type of Yemenis as described above).

Compliance is at its worst with Arab population. They just do not believe in any "long-term" therapy. Many of my patients come for a yearly check-up. Yet at the next examination they have been "off" their tablets for at least few months! They do not comply with low salt diet. They do not lose weight. They continue smoking though fewer cigarettes. But curiously enough, I often do not find their condition deteriorating!

The Arab population tolerates hypertension much better than many others in the world. Hypertensive retinopathy, nephropathy and cardiopathy are rarities. Strokes do occur, but less frequently in spite of the high incidence of hypertension in this population.

Since these patients enjoy getting investigated, it is interesting to note that renal and renovascular causes of hypertension are rare in this population, leave alone the other rare causes like phaeochromocytoma etc. The incidence of kidney stones on l.V.P. is same as in non-hypertensive population.

Finally sometimes, when I do see chronic renal failure in a patient having hypertension, I find that it is a complication of renal stones with superadded chronic pyelonephritis or bladder neck obstruction, often due to prostatic enlargement.

Before I conclude with the subject of hypertension, I must hasten to add that Arab patients are very "afraid" of hypertension ("Dakht"). The moment you start recording the blood pressure, they are curious to hear the reading. Especially those who have headache, giddiness, weakness etc. are "so relieved" to hear from you that their blood pressure is normal, that they immediately thank.... not "you" but—"Insha Allah"!

C. Aorta—Regarding the consciousness of the pulsations of a normal abdominal aorta felt by the patient in the epigastrium, I have already discussed this subject elsewhere. This symptom is complained of as "Fooaat Gulb" especially by Omanis

"Atheroma" of aorta is common in Arab patients. I have seen even middle aged women with extensive linear calcification of abdominal aorta. This stands out prominently in the lateral view (X-ray) of lumbar spine. It is one of the X-rays which invariably has to be asked for nearly in every alternate Arab patient because of the universal complaint of backache. Although rarely these patients may suffer from associated Angina Pectoris and hypertension, most of the times, aortic atheroma is symptomless and harmless to the patient (see fig. alongside).

Symptoms of aortic arch syndrome, renal artery or mesenteric artery stenosis (intestinal angina) are hardly ever seen. off and on, in elderly Arabs, Lehriche's syndrome is discovered. But symptoms have hardly been severe enough to coax the patient for surgery.

D. Peripheral vascular disease—is rare in Arabs. The symptoms of ischaemia are very uncommon even when peripheral pulsations are not palpable. Calf pains, when present are more due to tension and anxiety.

In spite of heavy smoking the entity of thrombo-angiitis obliterans is relatively rare.

E. Deep vein thrombosis—I am surprised to find a low incidence of deep vein thrombosis in Arab ladies who undergo, on an average, half to one dozen deliveries!! As mentioned earlier, this condition is more common in Bahraini females. In Arabs, the veins (and their valves) behave definitely better than those of Indian or western population ! !

F. Raynaud's phenomenon—Many Arab patients, especially females, complain that their hands and feet, ("Yad" and "Rijley") become cold ("Baraad") when they are in air-conditioned rooms. Now ask the patient if she also feels the limbs hot ("Haar") off and on. The answer is always "yes". Also the limbs do not become blue. The burning complained of does not follow immediately the feeling of cold. Thus, you can exclude Raynaud's phenomenon.

Incidentally collagen disorders like Scleroderma or S.L.E. which are etiological factors of this symptom, are very rare in Arabs.