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Fortis Escorts Hospital, Jaipur, India; 2 Government Medical College, Akola, India; 3 Madras Diabetes Research Foundation, Chennai, India; 4 Public Health Foundation of India, New Delhi, India; 5 Population Health Research Institute, McMaster University, Hamilton, Canada Correspondence to: Dr R Gupta, Fortis Escorts Hospital, JLN Marg, Malviya Nagar, Jaipur 302017, India; rajeevg@satyam.net.in Accepted 4 September 2007
The World Health Organisation (WHO) reports that in the year 2005 cardiovascular diseases caused 17.5 million (30%) of the 58 million deaths that occurred world wide.1 Cardiovascular diseases such as coronary heart disease (CHD) and strokes are the largest causes of death in developing countries and are one of the main contributors to disease burden.2 Between 1990 and 2020 these diseases are expected to increase by 120% for women and 137% for men in developing countries as compared with 3060% in developed countries.3 It has been projected that by the year 2010 60% of the worlds patients with heart disease will be in India.2 Agestandardised cardiovascular disease death rates (per 100 000) in middle-aged subjects (3069 years) are low in developed countries such as Canada (120) and Britain (180) and high in developing countries Brazil (320), China (280), Pakistan (400), Nigeria (410), Russia (680) and India (405).1 Moreover, in India about 50% of CHD-related deaths occur in people younger than 70 years compared with only 22% in the West.2 In developing countries 94% of deaths from stroke occur in people aged ,70 years in contrast to 6% in developed countries.2 This article summarises the evidence which shows that in India there is a fully developed epidemic of cardiovascular diseases such as CHD and stroke. Several studies from India show that the disease burden estimated by disease prevalence studies is increasing in both urban and rural populations, the risk factors for this epidemic are similar to those elsewhere in the world, and there has been a substantial increase in these risk factors in India in recent years. 16
commonest causes of death.7 These studies show that these diseases are a major cause of death in Indian urban and rural locations. The continuing prospective Sample Registration System Verbal Autopsy (SRS-VA) Million Deaths Study in India8 and the Prospective Urban Rural Epidemiology (PURE) Study9 should provide more definitive answers.
size, variable and, at times, low response rates, inappropriate diagnostic criteria such as history, non-specific electrocardiographic changesfor example, abnormal ST-T waves, lack of age standardisation, and incomplete reporting of results.12 13 On the other hand most of these studies used similar populationbased recruitments, methodology and diagnostic criteria (known CHD, Rose questionnaire angina and/or electrocardiographic Q-ST-T changes) as shown in table 2. The age groups evaluated in these studies are variable and therefore we compared studies that included subjects aged >25 30 years to determine secular trends. A high prevalence is consistently seen in studies at urban locations (Chandigarh 6.6%,16 Rohtak 3.6%,17 Delhi 9.7%,18 Varanasi 6.5%,19 Jaipur 9.2%,20 Trivandrum 12.7%,21 Chennai 11.0%,22 Jaipur 9.1%,23 and Goa 12.5%24) as compared with the rural (Haryana 2.1%,26 Haryana 2.7%,28 Punjab 3.1%30 and Rajasthan 4.3%31). There are significantly increasing trends in urban (r2 = 0.60) as well as rural (r2 = 0.31) populations (fig 1). Analyses of prevalence studies in various decades in India also provide significant information about the absolute number of CHD cases.12 Decadal variations indicate that the adult prevalence has increased in urban areas from about 6.5% in the mid-1960s to 7.0% in 1980, 9.5% in 1990 and 10.5% in 2000, while in rural areas it increased from 2% in 1970s to 2.5% in 1980, 4% in 1990 and 4.5% in 2000. This would translate into 4.5 million urban subjects in 1970, 5.6 million in 1980, 9.7 million in 1990 and 14.1 million in the year 2000, and in rural populations into 4.1 million in 1970, 6.4 million in 1980, 11.8 million in 1990 and 15.7 million in 2000.12 Thus, epidemiological studies show that there are at present 29.8 million patients with CHD in this country, which is similar to the numbers obtained by the National Commission on Macroeconomics and Health.35 As epidemiological studies do not identify patients with silent and asymptomatic CHD the actual number of cases may be much greater.
Figure 1 Coronary heart disease (CHD) prevalence (%) in Indian urban and rural subjects aged .30 years as reported in epidemiological studies. The diagnostic criteria used were either known CHD, or angina on the Rose questionnaire or electrocardiographic Q/ST/T wave changes. There is a significantly increasing trend of CHD in both urban and rural populations. Heart 2008;94:1626. doi:10.1136/hrt.2007.132951
1960 1962 1968 1975 1990 1990 1995 1995 2001 2002 2004 2006 2007
Agra Delhi Chandigarh Rohtak Delhi Varanasi Jaipur Trivandrum Chennai Jaipur Panjim Chandigarh Srinagar
1046 1642 2030 1407 13 723 648 2212 506 1150 1123 371 1012 1576
3070 3070 3070 3070 2565 3070 2080 3080 2070 2080 3564 3580 4080
K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T in random sample K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q K+H+ECG-Q-ST-T
1.05 1.04 6.60 3.63 9.67 6.48 7.59 12.65 11.00 8.12 13.21 7.21 8.37
1974 1988 1989 1993 1994 1994 2002 2006 2006 2007 2007
Haryana Vidarbha Haryana Kerala Punjab Rajasthan Himachal Haryana Punjab (semiurban) Andhra Kashmir
1506 2433 1732 1130 1100 3148 1160 1188 1685 345 1552
3070 3070 3565 2565 3070 2080 2080 3580 3580 2090 4080
K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T in random sample K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q-ST-T K+H+ECG-Q K+H+ECG-Q K+H+ECG-Q K+H+ECG-Q-ST-T
2.06 1.69 2.71 7.43 3.09 3.53 5.00 1.60 2.91 3.60 6.70
K, known coronary heart disease; H, history of angina as assessed by WHO questionnaire; ECG, electrocardiogram; Q-ST-T, electrocardiographic waves.
studies in India that determined the community stroke prevalence. The crude prevalence rates of stroke appear to be higher in urban populations than in rural subjects, but there are location-based differences as seen by a very high prevalence among Parsis in Mumbai (842/100 000)46 as compared with the Mumbai general population (220/100 000)38 Evaluation of secular trends in stroke in India is not possible owing to the small numbers of studies. The incidence of stroke has been reported by a study from West Bengal in India and was significantly greater in rural
subjects than in the urban population.47 In a 5-year prospective study among 20 842 rural subjects the age-adjusted incidence rate was 262/100 000 a year,48 while in a study among 50 291 urban subjects the incidence was 105/100 000.39 These studies have excluded deaths from stroke and the data are likely to be underestimates. The Global Burden of Diseases Study reported an estimated population-based annual stroke incidence in India of 89/100 000 in 2005, which is projected to increase in 2015 to 91/100 000 and in 2030 to 98/100 000.10 This is compounded by high stroke mortality in India. In hospital-based studies 30-day
First author Urban Bansal BC37 Bharucha NE46 Dalal PM38 Banerjee TK39 Gourie-Devi M40 Rural Abraham J41 Gourie-Devi M42 Razdan S43 Das SK44 Saha SP45 Gourie-Devi M40
Sample size
79 14 145 50 51
424 334
258 57 63 37 20 51
84 244 262
18
We then determined the importance of various risk factors in CHD using logistic regression and reported that smoking was an independent risk factor in both rural and urban subjects. Other major risk factors were obesity, high WHR, hypertension and lipid abnormalities. This showed that standard cardiovascular risk factors were important in Indians. Emigrant versus native South Asian casecontrol studies have reported a greater prevalence of risk factors such as diabetes, impaired glucose tolerance and other lipid abnormalities to explain the greater prevalence of CHD in emigrant South Asians.5355 The prevalence of stroke seems to be similar in urban and rural populations, but only a limited number of comparable studies exist. Smoking and hypertension are well-known stroke risk factors and explain the greater stroke incidence among the Chinese population.36 It is well known that smoking and tobacco use is greater among the rural populations in India.56 Recent studies have reported a high prevalence of hypertension in rural subjects in different parts of the country.57 Thus, stroke in rural populations may be explained by these standard risk factors, although results of continuing studies using either a cross-sectional design (eg, INTERSTROKE Study)50 or a prospective design (namely, PURE Study)9 are awaited to evaluate accurately stroke determinants in India.
Figure 2 Proportionate probability of acute myocardial infarction in South Asian (SA) subjects as compared with subjects from rest of the world (ROW). There is greater probability of acute myocardial infarction in young South Asian subjects as compared with people from other countries (p = 0.001). However, the difference disappears when the probability is adjusted for the nine INTERHEART risk factors (p = 0.27). Adapted from Joshi et al.74
were smoking, raised fasting glucose and a high WHR. Smoking has been identified as the most important risk factor among the young survivors of myocardial infarction in many studies.58 The INTERHEART study was a large casecontrol study performed in 52 countries of the world with 15 152 cases of first myocardial infarction and 14 820 controls.73 This study identified nine well-known coronary risk factorsabnormal lipids, smoking, hypertension, diabetes, a high WHR, psychosocial factors, low fruit and vegetable consumption, low alcohol consumption, and lack of physical activityas accounting for more that 90% cases of acute myocardial infarction world wide. An important finding of this study was a younger age of occurrence of acute myocardial infarction in South Asians.74 The mean (SD) age of occurrence of a first myocardial infarction among 1732 participants from South Asia was 53.0 (11.4) years as against 58.8 (12.2) years in other countries. Although the mean age of myocardial infarction was lower in South Asians than in subjects from other countries, the risk factors were similar. Before adjustment for the nine INTERHEART risk factors there was a higher probability of patients who were younger than 40 years in the South Asian group (p = 0.001), but after adjustment for these risk factors the difference was attenuated and not significant (p = 0.27) (fig 2). The risk factors that were found to be important in the overall INTERHEART cohort were also important in the South Asian cohorts (table 4).74 Some harmful risk factors were more common in South Asians (raised Apo B/Apo A-1 ratio and diabetes) and all the risk factors occurred at a younger age in this group. Bidi smoking as well as use of non-smoked tobacco, which is peculiar to the Indian subcontinent, also emerged as an important risk factor.74 In the INTERHEART Study bidi smoking was associated with age and sex adjusted odds ratio (OR) of 2.89 (95% confidence interval (CI) 2.11 to 3.96) in the overall cohort and was same in South Asians (OR = 2.73, 95% CI 1.90 to 3.92).75 Participants who were current smokers of cigarettes or bidis and who chewed tobacco had an OR of 4.09 (95% CI 2.98 to 5.61) while those who chewed tobacco were also at increased risk (OR = 2.23, 95% CI 1.41 to 3,52). These data are especially relevant for India where tobacco smoking and chewing are widely prevalent both in men and women.76
20
Risk factor
Apolipoprotein B/A-1 ratio (highest vs lowest quartile) Other countries 48.3 South Asia 61.5 Current and former smoking Other countries South Asia Hypertension Other countries South Asia Diabetes Other countries South Asia High waist:hip ratio Other countries South Asia Psychosocial factors Other countries South Asia Moderate to intense exercise Other countries South Asia Alcohol consumption .1/week Other countries South Asia
31.8 43.8
65.7 61.6
49.4 40.8
40.5 29.6
23.6 12.7
18.2 20.2
7.2 9.5
46.7 44.0
34.0 29.6
84.2 86.0
82.0 82.6
15.8 4.6
21.6 6.1
25.7 13.3
26.9 10.7
Fruit and vegetable consumption .1/day Other countries 38.3 South Asia 20.0 Combined effects Other countries South Asia
45.2 26.5
are associated with a reduced risk of stroke and excessive fried foods and fat intake with an increased risk.77 Excessive alcohol intake is also a risk factor for stroke. Folate supplementation has been reported to be associated with a reduced risk of stroke in a meta-analysis.83 Regular physical activity is also protective. No population-based prospective studies exist in India, and data on stroke risk factors still rely on small casecontrol studies.38 49 In certain geographical areas socioeconomic factors, ethnicity and race are important risk factors for stroke.78 It is also important to realise that specific infections common in India may also contribute to stroke. These infections include malaria, neurocysticercosis, leptospirosis and viral haemorrhagic fevers. Conditions such as sickle cell anaemia, and snake bites are other prevalent disorders that can produce a stroke-like picture owing to intracerebral haemorrhage.84 Cerebral venous sinus thrombosis is a common cause of stroke among women in India, especially during the postpartum period.85 In India only small casecontrol studies to identify risk factors have been performed. Dalal reported that diabetes, hypertension, tobacco use and low haemoglobin levels were important risk
factors in a study in Mumbai.38 A study in urban subjects in Kolkata reported that hypertension was the most important risk factor, whereas another study in West Bengal rural subjects reported that existing heart disease, hypertension and smoking were important.47 All these studies were small and larger studies that are currently in progress such as the INTERSTROKE Study50 should be able to identify risk factors more accurately.
Figure 3 Trends in age-adjusted prevalence of various risk factors in Jaipur Heart Watch (JHW) studies among urban subjects aged 2059 years in India. These studies were performed in 19924 (JHW-1),20 19992001 (JHW-2),23 20034 (JHW-3)91 and 20056 (JHW-4).92 There are significantly escalating trends in prevalence of obesity (BMI >25 kg/m2), high WHR (.0.95), hypertension and hypercholesterolaemia (cholesterol >5.10 mmol/l) in both men and women.
Smoking
Smoking and tobacco use became a fashion statement in the past century in India. This phase was characterised by a large increase in its consumption driven by prevalent attitudes and cultural changes. The British studies and US Surgeon Generals reports on the harm of smoking and tobacco use led to a gradual decline in smoking in developed countries. On the other hand, populations of low- and middle-income countries have been increasing their cigarette consumption since about 1970.86 In these countries the per capita annual consumption of cigarettes increased from 800/year to more than 1200 from 19702 to 19902. In India, tobacco use increased by 36% over the same period.87 According to World Development Report, in India, the per capita tobacco consumption was 0.7/kg/year in 19746 and 0.8/kg/year in 1980 and was projected to increase to 0.9 kg/year by 2000 in contrast to developed countries where it was poised to decline from 2.9/kg/year in 1974 to 1.8 in 2000.88 The prevalence of smoking and tobacco use varies in different regions of India. In the second National Family Health Survey high smoking and tobacco use was reported among men and women in northeastern and northern Indian states while a low prevalence was observed in Punjab and Maharashtra.56 The habit of smoking is more prevalent in rural subjects (3060%) than in the urban population (1030%).76 Although smoking is low among women, use of non-smoked tobacco is high.76 There is an urgent need to curb the tobacco epidemic in India. Important policy steps in this direction are faithful implementation of the WHO Framework Convention for Tobacco Control initiative in India and strict application of the Indian Tobacco Control Act.76 Most of the recent Indian epidemiological studies have reported an inverse association between smoking/tobacco use and educational status,56 89 and it seems that improving the literacy levels of the population is an efficient method to decrease tobacco consumption.
increased to 5.79 in 1961, 5.23 in 1966, 5.85 in 1971, 5.21 in 1976, 6.48 in 1981 and 6.97 in 1986. This consumption is much lower than in European Union countries (38.98), USA (39.72), Canada (34.83) and Japan (19.84). Consumption of oils and hydrogenated oils is increasing similarly. This may be associated with increasing obesity, although no national data are available. The Jaipur Heart Watch (JHW) studies reported significantly escalating trends in obesity and high WHR in an Indian urban population. These studies were performed in 19924 (JHW-1),20 19992001 (JHW-2),23 20034 (JHW-3)91 and 20056 (JHW-4).92 Age-adjusted prevalence in subjects aged 2059 years shows that obesity (BMI >25 kg/m2 and high WHR .0.95) has increased significantly (fig 3). There was a significant correlation of increasing socioeconomic status (literacy levels) with increasing obesity and truncal obesity.93 These studies show that in India increasing socioeconomic status is associated with increasing obesity in contrast to high- and middle-income countries, where poverty is associated with greater obesity.94
Hypertension
A review of studies of the prevalence of hypertension in India has shown a high prevalence in both urban and rural areas.95 Indian urban population-based studies using WHO guidelines for diagnosis (known hypertension or blood pressure >160 mm Hg systolic or 95 mm Hg diastolic, or both) have shown increasing hypertension among adults aged >20 years from about 5% in the 196070s to 1115% in the late 1990s.57 The prevalence of hypertension using recent criteria (blood pressure >140/>90 mm Hg) has been reported among some urban Indian populations. Gupta et al reported hypertension in Jaipur in 30% of men and 33% of women,20 Joseph et al reported it in 31% of men and 41% of women in Trivandrum,96 whereas Mohan et al reported a crude prevalence rate of 21% in Chennai.97 In Mumbai, Anand reported hypertension in 34% of middle-class executives,98 whereas Gupta et al reported hypertension in 44% of men and 45% of women in Mumbai.99 We determined trends in the age-adjusted prevalence of Heart 2008;94:1626. doi:10.1136/hrt.2007.132951
Figure 4 Increasing age-adjusted prevalence (%) of diabetes and impaired glucose tolerance in Chennai in South India.107
hypertension in JHW studies in subjects aged 2059 years (fig 3). A significant escalation of hypertension prevalence was seen in both men and women. These findings are in accord with those of many developed countries where it has been reported that, at any one time, about half of the population have high blood pressure.100
Other factors
Many small studies from India have evaluated unconventional cardiovascular risk factors, including lipid subfractions, platelet functional abnormalities, inflammatory markers, homocysteine and thrombotic factors. Larger studies are needed. Barkers hypothesis that focuses on the adverse long-term cardiovascular impact of fetal undernutrition and low birth weight has been proposed as a cardiovascular risk factor.110 Studies have reported that neonates with a low birth weight have higher insulin levels and insulin resistance than normal weight neonates.111 This trend persists into early and mid-childhood.112 113 In the UK it has been observed that South Asian children have a lower birth weight and greater insulin resistance than Caucasians.114 The long-term prognostic impact of this finding has been studied in the New Delhi Birth Cohort Study, which showed that an increase in birth weight early in life resulted in greater insulin resistance and more diabetes in low birth weight children at 30 years of age.115 More studies are needed to evaluate the longterm cardiovascular consequences of this finding. Cardiovascular risk factor antecedents at childhood and adolescence have been sparsely studied in India.116 In the Indian cohort of Global Youth Tobacco Survey a variable prevalence of tobacco consumption was reported in different regions, with high use in eastern and central Indian states.117 From Delhi it has been reported that smoking among children is rapidly increasing, although a study reported that within a period of 2 years the habit declined.118 This was attributed to better health awareness and tobacco control initiatives. In affluent Indian children there seems to be an epidemic of obesity while among children of low socioeconomic status low body weight is widely prevalent.119 A high prevalence of high blood pressure, high cholesterol levels and high glucose levels in children has been reported from a few centres while many centres report a low prevalence of these conditions.120 121 The 23
Diabetes
The first systematic investigation of diabetes in India was performed by the Indian Council of Medical Research Task Force on diabetes in the 1970s.104 The population aged .14 years was screened using a post 50 g glucose load, and capillary blood glucose .4.40 mmol/l (.170 mg/dl) was taken Heart 2008;94:1626. doi:10.1136/hrt.2007.132951
APPROACHES TO PREVENTION
The increasing burden of coronary heart disease and stroke emphasises the importance of containing the epidemic of cardiovascular disease in India as well as combating its impact and minimising its toll.122 The INTERHEART Study has conclusively demonstrated that the usual cardiovascular risk factors are important in Indians.73 Primordial, primary as well as secondary prevention efforts should be directed towards these factors. At a macrolevel, better social, economic and cultural status correlates inversely with lifestyle factors of smoking, abnormal food patterns and exercise and is recommended for primordial prevention. Public broadcasting systems, television and newspapers have an important role in the dissemination of health-related information among populations. Suitable strategies to impart information to these print and electronic media should be developed locally. In Indians greater literacy levels and awareness have led to a decrease in some cardiovascular risk factorsfor example, smoking, in the well educated.89 Public awareness and demand has led to an increase in the number of physical activity centres such as parks and walkways in many urban locations. A new public health education campaign focusing on lifestyle changes (increased physical activity, prudent diet and tobacco cessation) has been launched in Chennai and preliminary results are encouraging.123 The measures that have the greatest impact on populationbased prevention are policy initiatives. The initiatives that might have an impact even in the short term include an increase in tobacco taxes, economic and labelling disincentives for unhealthy foods, removal of trans fats especially in processed foods, reduction in salt in home-made and processed foods, and urban design features which promote safe and pleasurable physical activity. These are more likely to have a much greater impact than limited community initiatives which will take a long time to develop and are resource intensive. In India some of these policy changes are already progressing and tobacco legislation has been approved by parliament. Some other national initiatives for prevention and control of cardiovascular diseases are being planned.122 A high-risk intervention approach is also important. The effectiveness of this depends directly on practising doctors and healthcare workers. Doctors and other healthcare providers serving the populations need to be educated as to the specific cultural barriers and opportunities that would encourage implementation of CHD prevention practices. The Indian Council of Medical Research has developed a chronic diseases risk factor surveillance programme for India.124 Pilot surveys have been carried out in various locations in the country using the WHO-Steps methodology, which outlines the sequential measurement of behavioural, physical and biochemical risk factors through its core, expanded and optional modules.125 Preliminary risk factor data in the 1564-year age group indicate a high rate of multiple cardiovascular risk factors, with a greater prevalence of risk factors in respondents residing in urban areas than in those residing in slum/peri-urban and rural areas.124 Successful adaptation and implementation of the WHO stepwise approach for non-communicable disease risk factor surveillance has paved the way for developing a module for risk factor surveillance in the National Integrated Disease Surveillance Programme (IDSP).124 A few primary prevention efforts have focused on individual risk factors. The Indian Diabetes Prevention Programme (IDPP) 24
evaluated increased physical activity versus metformin for prevention of diabetes in subjects with impaired glucose tolerance.126 At a median follow-up of 30 months, lifestyle modification reduced progression to diabetes by 28.5%, which was same as with metformin (26.4%) and also with combined metformin and lifestyle changes (28.2%). A yoga-based comprehensive lifestyle change has been evaluated in primary and secondary prevention of CHD risks and preliminary results are encouraging.127 For comprehensive cardiovascular primary prevention, The Indian Polycap Study (TIPS) is evaluating the usefulness of various drug combinations for reduction of cardiovascular risks.128 Secondary prevention practices in Indian are woefully inadequate both in acute care settings and in long-tem medical care facilities.129 The influence of the appropriate use of evidence-based treatments on outcomes in patients with CHD or stroke is not known in India. The Heart Outcomes Prevention Evaluation-3 (HOPE-3) Trial will evaluate the effect of statins and/or angiotensin receptor blockers on cardiovascular outcomes including a large sample from India.130 Some national initiatives for prevention and control of cardiovascular diseases in India are being planned.122 In conclusion, cardiovascular diseases, especially CHD and stroke, are major health problems in India. Risk factors for these conditions in Indian subjects are similar to those in populations elsewhere in the world and seem to be escalating. It is imperative that primordial, primary and secondary prevention efforts that have been shown to be effective in other regions of the world131 are translated into active regional and national initiatives in this country.
Competing interests: None declared.
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Notes