Online edition of India's National Newspaper
Saturday, Jul 14, 2007
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Online edition of India's National Newspaper Saturday, Jul 14, 2007 ePaper |
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Tamil Nadu
Cardiovascular disease, coronary artery disease (blockade of vessels supplying the heart muscle) and stroke (blockade of vessels of the brain), remain the single leading cause of death in adults worldwide and is expected to further rise into this century. The incidence of coronary artery disease among overseas Asian Indians worldwide are 50% to 400% higher than the people of other ethnic origin irrespective of gender, age, socio-economic status and other conventional risk factors like diabetes, hypertension, obesity, dyslipidaemia (abnormal cholesterol fractions) and smoking. There is a clear transition of communicable to non-communicable disease worldwide and especially this transition has been rapid and peculiar as well as severe as far as coronary artery disease is concerned in Indian population. Whereas the rates of Coronary Artery Disease have halved in the West in the last three decades, the rates have almost doubled in India with no signs of downturn yet. The mortality in Indian population suffering heart attacks is also 20% to 50% higher than their counterparts in the Western population. Many young patients present with Acute Coronary Syndromes or Acute Myocardial Infarction and some of them are brought to the hospital only to be declared dead. Some of them are misdiagnosed as gastritis and succumb to death. Many general practitioners practising in villages / towns may suspect or diagnose Acute Coronary Syndromes or Acute Myocardial Infarction, but are helpless for want of either expertise or facilities to treat these patients. The pre-hospital delay, which is due to many factors beyond our control, results in complications or death on most occasions. Even in well equipped hospitals, the avoidable delay in door -to- needle time has not come down in many places in our country. Then comes the affordability; many rural folks with acute Myocardial Infarction are refused admissions into Intensive Care Unit (ICU) or are not thrombolysed (dissolving clots) for want of money in most of the hospitals. If the stay is uneventful after thrombolysis, many of them can not afford the follow up treatment especially revascularisation procedures and have to be managed medically, that too, with great difficulty and by persuasion by physicians / cardiologists. Patients who have not received thrombolysis, due to extensive myocardial (heart muscle) damage, either develop Left Ventricular Failure (heart failure) even while in the hospital or develop asymptomatic Left Ventricular (LV) dysfunction. And, after discharge the quality of life suffers and the prognosis becomes unsatisfactory. Patients who receive thrombolysis and who can afford revascularisation procedures / surgery are very few, may be less than 5% in the rural setting and it may not exceed 50% even in the urban and affordable population due to various factors. In addition, patients with established Coronary Artery Disease require long term medical care in the community and the consequent morbidity represents a significant health problem as well as imposing a substantial economic burden. Cardiovascular disease especially Coronary Artery Disease has been estimated to account for about 15% of health care delivery costs, making it the significant expensive disease category. As the treatment cost is most expensive, for a population of 110 billion in our country, the total economic burden is expected to drain large economic in sources which can otherwise be utilized for industrial, agricultural and IT sectors towards modernization of India. It has been estimated that more than 80% of all Coronary Artery Disease cases could be prevented, if the population adhered to basic behavioral guidelines, such as regular exercise, weight reduction, healthy diet, not smoking and other related life style changes. The recent INTERHEART study showed that nine potentially modifiable risk factors account for over 90% of the risk of an initial acute myocardial infarction. In decreasing order of population attributable risk factors, they are dyslipidemia (abnormal cholesterol fractions), smoking, psychosocial factors, abdominal obesity, hypertension, inadequate fruit and vegetable consumption, lack of physical exercise, diabetes and alcohol consumption. An individual with a number of modest abnormalities in risk factors may be at considerably higher risk than another person with just one highly abnormal risk factor. As a result of these findings, the concept of an integrated and comprehensive approach to Coronary Artery Disease risk assessment and management are essential. Despite the observation that early mortality from cardiovascular disease is falling, the prevalence of Coronary Artery Disease and stroke is reaching almost epidemic proportion throughout the world, and it is even more greater in the Indian scenario due to peculiar risk factors. The excess burden of premature and malignant Coronary Artery Disease in Indians apart from conventional risk factors, is due to a genetic susceptibility mediated through elevated levels of lipoprotein (a) (Lp (a)), higher incidence of individuals with metabolic syndrome, which magnifies the adverse effects of life style factors associated with urbanization, affluence and diet. Even the cut off points for Body Mass Index (BMI) in Indians are lower than for Whites by 2 units for overweight and 5 units for obesity for both men and women. The optimum BMI is <23, whereas 23 to 25 is considered overweight and >25 obese for Indians. Hence a more aggressive approach to prevention and treatment of conventional and emerging risk factors is warranted in our context. As there is a huge unmet clinical need in the prevention and treatment of Coronary Artery Disease, greater collaboration between policy makers, public health surveillance and health-promotion organization is required. Moreover, the conventional approaches to screening of the population also have to be modified as the conventional risk factors do not explain the excess burden of Coronary Artery Disease in Indians. This will include tracking Lp(a) from early life, aiming for a tobacco/smoke free population, early detection and control of high blood pressure and diabetes, changing life style measures like increasing physical activities and adopting walking exercises, modifying dietary intake and integrating yoga practices etc., Dr.N.Chidambaram
Rajah Muthiah Medical
College and Hospital
Annamalai University
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