Heart of a 21st Century Indian.

Trouble!!! Yes My Friends We are in trouble. Be it an Indian in America, in Australia, an Indian in India or any other part of this world they have proved their mettle in every aspect of life. But as it is a well known statement that with too much of good there is always something bad. No different is this scenario. Indians are considered to be a very cordial race by heart. BUT!!!!! How amiable a person can be by heart if the same organ is not in its fully efficient condition? When we have an overlook of the epidemiological transition of Coronary Vascular Diseases (CVD) or lets say a heart disease it is not something new that popped out from nowhere like batman on a dark haunting night but has been persistent throughout the ages in different predominant forms. Like in Sub Saharan Africa during the age of pestilence and famine 5-10% of deaths where due to CVD (Rheumatic Heart disease). Similarly in ages of receding pandemics, degenerative man made diseases, delayed degenerative diseases the percentage of deaths due to CVD has only increased in double figures. Presently when we prioritise the non communicable health conditions in India, by share in the burden of diseases we find no comparable competitor to cardiovascular disease (31%) in leading the charts.

This 31% accounts for an estimated 14 million deaths due to CVD and is likely to increase to 40% by 2025 i.e. 30 + million deaths due to the same. As per the various surveys, trials and track record of CVD it is believed that country wise India will be the top contributor of mortality due to cardiovascular disease by 2025.

These gigantic figures put India beyond any reasonable doubt into the zone of distress, alarm and concern. Cardiovascular Diseases among Indians have been always perceived as disease of old but when we visualise the estimates and trends of coronary heart disease (CHD) in various age groups the results are very disturbing.

It shows that frequency of occurrence of CHD over a period of time in various age groups remains constant; in fact, there is an increased chance of CHD in young age groups (20-29). A young Indian is likely to have a CHD 5-10 years earlier than that of other communities of world. Now the question arises. Should I or any other Indian with no past history of CHD be worried about these alarming statistics? The answer is big humpty dumpty YES. If we compare Indians with other communities we find ourselves more susceptible to CHD than any other ethnic group. We are 3.6 times more susceptible to CHD than Americans, 6 times more than Chinese and 20 times more than Japanese. So if I go by the numbers or the statistics it will makes my heart at the age of 40 same as that of 80 year old Japanese. Besides, The Genetic predisposition, Poor handling of Fats and metabolic syndrome (High BP, Diabetes, etc.), Environmental insults like urbanisation and sudden changes in lifestyle highly aggravate the possibility of CHD among Indians. So what is it that needs to be done or what necessary measures we can take to avoid these formidable circumstances?

Before going into the Risk Factor modifications that results in CHD Prevention lets first analyse the Risk Factors. A large international case-control study known as Inter Heart study was conducted worldwide around 52 countries with 12,461 cases and 14,637 controls to determine the Risk Factors associated with first Myocardial infarction (MI) or in a layman terms Heart attack. This study started in February 1999 and took 4 years for its completion in March 2003. It was published in Lancet on September 3 2004.

As per the study the various risk factors responsible for CHD may have a positive or a negative effect which determine the onset of a first myocardial infarction (MI).

The Risk factor that contribute to the increased risk of MI falls under the category of Negative Risk factors and include 1) Smoking 2) Hypertension 3) Diabetes 4) Obesity 5) Alcohol in Excess. 6) Psychosocial Factor. 5

It has happened for the first time in medical history that Stress under Psychosocial factors was quantified i.e. was shown to have direct involvement with the CHD. The prevalence of these risk factors varied substantially when subdivided by sex e.g. Population attributable risk (PAR) attributable to smoking is 16% in women and 44% in men. Current smoking and raised ApoB/ApoA1 (lipids) are the two strongest Risk factors followed by the history of Diabetes, Hypertension and psychological Factors. Cumulative effect of Negative Risk Factors can substantially increase the chances of CHD. a) Current Smoking + Hypertension + Diabetes gives odd ratio = 13.01; PAR 53% b) + ApoB/ApoA1 gives odd ratio = 42.30; PAR 75% c) + Abdominal Obesity PAR 80%. While there are other Risk Factors which try to cut down the chances of first MI. These come under the category of Positive Risk factors and include 1) Consumption of Fruits and Vegetables 2) Low Consumption of Alcohol 3) Physical activity These nine Risk Factors are accountable for 90% PAR in Men And 94% PAR in Women, young or old and in all regions of the world. As far as the people who consume alcohol, Inter Heart study has been a blessing in disguise. People who consume alcohol in moderate amount especially Red Wine are preferably at low risk of suffering MI or heart attack as compared to person who dont consume alcohol at all. Now as we are aware of the Risk Factors that lead to first MI we need to take certain preventive measures by bringing about certain modifications in life style based on above mentioned Risk factors. These so called therapeutic life style changes (TLC) are recommended for all persons irrespective of their age and baseline risk. They consist of

1) Absolute abstinence from smoking 2) Regular exercise 3) Diet rich in fruits and vegetables 4) Diet low in saturated fatty acids 5) Weight reduction to ideal levels 6) Strict control of Diabetes and Hypertension 7) Bringing lipid levels to lowest possible targets 8) Decreasing levels of psychosocial stress 9) Alcohol intake in moderation.

These changes are aimed at decreasing the intensity of above mentioned Risk Factors to achievable target levels. Some people will achieve these targets simply by these lifestyle modifications while others will require medications in addition to TLC. After all the best and the most beautiful things in the world can not be seen or touched.But are felt in HEART.