Comparing Gastroesophageal Reflux Disease (GERD) and Non-GERD Patients Based on Knowledge Level of Acute Myocardial Infarction Symptoms, Risk Factors and Immediate Action Taken in Eastern Province, Saudi Arabia

Introduction: A major cause of death globally is cardiovascular disease (CVD). Chest pain, nausea, vomiting, and heartburn are common symptoms of acute myocardial infarction (AMI). Chest pain is also the main symptom of gastroesophageal reflux disease (GERD). Therefore, the differential diagnosis of chest pain can become more challenging when GERD and AMI coincide. This study evaluated and compared the knowledge of the signs, symptoms, and immediate action that must be taken regarding AMI among GERD and non-GERD patients. Methodology: An observational cross-sectional study using an online questionnaire was created and published between October and November 2022 to collect data from Saudi males and females 18 or older willing to participate in the study. Participants who were not Saudi had declined to complete the survey or had not fully completed it was excluded. The questionnaire contained three sections; after collecting informed consent, it made inquiries regarding respondents’ GERD status, demographic information, and knowledge and attitudes regarding GERD. Results: This study included 691 responses from 300 non-GERD participants and 391 GERD participants. The study showed a high level of awareness (75.5%) of GERD, with significant differences in the level of awareness according to marital status, education levels, and occupation status. There was no significant difference in the level of awareness according to gender and GERD diagnosis, where the p-value > 0.05. The most common source of information about AMI was the Internet, followed by health care professionals. The most commonly known symptoms of AMI were sudden pain or discomfort in the chest, followed by a sudden shortness of breath. Additionally, there was no significant association between the diagnosis of GERD and known risk factors. The association between GERD and other diseases (chi-square = 46.94, p-value 0.01). Obesity and smoking were the two main risk factors for heart attacks. Conclusion: This study demonstrated that there was no significant difference between GERD and non-GERD participants regarding the knowledge and awareness level of AMI. Moreover, it showed that there was a lack of general knowledge and awareness of AMI in Saudi Arabia. The authors recommend initiating more awareness programs in Saudi Arabia to inform people about AMI and cardiovascular disease. More research is required to determine whether other patients are aware of AMI.


Introduction
Cardiovascular diseases (CVD) are one of the leading causes of mortality worldwide, with approximately 17.9 million deaths reported annually [1]. Saudi Arabia reported a rise in CVD rates in recent years, with an overall prevalence of 5.5% [2]. Additionally, acute coronary syndrome (ACS) death rates in Saudi Arabia were 4%, 5.8%, and 8.1% in-hospital, at one month, and at one year, respectively [3]. Gastroesophageal reflux disease (GERD) results from the regurgitation of gastric contents into the esophagus [4]. More than 40% of adults in the United States suffer from GERD each month [5]. In Saudi Arabia, the estimated range of GERD prevalence is between 23.47% and 45.4% [6]. The classic symptoms of acute myocardial infarction (AMI) include chest pain, nausea, vomiting, and heartburn. These symptoms are also associated with GERD [7]. Moreover, the coexistence of GERD and AMI at the same time can make the differential diagnosis of chest 1 2 2 2 2 3, 2 pain more complicated [8]. GERD shares similar risk factors with AMI that include obesity, diabetes, hypertension, and hyperlipidemia, along with behavioral risk factors, including smoking and alcohol use [9][10][11][12]. Recent studies in Saudi Arabia showed a suboptimal awareness level of coronary artery disease (CAD) risk factors [13,14]. Since GERD is the most common cause of non-cardiac chest pain, it is crucial to assess public knowledge about the differences between heart attack and heartburn. No such work appears to have been published regarding such awareness among GERD patients. This study assesses and compares the understanding of early signs, symptoms, and appropriate responses in cases of AMI among GERD and non-GERD patients in Saudi Arabia.

Study design and selection criteria
An observational cross-sectional study was carried out using an online questionnaire to obtain responses from male and female citizens of Saudi Arabia who are older than 18 years of age and willing to participate in the study. Non-Saudi citizen participants, people who declined participation, and people who did not complete the entire questionnaire were excluded.

Questionnaire design
The questionnaire was designed in Arabic, as it is the native language of Saudi Arabia, and distributed randomly via Google Forms using social media platforms such as WhatsApp, Twitter, and Telegram. The questionnaire consisted of three sections and was presumed to take approximately three minutes to be completed. The questionnaire was developed and published between October and November 2022 and generated 691 responses, with 391 suffering from GERD who were self-diagnosed based on their symptoms and 300 who have never experienced such symptoms. The first section began with gathering informed consent from participants, followed by a query regarding the respondent's status with regard to GERD. The second section addressed demographic data, including age, gender, marital status, educational level, and occupational status of respondents. Finally, the third section contained questions regarding the knowledge and attitude of GERD respondents' knowledge of and attitude toward AMI among GERD and non-GERD patients in Saudi Arabia.

Ethical consideration and statistical analysis
This study was approved by the Ethics Committee of King Faisal University with an ethical approval code KFU-REC-2022-SEP-ETHICS172. Participants were given a statement guaranteeing that their confidential information and privacy would be protected before proceeding to the questionnaire. Completion and submission of the questionnaire were considered as consent for inclusion in the study. Data were extracted, reviewed, coded, and entered into IBM Statistical Package for the Social Sciences (SPSS) software, version 22 (SPSS, Inc., Chicago, IL).

Results
The results showed a significant difference in awareness level according to marital status; the highest awareness level was among single people and the lowest awareness was among widowed people (F= 3.602, pvalue = 0.013). By educational level, the highest level of awareness was among bachelors and the lowest awareness level was among people with diplomas (F= 8.328, p-value < 0.01). By occupational status, the highest awareness level was among students and the lowest was among housewives (F= 8.328, p-value < 0.01). There were no significant differences in awareness according to gender or GERD diagnosis (p-value > 0.05) (  11.3% were retired, 9.7% were housewives, and 8% were looking for a job. The majority (53.5%) earned monthly incomes of less than 3,000 SR, 23.4% had incomes from 3,000 SR to 10,000 SR, 15.5% had incomes from 10,000 SR to 20,000 SR, and 7.5% had incomes of more than 20,000 SR (  Table 3). Levels of awareness among respondents regarding heart attack information were high (mean: 75.5%). The most identified item was that sudden heart attacks require prompt treatment (91.8%), then hearing about heart attacks (91.5%), and the least-known item was what to do first when witnessing signs/symptoms of heart attack (49.5%) ( Table 4). There was a significant association between GERD diagnoses and other diseases (chi-square = 46.94, p-value < 0.01). There were also significant associations between this diagnosis and knowing someone who had experienced a heart attack before (chi-square = 8.094, p-value = 0.004). However, there were no significant associations between this diagnosis and other factors (hearing about heart attacks, receiving information related to heart attacks, knowing the need for prompt treatment for sudden heart attacks, knowing the proper actions to take when witnessing signs/symptoms of heart attack, knowing the ambulance phone number). The p-value for these factors was > 0.05 ( Table 5). The most popular source of information about heart attack was the Internet (28.1%), followed by health care professionals (21%), books (15.8%), TV (13.9%), media (13.6%), seminars (4.8%), and promotional leaflets (2.8%) ( Table 6). The most identified risk factor for heart attack among respondents was obesity (14.5%), followed by smoking (13.9%), heart diseases (11.6%), high cholesterol (9.8%), stress (9.1%), diabetes (8.4%), unhealthy diet (8%), lack of exercise (7.2%), alcohol (6.1%), genetics (5.5%), atrial fibrillation (4.6%), and exercise (0.9%). 0.5% were not aware of any risk factors ( Table 7). The most frequently identified symptoms of heart attack were sudden pain or discomfort in the chest (26.2%), sudden shortness of breath (21.2%), sudden pain or discomfort in the arms or shoulders (16.9%), sudden pain or discomfort in jaw, neck, or back (15.2%), weakness or dizziness (11.2%) and sudden disturbance of the vision in one or both eyes (9.2%) ( Table 8).

Discussion
The current study assessed the awareness of early signs and symptoms of AMI among GERD and non-GERD patients in Saudi Arabia and their knowledge of the best course of action to be taken from the onset of symptoms. The result showed that 43.6% of participants were male and 56.4% were female. Out of the respondents, 56.6% had received a diagnosis of GERD, and 43.3% had not received such a diagnosis. The result demonstrated a high level of awareness toward AMI in both groups of respondents (GERD and non-GERD), which was higher than expected. Moreover, there was a significant difference in the level of awareness according to an educational level only. Conversely, there were no significant differences between males and females and between GERD/non-GERD diagnoses. The knowledge of proper action in response to AMI was low. The result showed a high level of knowledge of AMI in GERD patients. This might be due to the disease itself; it could encourage patients to be more aware of complications and other diseases that share similar risk factors. The present findings seem to be consistent with other research, which found high levels of knowledge of AMI (60.4%) among hypertensive patients [15]. Similarly, a study conducted in Nepal illustrated that more than half of the participants knew that AMI could be a complication of diabetes mellitus [16]. Additionally, there were no significant differences between participants who had GERD and those who did not have GERD regarding knowledge of AMI. This might be explained by the fact that most participants had a high level of education. The most common symptoms identified by the participants were sudden pain in the chest, followed by a sudden shortness of breath and sudden pain in the arm or shoulder. However, a study in the United States reported that the most common symptoms of AMI are chest pain and jaw, neck, or back pain. Furthermore, the knowledge of the most common symptoms of AMI was higher in that study compared to this one [17]. The most prevalent risk factors recognized among respondents were smoking (13.90%) and obesity (14.50%). This aligns with a study that was conducted in the western region of Saudi Arabia, where 66.7% of respondents identified smoking as a risk factor [18]. Moreover, two other studies in Saudi Arabia and Kuwait reported very high awareness levels of smoking as a risk factor, reaching over 95% of respondents [19,20]. The results showed that the level of knowledge regarding the appropriate action to be taken in the presence of AMI symptoms (49.5%) was low compared with Korea (67.0%) [21], Poland (87.4%) [22], and the United States (86.8%) [17].

Limitations
This study's strength was its high enrollment of participants who had been diagnosed with GERD or heartburn; this strengthened the result. However, there were some limitations in the study. First, the database did not contain data on the source of participants' GERD diagnoses and whether they had been made by a doctor or by the participants themselves. Second, Saudi residents in Saudi Arabia were included in the study, but residents of other nationalities and Saudis residing abroad were not included. Third, the majority of the participants were of young age; the mean age was 31.6, with a standard deviation of 13.66. If there was a greater diversity in respondent age, the study might have shown additional information. Future studies should take these limitations into consideration.

Recommendation
Based on the findings of this study, annual awareness and education campaigns would be appropriate, with a focus on GERD patients and high-risk people, in order to raise knowledge of AMI symptoms and the appropriate course of action that should be taken if symptoms develop.

Conclusions
The study showed that the overall knowledge and awareness of AMI were suboptimal. The majority of participants had previously heard about AMI, but they were unsure regarding the proper first step to be taken when witnessing signs or symptoms. There was no significant difference in awareness levels among people who reported GERD diagnoses and those who did not. The authors suggest launching additional awareness campaigns about AMI and what to do next and educating people about cardiovascular disease in Saudi Arabia, especially among members of high-risk groups. More studies are needed to identify awareness of GERD complications and also to detect awareness regarding AMI among other patients.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Research Ethics Committee at King Faisal University issued approval KFU-REC-2022-SEP-ETHICS172. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.