International Journal of Vascular Medicine
Volume 2017 (2017), Article ID 1925176, 6 pages
https://doi.org/10.1155/2017/1925176

Research Article

Polygamy and Risk of Coronary Artery Disease in Men Undergoing Angiography: An Observational Study

Amin Daoulah,¹ Amir Lotfi,² Mushabab Al-Murayeh,³ Salem Al-kaabi,⁴ Salem M. Al-Faifi,⁵ Osama E. Elkhateeb,⁶ Mohamed N. Alama,⁷ Ahmad S. Hersi,⁸ Ciaran M. Dixon,⁹ Waleed Ahmed,¹⁰ Mohamed Al-Shehri,³ Ali Youssef,¹¹ Ahmed Moustafa Elimam,⁷ Ayman S. Abougalambou,⁶ Waheed Murad,⁴ and Alawi A. Alsheikh-Ali12,13

¹Section of Adult Cardiology, Cardiovascular Department, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
²Division of Cardiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA
³Cardiovascular Department, Armed Forces Hospital, Southern Region, Khamis Mushayt, Saudi Arabia
⁴Cardiovascular Department, Zayed Military Hospital, Abu Dhabi, UAE
⁵Section of Pulmonology, Internal Medicine Department, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
⁶Cardiac Center, King Abdullah Medical City in Holy Capital, Makkah, Saudi Arabia
⁷Cardiovascular Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
⁸Cardiovascular Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
⁹Emergency Department, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
¹⁰Section of Infectious Disease, Internal Medicine Department, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
¹¹Cardiovascular Department, Suez Canal University, Ismailia, Egypt
¹²College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
¹³Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, UAE

Correspondence should be addressed to Amin Daoulah; amindaoulah@yahoo.com

Received 20 August 2016; Accepted 5 January 2017; Published 30 January 2017

Academic Editor: Bhagwan Satiani

Copyright © 2017 Amin Daoulah et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Epidemiologic evidence suggests a link between psychosocial risk factors such as marital status and coronary artery disease (CAD). Polygamy (multiple concurrent wives) is a distinct marital status practiced in many countries in Asia and the Middle East, but its association with CAD is not well defined. We conducted a multicenter, observational study of consecutive patients undergoing coronary angiography during the period from April 1, 2013, to March 30, 2014. Of 1,068 enrolled patients, 687 were married men. Polygamy was reported in 32% of married men (1 wife: 68%, 2 wives: 19%, 3 wives: 10%, and 4 wives: 3%). When stratified by number of wives, significant baseline differences were observed in age, type of community (rural versus urban), prior coronary artery bypass grafting (CABG), and household income. After adjusting for baseline differences, there was a significant association between polygamy and CAD (adjusted OR 4.6 [95% CI 2.5, 8.3]), multivessel disease (MVD) (adjusted OR 2.6 [95% CI 1.8, 3.7]), and left main disease (LMD) (adjusted OR 3.5 [95% CI 2.1, 5.9]). Findings were consistent when the number of wives was analyzed as a continuous variable. In conclusion, among married men undergoing coronary angiography for clinical indications, polygamy is associated with the presence of significant CAD, MVD, and LMD.

1. Introduction

Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. In addition to the conventional risk factors for CAD, there is increasing awareness of the role played by psychosocial determinants such as marital status. It is well described that marriage offers health benefits and is associated with lower risk of all-cause mortality and lower risk of ischemic heart disease in men; however, the underlying mechanism is not well understood and several hypotheses have been proposed [1–8]. The majority of studies examining the relationship between marital status and CAD were conducted in western societies or developed countries, and none examined the role of multiple concurrent marriages (polygamy). Polygamy is a distinct marital status practiced in many developing countries, including those in Asia and the Middle East, but its association with CAD is not well defined. We therefore conducted an observational study examining the association between polygamy and the presence of significant CAD among men undergoing coronary angiography for clinical indications.

2. Methods

2.1. Patient Population

This is a multicenter, multiethnic, cross-sectional observational study. Data were collected prospectively from five hospitals in two Gulf regions (the Kingdom of Saudi Arabia and the United Arab Emirates), during the period from April 1, 2013, to March 30, 2014. The study was approved by King Faisal Specialist Hospital & Research Center Institutional Review Board, and an invitation letter was given to all participants who affirmed verbal consent prior to their enrollment. For each patient undergoing coronary angiography for a clinical indication, two separate data forms, one general and one angiographic, were filled out by the research assistant and assigned cardiologist, respectively (Supplementary Material available online at https://doi.org/10.1155/2017/1925176). Both forms were completed before the patients were discharged from the hospital. All data forms were reviewed by the assigned cardiologist and then sent online to the principle investigator, who also checked the forms before submission for analysis.

The general data form recorded the following information:

(i)Demographic data: age, gender, and ethnic background(ii)Physiologic status: history of hypertension, diabetes, or dyslipidemia and body mass index(iii)Life style: smoking history (current/ex-smoker)(iv)Past medical history: coronary artery disease, percutaneous coronary intervention, coronary artery bypass surgery, cerebral vascular disease, peripheral arterial disease, congestive heart failure, atrial fibrillation, or chronic kidney disease(v)Socioeconomic data: occupation (unemployed, private sector, government sector, and self-employed), living in rural or urban area, last level of education completed (illiterate, secondary school, university, masters, or doctorate), monthly income (<1300, 1300 to 2600, 2600 to 5300, 5300 to 7900, 7900 to 10600, and >10600 US dollars)(vi)Ethnicity: Arabic from Gulf region, Arabic from non-Gulf region, and non-Arabic.(vii)Current marital status (number of wives): One wife or polygamy (multiple concurrent wives)

The angiographic data form recorded the following:

(i)Reason for coronary angiography (elective versus urgent/emergent)(ii)Number of vessels involved (severity)(iii)Treatment (medical versus revascularization)

All patients who underwent coronary angiography were eligible for the study. There were no exclusion criteria.

2.2. Definitions

Significant coronary artery disease was defined as ≥70% luminal stenosis in a major epicardial vessel or ≥50% stenosis in the left main coronary artery. Multivessel disease (MVD) was defined as having more than one significant coronary artery disease.

2.3. Statistical Analysis

Standard summary statistics were used to describe the cohort. Continuous variables are presented as mean ± standard deviation and were compared across multiple groups using the analysis of variance test. Categorical variables are presented as percentages and compared using the Chi-square test. The association between polygamy and CAD was examined using logistic regression with and without adjustment for baseline differences. was considered statistically significant.

3. Results

3.1. Overall Patients Baseline Characteristics

We enrolled 1,068 patients, 687 (64%) were married men who underwent a coronary angiogram for elective (48%) or nonelective (52%) indications. Nonelective indications included non-ST elevation acute coronary syndrome (NSTEACS) (46%) and ST elevation acute myocardial infarction (STEMI) (6%). They were relatively young (age ), predominantly of Arab Gulf origin (87%), and from an urban setting (73%). Comorbid conditions including conventional risk factors for cardiovascular disease were common, most notably dyslipidemia (66%), hypertension (57%), diabetes mellitus (56%), and current or past smoking (54%). Many had a prior history of CAD (45%) or coronary revascularization (percutaneous coronary intervention [PCI] in 24% or coronary artery bypass graft surgery [CABG] in 6%). Other reported manifestations of cardiovascular or associated comorbid conditions included atrial fibrillation (5%), congestive heart failure (13%), cerebrovascular disease (4%), chronic kidney disease (14%), depression (8%), and peripheral vascular disease (2%). Nearly half of the patients were illiterate (42%). Most patients (80%) reported income levels of less than the equivalent of 32,000 USD annually, and 21% were not employed at the time of the study (Table 1).

Table 1: Overall patients baseline characteristics stratified by their number of wives.

All ()
1 wife ()
2 wives ()
3 wives ()
4 wives ()
value

Age
59 ± 12
58 ± 13
60 ± 11
61 ± 10
59 ± 13
0.01

BMI
28 ± 6
27 ± 6
28 ± 6
28 ± 6
27 ± 8
0.48

Rural (%)
27
24
32
36
43
0.027

DM (%)
56
55
58
61
48
0.726

Hypertension (%)
57
54
65
61
57
0.147

Smoking (%)
54
55
51
57
48
0.613

Dyslipidemia (%)
66
65
64
79
67
0.136

Past history (%)

    CAD
45
42
51
51
43
0.224

    PCI
24
23
29
20
14
0.264

    CABG
6
4
12
13
10
0.001

    AF
5
5
5
4
0
0.746

    CHF
13
12
15
13
14
0.848

    CVA
4
3
5
9
5
0.134

    CKD
14
13
15
23
10
0.13

    Depression
8
9
6
7
5
0.666

    PAD
2
2
4
4
0
0.199

Ethnicity (%)

0.215

    Arabic Gulf region
87
86
90
86
100

    Arabic Non-Gulf
6
7
3
10
0

    Non-Arabic
7
7
7
4
0

Monthly income (%)

<0.001

    <$1300
50
52
49
44
40

    $1300–2600
29
29
26
29
35

    $2600–5300
13
14
12
10
10

    $5300 to 7900
4
3
9
7
0

    $7900 to 10600
2
1
2
6
5

    >$10600
2
1
2
4
10

Job category (%)

0.127

    Jobless
21
22
20
21
19

    Private
18
17
20
20
10

    Government
43
40
46
50
62

    Self-employee
18
21
14
9
9

Education level (%)

0.778

    Illiterate
42
41
43
43
38

    Secondary school
38
39
38
34
33

    Postgraduate
16
15
16
16
29

    Masters
3
4
3
4
0

    Ph.D.
1
1
0
3
0

DM, diabetes mellitus; CAD, coronary artery disease; BMI, body mass index; CAD, coronary artery disease; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; AF, atrial fibrillation; CHF, congestive heart failure; CVA, cerebrovascular accident; CKD, chronic kidney disease; PAD, peripheral arterial disease; $, USA dollars; Ph.D., a doctor of philosophy.

3.2. Coronary Angiogram Findings

Coronary angiogram revealed significant coronary artery disease in 72% of patients, multivessel disease in 48%, and left main disease in 12%. Consequently, 47% underwent PCI and 17% CABG during the index admission, and the remainder (36%) were treated with medical therapy alone (Table 2).

Table 2: Coronary angiogram findings stratified by their number of wives.

All ()
1 wife ()
2 wives ()
3 wives ()
4 wives ()
value

Indication for CAG (%)

0.062

    Elective
48
52
44
30
33

    NSTEACS
46
42
50
63
57

    STEMI
6
6
6
7
10

Findings on CAG (%)

<0.001

    No CAD
28
37
19
0
0

    Single vessel disease
24
24
34
6
4

    Double vessel disease
26
28
30
11
10

    Triple vessel disease
22
11
17
83
86

    Multivessel disease
48
39
47
94
96
<0.001

    Left main disease
12
7
10
41
38
<0.001

Intervention (%)

<0.001

    Medical therapy
36
39
45
3
5

    PCI
47
53
49
16
14

    CABG
17
8
6
81
81

CAD, coronary artery disease; STEMI, ST segment elevation myocardial infarction; NSTEACS, non-ST-segment elevation acute coronary syndromes; CAG, coronary angiography; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting.

3.3. Polygamy and CAD

Married men () were categorized according to number of wives, and nearly one-third were polygamous. The majority had one wife (68%), and the remainder had two wives (19%), three wives (10%), or four wives (3%). Men with more than one wife were more likely to be older, live in a rural area, have a higher income level, and have a history of prior CABG (Table 1). With increasing number of wives, there were a higher proportion of men with CAD, MVD, or LMD (Figure 1). After adjusting for baseline differences, there was a significant association between polygamy and CAD (adjusted OR 4.6 [95% CI 2.5, 8.3]), MVD (adjusted OR 2.6 [95% CI 1.8, 3.7]), and LMD (adjusted OR 3.5 [95% CI 2.1, 5.9]) (Table 3). Findings were consistent when the number of wives was analyzed as a continuous variable (Table 3).

Table 3: Association of number of wives and polygamy with coronary artery disease in univariate and multivariate logistic regression.

Polygamy
Number of wives

Univariate
Multivariate
Univariate
Multivariate

Coronary artery disease
4.5 [2.9, 7.2]
4.6 [2.5, 8.3]
3.7 [2.5, 5.4]
4.0 [2.4, 6.6]

Multivessel disease
3.2 [2.3, 4.4]
2.6 [1.8, 3.7]
2.8 [2.2, 3.6]
2.6 [2.0, 3.4]

Left main disease
3.7 [2.3, 5.9]
3.5 [2.1, 5.9]
2.4 [1.9, 3.1]
2.5 [1.9, 3.2]

Adjusted for age, body mass index, history of smoking, diabetes, dyslipidemia, hypertension, coronary artery disease, percutaneous coronary intervention, coronary artery bypass graft surgery, indication for coronary angiography, income level, and community (rural versus urban).

Figure 1: Relationship between number of wives and coronary angiogram findings.

4. Discussion

Numerous studies have shown that marriage offers better overall health and mortality outcomes [1–8]. Also, it has been shown that remarried men do not differ in health outcome compared to men in a lifelong marriage [9–11]. On the other hand, the influence of polygamy (a distinct marital status of multiple concurrent wives) on cardiac disease has not been studied. To the best of our knowledge, the present study is the first to assess the association between polygamy and the severity and number of coronary artery lesions. Among men undergoing coronary angiography for clinical indications, a polygamous relationship was associated with 2 to 4 times higher odds of CAD, multivessel disease, or left main disease. This association persisted after adjusting for baseline differences and when the number of wives was treated as a continuous variable. In our cohort population, polygamy was more frequent in rural areas because it is more culturally acceptable, and getting married at a young age is more common in these areas. Men with multiple wives have to be well supported financially, and although Saudis and Emirati citizens are supported by their governments, polygamists may need more than one income. They may therefore take on extra employment or have the added pressure of travelling daily to urban areas for higher paid work.

A number of possible mechanisms may contribute to the association between polygamy and the severity and number of coronary artery lesions. It could be that the need to provide and maintain separate households multiplies the financial burden and emotional expense of polygamy. Each household must be treated fairly and equally, and it is likely that the stress of doing that for several spouses and possibly several families of children is considerable [12, 13]. Also, psychosocial factors may play a role in making them less compliant with their cardiac medication and having less time for physical activity, which could be relevant in those with prior CABG [14–17]. It is also possible that biological mechanisms related to the stress of polygamy can significantly lower testosterone levels secondary to increased cortisol levels [18–20]. Gray et al. looked at the relationship between testosterone levels and marriage among Ariaal men of Northern Kenya who are considered aloof spouses and provide minimal parenting. They found that men with more than one wife (polygynously married men) had lower levels of testosterone compared to their monogamously married counterpart [21]. Also, stress related to polygamy may have a role in blood pressure reactivity, increased hemoglobin A1C, reduced sleep time, impairment of efforts to be physically active, and poor dietary habits [6, 22–27]. In addition, the sympathetic nervous system may be activated, resulting in hemodynamic changes that may cause increased vascular resistance, transient myocardial ischemia, and/or disruption of vulnerable coronary plaques. In addition, stress may have proinflammatory and prothrombotic effects [28]. This study provides us with new information regarding the association between CAD and polygamy in a Gulf population. A larger study is required to confirm these findings. Future studies should involve additional regions and a more racially diverse group of subjects. Study designs aimed at elucidating potential mechanisms underlying these associations as well as the effect of polygamy on women’s coronary risk should be sought.

The strengths of this study are that it is the first to look at the association between distinct marital status (polygamy) and CAD using coronary angiography in a Gulf population.

We acknowledge a number of limitations. First, our study had a small sample size. Second, the time interval from being married with more the one wife to the cardiac catheterization was not recorded; this interval may have an influence on the findings. Third, our study population was selected to undergo coronary angiography if clinically indicated and as such cannot be generalized to all men who practice polygamy in the Gulf region. In the absence of reliable statistics on the prevalence of polygamy in the region, it is not clear if the prevalence we observed in our sample is significantly different from that of the general population. Fourth, adjustment for measured variables (e.g., age) may not have completely accounted for their potential confounding effects, and unmeasured confounding variables such as dietary habits, medication adherence, number of children, physical activity, or other unconsidered variables may also have influenced the association.

5. Conclusion

Among married men undergoing coronary angiography for clinical indications, polygamy is associated with the presence of significant CAD, MVD, and LMD.

Competing Interests

The authors declare that they have no conflict of interests.

Authors’ Contributions

Amin Daoulah participated in study design, acquisition of the data, review of clinical records, analysis and interpretation of the data, drafting of the manuscript, and revision of the manuscript for important content. Alawi A. Alsheikh-Ali participated in data analysis, interpretation of the data, and critical revision of the manuscript. All other authors participated equally in data collection and data reviewing.

Acknowledgments

The authors would like to sincerely thank all patients who agreed to participate in this study.

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