several studies suggest that patients with serious mental illness die about 20 years earlier than the general population , with cardiovascular disease being the leading cause of mortality in patients with schizophrenia . a population - based study in a nationally representative sample from united states reported two - fold increase in the risk of mortality in persons with mental disorders , with an average life span of 8.2 years less than the rest of the population , with the majority of deaths ( 95.4% ) attributed to medical causes rather than unnatural causes . relative risk of all - cause mortality for patients with schizophrenia has been reported to be 2.6 . poor health status , socioeconomic deprivation , adverse health behaviors , and poor quality of medical care are important factors associated with high mortality in subjects with severe mental illness . despite this recently , some studies have assessed the prevalence of cardiovascular risk ( cvr ) factors in patients with schizophrenia and have calculated the 10-year risk of having a cardiovascular event using various parameters such as framingham risk equation score and systematic coronary risk evaluation ( score ) function indicating 10-year cardiovascular mortality risk ( cmr ) . the framingham risk equation score , provides a validated calculation of 10-year risk of development of coronary heart disease ( chd ) and the score function indicates the 10-year cmr . recognition of these factors is emphasized as these are modifiable risk factors , which if identified and managed properly in time can contribute to a reduction in cardiovascular mortality . few studies have assessed the future risk of cardiovascular events in the patient of schizophrenia . reported a 10-year chd risk of 6.5% for inpatients with schizophrenia ( n = 111 ) . they also reported that 23.4% of patients with schizophrenia had a chd risk more than equal to 10% . in the clinical antipsychotic trials of intervention effectiveness study , it was observed that patients with schizophrenia had significantly higher 10-year risk of chd than the general population ( 9.4% vs. 6.3% in males and other studies reported 10-year chd risk of 6.5 - 7.2% and cmr to be 0.9% in patient with schizophrenia with high / very high risk of chd ( 10% ) in 22 - 23% patients with schizophrenia and high cmr risk ( 5% ) in 6.5 - 8% patients with schizophrenia . although several studies have evaluated the prevalence of ms in patients with schizophrenia in india , no study from india has evaluated the prevalence of cardiovascular factors in patients with schizophrenia as framingham function for development of chd and the score function  10-year cmr . the present study aimed at estimating the prevalence of cvr factors as the framingham function for development of chd and the score function - 10-year cmr , in patients with schizophrenia . informed consent was sought from all patients who were part of this study . if the patient was incompetent on account of the severity of illness to provide informed consent , the primary caregiver staying with the patient the study was carried out at the inpatient unit of a multi - specialty tertiary - care hospital in north india . all consecutive patients ( aged 20 or above ) , admitted to the inpatient unit from january 2009 to december 2011 and diagnosed with schizophrenia according to the international classification of diseases - classification of mental and behavioral disorders - clinical descriptions and diagnostic guidelines 10 revision were invited to participate in the study . data pertaining to the prevalence of metabolic syndrome in a subgroup of this cohort was published earlier . patients found to have metabolic abnormalities , and high cvr factors were informed about the same and they were provided information about the need for proper diet and regular exercise , and were referred to specialist care whenever required . calibrated scales were used to measure body weight in kilogram ( kg ) and height in centimeters ( cm ) . waist circumference was measured in centimeters ( cm ) , at a point midway between the inferior costal margin and the superior iliac crest , at the end of the normal expiration while standing . by using standard mercury manometer at least two readings at 5-min intervals , were taken to measure the blood pressure ( bp ) in the supine position . if bp was found to be high ( 140/90 ) then a third reading after 30 min was obtained ; the lowest of these readings was taken . fasting venous blood sample was collected under aseptic condition to estimate fasting blood sugar , triglycerides ( tga ) and high - density lipoprotein ( hdl ) . metabolic syndrome was defined by the consensus definition , according to which presence of abdominal obesity is no more a mandatory criterion for defining ms and presence of any of three of five risk factors indicates the diagnosis of ms . for waist circumference ten years cvr was evaluated on the basis of framingham risk equation and score function . both of these methods are mathematical probability models which were developed by using multivariate analysis on the basis of findings of follow - up studies of individuals from the general populations who had fatal or nonfatal chd event in relation to the individual risk factors . framingham risk score provides an estimate of the chances that a person will develop cardiovascular disease over a specified period , usually 10-year . it includes fatal and nonfatal events such as angina , myocardial infarction , stroke , other type of coronary ischemia , congestive heart failure , intermittent claudication or peripheral arterial ischemia . the score is estimated on the basis of age , gender , total cholesterol , hdl cholesterol , systolic arterial pressure , diabetes mellitus and smoking habit . on the basis of the framingham risk score higher percentage score indicates higher risk and the percentage scores are categorized arbitrarily into as low risk ( < 10% ) , and high risk ( > 10% ) . the score function estimates the risk for cvm risk ( including coronary death , sudden death , stroke , aortic aneurism , and heart failure ) within 10-year . it takes into account the age , gender , total cholesterol , hdl cholesterol , systolic arterial pressure , and smoking habit . both framingham risk score and score function can be calculated by using various websites ( framingham risk equation - [ http://www.framingham heartstudy.org/risk/coronary.html ] and score function at website [ https://escol.escardio.org/heartscore/calc.aspx?model = europehigh ] ) . in this study , patients were classified according to the probability of presenting  very high / high  chd risk if they had framingham function of 10% and  high  cmr risk if they had score 5% . it has been suggested that for patients with diabetes mellitus , the score function generated by the equations be multiplied by two for men and four for women . the spss version 14.0 for windows ( chicago , illinois , usa ) was used for analysis . frequencies with percentages were calculated for nominal and ordinal variables and mean , and standard deviation were calculated for continuous variables . chi - square test and t - test were used for comparisons . for variables with a skewed distribution , nonparametric tests like mann  whitney calibrated scales were used to measure body weight in kilogram ( kg ) and height in centimeters ( cm ) . waist circumference was measured in centimeters ( cm ) , at a point midway between the inferior costal margin and the superior iliac crest , at the end of the normal expiration while standing . by using standard mercury manometer at least two readings at 5-min intervals , were taken to measure the blood pressure ( bp ) in the supine position . if bp was found to be high ( 140/90 ) then a third reading after 30 min was obtained ; the lowest of these readings was taken . fasting venous blood sample was collected under aseptic condition to estimate fasting blood sugar , triglycerides ( tga ) and high - density lipoprotein ( hdl ) . metabolic syndrome was defined by the consensus definition , according to which presence of abdominal obesity is no more a mandatory criterion for defining ms and presence of any of three of five risk factors indicates the diagnosis of ms . for waist circumference , country - specific cut offs have been suggested . ten years cvr was evaluated on the basis of framingham risk equation and score function . both of these methods are mathematical probability models which were developed by using multivariate analysis on the basis of findings of follow - up studies of individuals from the general populations who had fatal or nonfatal chd event in relation to the individual risk factors . framingham risk score provides an estimate of the chances that a person will develop cardiovascular disease over a specified period , usually 10-year . it includes fatal and nonfatal events such as angina , myocardial infarction , stroke , other type of coronary ischemia , congestive heart failure , intermittent claudication or peripheral arterial ischemia . the score is estimated on the basis of age , gender , total cholesterol , hdl cholesterol , systolic arterial pressure , diabetes mellitus and smoking habit . on the basis of the framingham risk score higher percentage score indicates higher risk and the percentage scores are categorized arbitrarily into as low risk ( < 10% ) , and high risk ( > 10% ) . the score function estimates the risk for cvm risk ( including coronary death , sudden death , stroke , aortic aneurism , and heart failure ) within 10-year . it takes into account the age , gender , total cholesterol , hdl cholesterol , systolic arterial pressure , and smoking habit . both framingham risk score and score function can be calculated by using various websites ( framingham risk equation - [ http://www.framingham heartstudy.org/risk/coronary.html ] and score function at website [ https://escol.escardio.org/heartscore/calc.aspx?model = europehigh ] ) . in this study , patients were classified according to the probability of presenting  very high / high  chd risk if they had framingham function of 10% and  high  cmr risk if they had score 5% . it has been suggested that for patients with diabetes mellitus , the score function generated by the equations be multiplied by two for men and four for women . the spss version 14.0 for windows ( chicago , illinois , usa ) was used for analysis . frequencies with percentages were calculated for nominal and ordinal variables and mean , and standard deviation were calculated for continuous variables . chi - square test and t - test were used for comparisons . for variables with a skewed distribution , nonparametric tests like mann  whitney during the study period of 3 years ( january 2009december 2011 ) , 560 patients were admitted to the inpatient unit . a total of 159 ( 28.4% ) patients were diagnosed with schizophrenia and of these 143 patients were aged 20 years or above . all of them / their caregivers provided informed consent to participate in the study and formed the study cohort . as shown in table 1 , the mean age of the sample was 31 years . about three - fourth of the patient 's belonged to urban locality and more than half belonged to nuclear families . nearly one - third patients were married and were on employment prior to admission to the inpatient unit . sociodemographic and clinical profile of the study sample ( n=143 ) the mean duration of illness was 69 months . paranoid schizophrenia ( 54.5% ) formed the most - common diagnostic subtype , and this was followed by undifferentiated ( 35.7% ) subtype . the most commonly present cvr factor was low hdl level , followed by hyperglycemia , high diastolic pressure , being a smoker and high cholesterol level . chd risk factors of the study sample ( n=143 ) framingham score for the study sample was 1.65 , and only 2% of the sample was found to have very high / high chd risk ( 10 ) . score value was 1.39 , and only 2% of the sample had high cmr risk ( 5 ) . compared to females , significantly higher proportion of males were smoker ( 23.8% vs. 7.8% ,  : 5.69 * , p < 0.05 ) , and had higher framingham score ( 1.96  2.74 vs. 1.09  0.41 , u value 1987.5 * , p < 0.05 ) . details of the anthropometric findings and physical examination findings and biochemical profile are shown in table 3 . one - third of the study sample ( 36.4% ) was found to have ms . increased waist circumference was the most common abnormality , followed by low hdl levels , high tga levels , increased fasting glucose level and abnormal bp was the least common abnormality noted . compared to males , significantly greater proportion of females had low hdl levels ( p < 0.001 ) . as shown in table 1 , the mean age of the sample was 31 years . about three - fourth of the patient 's belonged to urban locality and more than half belonged to nuclear families . nearly one - third patients were married and were on employment prior to admission to the inpatient unit . sociodemographic and clinical profile of the study sample ( n=143 ) the mean duration of illness was 69 months . paranoid schizophrenia ( 54.5% ) formed the most - common diagnostic subtype , and this was followed by undifferentiated ( 35.7% ) subtype . the most commonly present cvr factor was low hdl level , followed by hyperglycemia , high diastolic pressure , being a smoker and high cholesterol level . chd risk factors of the study sample ( n=143 ) framingham score for the study sample was 1.65 , and only 2% of the sample was found to have very high / high chd risk ( 10 ) . score value was 1.39 , and only 2% of the sample had high cmr risk ( 5 ) . compared to females , significantly higher proportion of males were smoker ( 23.8% vs. 7.8% ,  : 5.69 * , p < 0.05 ) , and had higher framingham score ( 1.96  2.74 vs. 1.09  0.41 , u value 1987.5 * , p < 0.05 ) . details of the anthropometric findings and physical examination findings and biochemical profile are shown in table 3 . one - third of the study sample ( 36.4% ) was found to have ms . increased waist circumference was the most common abnormality , followed by low hdl levels , high tga levels , increased fasting glucose level and abnormal bp was the least common abnormality noted . compared to males , significantly greater proportion of females had low hdl levels ( p < 0.001 ) . findings with respect to chd risk ( framingham score ) for patients with schizophrenia in the present study is less than that reported from the west ( 6.5 - 11.3% ) . the major reason for this difference could be a lower age and lower prevalence rate of smoking in our cohort compared to those evaluated in studies from the west , in which the mean age of the study groups was 40.7 years and the percentage of smokers varied from 53.7 to 58 . this findings also suggest that age is an important variable which influences the framingham risk score . however , the framingham score obtained in the present study was higher than that reported in patients with first episode psychosis ( 1.65 vs. 1 ) . this suggests that possibly with age and treatment the chd risk increases in patients with schizophrenia . studies from different ethnic groups and that from india have reported prevalence rate of ms to be 9 - 68% in patients with schizophrenia . in the present study , 36.4% of patients had ms , which is in the above reported range . however , the prevalence of ms in the patients with schizophrenia in the present study is significantly higher in comparison to findings reported in drug - nave schizophrenia patients from india this possibly suggests that treatment with antipsychotic contribute to the development of ms in patients with schizophrenia . greater proportion of females had low hdl levels which is similar to the finding of an earlier study in drug - nave subjects with schizophrenia . when we compare the rate of ms as reported in most of the studies from the west , which have assessed chd risk and cmr risk in patients of schizophrenia , the rate of ms in our study are much higher . this indicates a disparity between the prevalence of ms and chd rates compared to findings from the west . one possible reason for this discordance could be due to use of ethnic specific cut - offs for estimation of ms , compared to the methods used for assessment of chd risk and cmr risk , which are based on the western population . therefore , the chd risk and cmr risk estimated in this study serve as crude composite indices of the various factors affecting cvr factors rather than as accurate estimates of absolute risk , similar to an earlier study in the diabetic population of the capital of india . the disparity in the ms and chd risk also suggests that ms is independent of age , whereas framingham and score are age dependent , which may be a limitation of these indices . in a previous study from our center , we evaluated the chd risk and cmr risk in patients with bipolar disorder . in this study , 10-year chd risk was found to be 3.36% and 10-year cmr was 1.73% . in terms of severity of risk , one - tenth ( 10.7% ) of the sample was found to have very high / high chd risk ( 10 ) and 6.45% of the sample had high cmr risk ( 5 ) . when we compare the findings of the present study with patients of bipolar disorder , it is apparent that the chd risk and cmr risk are lower in patients with schizophrenia . however , this finding must be interpreted in the light of the fact that the mean age of patients with bipolar disorder was significantly higher than the schizophrenia cohort . to overcome this limitation , when we took an age and gender - matched group of patients with bipolar disorder and compared with patients of schizophrenia , no significant difference was noted between the two groups in terms of cmr risk , very high / high chd risk ( 10 ) and high cmr risk ( 5 ) . accordingly our findings suggest that the risk of cmr is similar in patients with schizophrenia and bipolar disorder . however , the risk of chd is higher in patients with bipolar disorder . the limitations of the present study are cross - sectional design , inclusion of inpatients only , which are usually more severely ill and lack of healthy control group . the relationship between the disease severity and impact of medication on the prevalence of ms was not studied . we also did not assess the effect of lifestyle factors , physical activity , dietary factors and family history of diabetes , all of which can confound the prevalence of ms . the study was also constrained by the lack of validation of the cvr scores used for 10-year risk projection in the indian population ( the framingham risk score is based on data from whites , whereas score was developed for european populations ) . in future studies with the longitudinal design to conclude , the present study suggests that about one - third of patients diagnosed with schizophrenia have ms . among the various subcomponents of ms , the cvr in terms of chd and cmr in patients with schizophrenia in patients from india may be less than that reported from the west . however , although the cvr factors in indian patients is less than that reported from the west , this risk can not be ignored . these findings suggest that patients of schizophrenia should be closely monitored for the cvr factors , especially the waist circumference and bp , which can be done easily without any extra cost . further , the cvr factors must be taken into account , while choosing various antipsychotics medications which are known to be associated with higher weight gain and metabolic abnormalities . there is a need to increase the awareness among mental health professional about the various cardio - metabolic risk factors in patients with schizophrenia and how to manage the same . further , there is a need for active collaboration between the treating psychiatrist and the cardiologists to address the various cvr factors to reduce the future risk of cardiovascular morbidity and cvm .
objective : the study aimed to evaluate the prevalence of cardiovascular risk ( cvr ) factors and metabolic syndrome ( ms ) in patients with schizophrenia.materials and methods : by consecutive sampling , 143 patients ( of age  20 years ) , out of total 159 patients with schizophrenia admitted to the inpatient unit were evaluated for the coronary heart disease ( chd ) risk as per framingham ( 10-year all chd events ) function / risk equation and systematic coronary risk evaluation ( score ) - 10-year cardiovascular mortality risk ( cmr ) . 
 prevalence of ms was estimated by using the consensus definition.results:fifty-two ( 36.4% ) patients fulfilled the criteria for ms . 
 10-year chd risk was 1.65% , and 10-year cmr was 1.39% . 
 compared to females , males had higher framingham score ( 1.96  2.74 vs. 1.09  0.41 , u value 1987.5 * , p < 0.05).conclusion : patients of schizophrenia have a high prevalence of ms and cvr factors . 
 hence , there is a need to screen the patient of schizophrenia for the same and manage the same as early as possible during the course of illness .